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Patel SM, Kang YM, Im K, Neuen BL, Anker SD, Bhatt DL, Butler J, Cherney DZI, Claggett BL, Fletcher RA, Herrington WG, Inzucchi SE, Jardine MJ, Mahaffey KW, McGuire DK, McMurray JJV, Neal B, Packer M, Perkovic V, Solomon SD, Staplin N, Vaduganathan M, Wanner C, Wheeler DC, Zannad F, Zhao Y, Heerspink HJL, Sabatine MS, Wiviott SD. Sodium Glucose Co-transporter 2 Inhibitors and Major Adverse Cardiovascular Outcomes: A SMART-C Collaborative Meta-Analysis. Circulation 2024. [PMID: 38583093 DOI: 10.1161/circulationaha.124.069568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/30/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Sodium glucose co-transporter 2 inhibitors (SGLT2i) consistently improve heart failure and kidney-related outcomes; however, effects on major adverse cardiovascular events (MACE) across different patient populations are less clear. METHODS This was a collaborative trial-level meta-analysis from the SGLT2i meta-analysis cardio-renal trialists consortium, which includes all phase 3, placebo-controlled, outcomes trials of SGLT2i across three patient populations (diabetes at high risk for atherosclerotic cardiovascular disease [ASCVD], heart failure [HF], or chronic kidney disease [CKD]). The outcomes of interest were MACE (composite of CV death, myocardial infarction [MI], or stroke), individual components of MACE (inclusive of fatal and non-fatal events), all-cause mortality, and death subtypes. Effect estimates for SGLT2i vs. placebo were meta-analyzed across trials and examined across key subgroups (established ASCVD, prior MI, diabetes, prior HF, albuminuria, CKD stages and risk groups). RESULTS A total of 78,607 patients across 11 trials were included: 42,568 (54.2%), 20,725 (26.4%), and 15,314 (19.5%) were included from trials of patients with diabetes at high risk for ASCVD, HF, or CKD, respectively. SGLT2i reduced the rate of MACE by 9% (HR 0.91 [95% CI 0.87-0.96], p<0.0001) with a consistent effect across all three patient populations (I2=0%) and across all key subgroups. This effect was primarily driven by a reduction in CV death (HR 0.86 [0.81-0.92], p<0.0001), with no significant effect for MI in the overall population (HR 0.95 [0.87-1.04], p=0.29), and no effect on stroke (HR 0.99 [0.91-1.07], p=0.77). The benefit for CV death was driven primarily by reductions in HF death and sudden cardiac death (HR 0.68 [0.46-1.02] and HR 0.86 [0.78-0.95], respectively) and was generally consistent across subgroups, with the possible exception of being more apparent in those with albuminuria (Pint=0.02). CONCLUSIONS SGLT2i reduce the risk of MACE across a broad range of patients irrespective of ASCVD, diabetes, kidney function or other major clinical characteristics at baseline. This effect is driven primarily by a reduction of CV death, particularly HF and sudden cardiac death, without a significant effect on MI in the overall population, and no effect on stroke. These data may help inform selection for SGLT2i therapies across the spectrum of cardiovascular-kidney-metabolic disease.
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Affiliation(s)
- Siddharth M Patel
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Yu Mi Kang
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - KyungAh Im
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Brendon L Neuen
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Stefan D Anker
- Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX; Department of Medicine, University of Mississippi School of Medicine, Jackson, MS
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, Ontario, Canada
| | - Brian L Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Robert A Fletcher
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - William G Herrington
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | | | - Meg J Jardine
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research (SCCR), Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Parkland Health, Dallas, TX
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Milton Packer
- Baylor University Medical Center, Dallas, TX and Imperial College, London United Kingdom
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Natalie Staplin
- Renal Studies Group, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Muthiah Vaduganathan
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Christoph Wanner
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center (CHFC), University Hospital, Würzburg, Germany
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Faiez Zannad
- Université de Lorraine, Inserm Centre d'Investigations Cliniques Plurithématique 1433, and CHRU, Nancy, France
| | | | - Hiddo J L Heerspink
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Marc S Sabatine
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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2
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Small AM, Melloni GEM, Kamanu FK, Bergmark BA, Bonaca MP, O'Donoghue ML, Giugliano RP, Scirica BM, Bhatt D, Antman EM, Raz I, Wiviott SD, Truong B, Wilson PWF, Cho K, O'Donnell CJ, Braunwald E, Lubitz SA, Ellinor P, Peloso GM, Ruff CT, Sabatine MS, Natarajan P, Marston NA. Novel Polygenic Risk Score and Established Clinical Risk Factors for Risk Estimation of Aortic Stenosis. JAMA Cardiol 2024; 9:357-366. [PMID: 38416462 PMCID: PMC10902779 DOI: 10.1001/jamacardio.2024.0011] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/28/2023] [Indexed: 02/29/2024]
Abstract
Importance Polygenic risk scores (PRSs) have proven to be as strong as or stronger than established clinical risk factors for many cardiovascular phenotypes. Whether this is true for aortic stenosis remains unknown. Objective To develop a novel aortic stenosis PRS and compare its aortic stenosis risk estimation to established clinical risk factors. Design, Setting, and Participants This was a longitudinal cohort study using data from the Million Veteran Program (MVP; 2011-2020), UK Biobank (2006-2010), and 6 Thrombolysis in Myocardial Infarction (TIMI) trials, including DECLARE-TIMI 58 (2013-2018), FOURIER (TIMI 59; 2013-2017), PEGASUS-TIMI 54 (2010-2014), SAVOR-TIMI 53 (2010-2013), SOLID-TIMI 52 (2009-2014), and ENGAGE AF-TIMI 48 (2008-2013), which were a mix of population-based and randomized clinical trials. Individuals from UK Biobank and the MVP meeting a previously validated case/control definition for aortic stenosis were included. All individuals from TIMI trials were included unless they had a documented preexisting aortic valve replacement. Analysis took place from January 2022 to December 2023. Exposures PRS for aortic stenosis (developed using data from MVP and validated in UK Biobank) and other previously validated cardiovascular PRSs, defined either as a continuous variable or as low (bottom 20%), intermediate, and high (top 20%), and clinical risk factors. Main Outcomes Aortic stenosis (defined using International Classification of Diseases or Current Procedural Terminology codes in UK Biobank and MVP or safety event data in the TIMI trials). Results The median (IQR) age in MVP was 67 (57-73) years, and 135 140 of 147 104 participants (92%) were male. The median (IQR) age in the TIMI trials was 66 (54-78) years, and 45 524 of 59 866 participants (71%) were male. The best aortic stenosis PRS incorporated 5 170 041 single-nucleotide variants and was associated with aortic stenosis in both the MVP testing sample (odds ratio, 1.41; 95% CI, 1.37-1.45 per 1 SD PRS; P = 4.6 × 10-116) and TIMI trials (hazard ratio, 1.44; 95% CI, 1.27-1.62 per 1 SD PRS; P = 3.2 × 10-9). Among genetic and clinical risk factors, the aortic stenosis PRS performed comparably to most risk factors besides age, and within a given age range, the combination of clinical and genetic risk factors was additive, providing a 3- to 4-fold increased gradient of risk of aortic stenosis. However, the addition of the aortic stenosis PRS to a model including clinical risk factors only improved risk discrimination of aortic stenosis by 0.01 to 0.02 (C index in MVP: 0.78 with clinical risk factors, 0.79 with risk factors and aortic stenosis PRS; C index in TIMI: 0.71 with clinical risk factors, 0.73 with risk factors and aortic stenosis PRS). Conclusions This study developed and validated 1 of the first aortic stenosis PRSs. While aortic stenosis genetic risk was independent from clinical risk factors and performed comparably to all other risk factors besides age, genetic risk resulted in only a small improvement in overall aortic stenosis risk discrimination beyond age and clinical risk factors. This work sets the stage for further development of an aortic stenosis PRS.
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Affiliation(s)
- Aeron M Small
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
| | - Giorgio E M Melloni
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frederick K Kamanu
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brian A Bergmark
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc P Bonaca
- Department of Medicine, Cardiology and Vascular Medicine, University of Colorado School of Medicine, Aurora
| | - Michelle L O'Donoghue
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert P Giugliano
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin M Scirica
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elliott M Antman
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Itamar Raz
- Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Stephen D Wiviott
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Buu Truong
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Peter W F Wilson
- Atlanta Veterans Affairs Medical Center, Decatur, Georgia
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kelly Cho
- Veterans Affairs Healthcare System, Boston, Massachusetts
- Division of Aging, Mass General Brigham and Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Christopher J O'Donnell
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
| | - Eugene Braunwald
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steve A Lubitz
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
| | - Patrick Ellinor
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Gina M Peloso
- Veterans Affairs Healthcare System, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Christian T Ruff
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc S Sabatine
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pradeep Natarajan
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston
- Center for Genomic Medicine, Massachusetts General Hospital, Boston
| | - Nicholas A Marston
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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3
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Zimerman A, Wiviott SD, Park JG, Murphy SA, Ran X, Bramson CR, Curto M, Ramos V, Jevne A, Kuder JF, Verma S, Wojakowski W, Terra SG, Sabatine MS, Bergmark BA, Marston NA. Hepatic fat changes with antisense oligonucleotide therapy targeting ANGPTL3. J Clin Lipidol 2024; 18:e261-e268. [PMID: 38158248 DOI: 10.1016/j.jacl.2023.12.001] [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: 10/30/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Angiopoietin-like protein 3 (ANGPTL3) is a novel therapeutic target for hyperlipidemia. Vupanorsen, an antisense oligonucleotide targeting ANGPTL3, reduced triglycerides up to 57% in a phase 2b trial, but caused dose-dependent increases in hepatic fat fraction (HFF). OBJECTIVE To determine the degree of HFF progression with escalating doses of vupanorsen, differential HFF increases in key patient subgroups, and the correlation between changes in HFF and liver enzymes. METHODS TRANSLATE-TIMI 70 was a randomized, placebo-controlled trial testing 7 dosing regimens of vupanorsen in 286 adults with hyperlipidemia. A total of 227 patients had HFF measured at baseline and 24 weeks and were included in this analysis. RESULTS The median HFF at baseline was 8.5%. Vupanorsen led to dose-dependent relative increases in HFF of up to 76% at 24 weeks (p < 0.001), corresponding to an absolute increase of up to 7.0% at the highest dose (p < 0.001). Increases in HFF were numerically greater in patients who had elevated baseline HFF, body mass index, triglycerides, or diabetes. Vupanorsen also increased liver enzymes in a dose-dependent manner, and changes in HFF were moderately positively correlated with changes in aspartate transaminase (AST) (rho = 0.49, p < 0.001) and alanine transaminase (ALT) (rho = 0.50, p < 0.001). CONCLUSION Vupanorsen, an inhibitor of ANGPTL3 protein synthesis, caused dose-dependent increases in HFF. Increases in HFF were only moderately correlated with elevations in AST and ALT, suggesting that liver enzymes are an imperfect indicator to detect increases in hepatic fat. These results highlight the need to monitor HFF in clinical trials of therapies targeting intracellular ANGPTL3 inhibition, especially those that are targeted to the liver.
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Affiliation(s)
- Andre Zimerman
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Jeong-Gun Park
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Xinhui Ran
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Candace R Bramson
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Madelyn Curto
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Vesper Ramos
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Alexandra Jevne
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Subodh Verma
- Department of Surgery, University of Toronto, Toronto, Canada (Dr. Verma)
| | | | - Steven G Terra
- Pfizer, Inc., New York, NY, USA (Drs. Bramson, Curto, Ramos) and Terra
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston)
| | - Nicholas A Marston
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA (Drs. Zimerman, Wiviott, Park, Murphy, Ran, Jevne), Kuder, (Drs. Sabatine, Bergmark, and Marston).
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4
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Patel SM, Morrow DA, Bellavia A, Berg DD, Bhatt DL, Jarolim P, Leiter LA, McGuire DK, Raz I, Steg PG, Wilding JPH, Sabatine MS, Wiviott SD, Braunwald E, Scirica BM, Bohula EA. Natriuretic peptides, body mass index and heart failure risk: Pooled analyses of SAVOR-TIMI 53, DECLARE-TIMI 58 and CAMELLIA-TIMI 61. Eur J Heart Fail 2024; 26:260-269. [PMID: 38131261 DOI: 10.1002/ejhf.3118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/09/2023] [Accepted: 12/19/2023] [Indexed: 12/23/2023] Open
Abstract
AIM N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations are lower in patients with obesity. The interaction between body mass index (BMI) and NT-proBNP with respect to heart failure risk remains incompletely defined. METHODS AND RESULTS Data were pooled across three randomized clinical trials enrolling predominantly patients who were overweight or obese with established cardiometabolic disease: SAVOR-TIMI 53, DECLARE-TIMI 58 and CAMELLIA-TIMI 61. Hospitalization for heart failure (HHF) was examined across strata of baseline BMI and NT-proBNP. The effect of dapagliflozin versus placebo was assessed for a treatment interaction across BMI categories in patients with or without an elevated baseline NT-proBNP (≥125 pg/ml). Among 24 455 patients, the median NT-proBNP was 96 (interquartile range [IQR]: 43-225) pg/ml and the median BMI was 33 (IQR 29-37) kg/m2, with 68% of patients having a BMI ≥30 kg/m2. There was a significant inverse association between NT-proBNP and BMI which persisted after adjustment for all clinical variables (p < 0.001). Within any range of NT-proBNP, those at higher BMI had higher risk of HHF at 2 years (comparing BMI <30 vs. ≥40 kg/m2 for NT-proBNP ranges of <125, 125-<450 and ≥450 pg/ml: 0.0% vs. 0.6%, 1.3% vs. 4.0%, and 8.1% vs. 13.8%, respectively), which persisted after multivariable adjustment (adjusted hazard ratio [HRadj] 7.47, 95% confidence interval [CI] 3.16-17.66, HRadj 3.22 [95% CI 2.13-4.86], and HRadj 1.87 [95% CI 1.35-2.60], respectively). In DECLARE-TIMI 58, dapagliflozin versus placebo consistently reduced HHF across BMI categories in those with an elevated NT-proBNP (p-trend for HR across BMI = 0.60), with a pattern of greater absolute risk reduction (ARR) at higher BMI (ARR for BMI <30 to ≥40 kg/m2: 2.2% to 4.7%; p-trend = 0.059). CONCLUSIONS The risk of HHF varies across BMI categories for any given range of circulating NT-proBNP. These findings showcase the importance of considering BMI when applying NT-proBNP for heart failure risk stratification, particularly for patients with low-level elevations in NT-proBNP (125-<450 pg/ml) where there appears to be a clinically meaningful absolute and relative risk gradient.
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Affiliation(s)
- Siddharth M Patel
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea Bellavia
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - P Gabriel Steg
- Université Paris Cité, INSERM U-1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
- FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin M Scirica
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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5
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Moura FA, Berg DD, Bellavia A, Dwyer JP, Mosenzon O, Scirica BM, Wiviott SD, Bhatt DL, Raz I, Feinberg MW, Braunwald E, Morrow DA, Sabatine MS. Risk Assessment of Kidney Disease Progression and Efficacy of SGLT2 Inhibition in Patients With Type 2 Diabetes. Diabetes Care 2023; 46:1807-1815. [PMID: 37556796 PMCID: PMC10516252 DOI: 10.2337/dc23-0492] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/14/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE To develop a risk assessment tool to identify patients with type 2 diabetes (T2D) at higher risk for kidney disease progression and who might benefit more from sodium-glucose cotransporter 2 (SGLT2) inhibition. RESEARCH DESIGN AND METHODS A total of 41,204 patients with T2D from four Thrombolysis In Myocardial Infarction (TIMI) clinical trials were divided into derivation (70%) and validation cohorts (30%). Candidate predictors of kidney disease progression (composite of sustained ≥40% decline in estimated glomerular filtration rate [eGFR], end-stage kidney disease, or kidney death) were selected with multivariable Cox regression. Efficacy of dapagliflozin was assessed by risk categories (low: <0.5%; intermediate: 0.5 to <2%; high: ≥2%) in Dapagliflozin Effect on Cardiovascular Events (DECLARE)-TIMI 58. RESULTS There were 695 events over a median follow-up of 2.4 years. The final model comprised eight independent predictors of kidney disease progression: atherosclerotic cardiovascular disease, heart failure, systolic blood pressure, T2D duration, glycated hemoglobin, eGFR, urine albumin-to-creatinine ratio, and hemoglobin. The c-indices were 0.798 (95% CI, 0.774-0.821) and 0.798 (95% CI, 0.765-0.831) in the derivation and validation cohort, respectively. The calibration plot slope (deciles of predicted vs. observed risk) was 0.98 (95% CI, 0.93-1.04) in the validation cohort. Whereas relative risk reductions with dapagliflozin did not differ across risk categories, there was greater absolute risk reduction in patients with higher baseline risk, with a 3.5% absolute risk reduction in kidney disease progression at 4 years in the highest risk group (≥1%/year). Results were similar with the 2022 Chronic Kidney Disease Prognosis Consortium risk prediction model. CONCLUSIONS Risk models for kidney disease progression can be applied in patients with T2D to stratify risk and identify those who experience a greater magnitude of benefit from SGLT2 inhibition.
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Affiliation(s)
- Filipe A. Moura
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - David D. Berg
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Andrea Bellavia
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jamie P. Dwyer
- Division of Nephrology and Hypertension, University of Utah Health, Salt Lake City, UT
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Benjamin M. Scirica
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Stephen D. Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Mark W. Feinberg
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - David A. Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Marc S. Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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Grinspoon SK, Fitch KV, Zanni MV, Fichtenbaum CJ, Umbleja T, Aberg JA, Overton ET, Malvestutto CD, Bloomfield GS, Currier JS, Martinez E, Roa JC, Diggs MR, Fulda ES, Paradis K, Wiviott SD, Foldyna B, Looby SE, Desvigne-Nickens P, Alston-Smith B, Leon-Cruz J, McCallum S, Hoffmann U, Lu MT, Ribaudo HJ, Douglas PS. Pitavastatin to Prevent Cardiovascular Disease in HIV Infection. N Engl J Med 2023; 389:687-699. [PMID: 37486775 PMCID: PMC10564556 DOI: 10.1056/nejmoa2304146] [Citation(s) in RCA: 61] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND The risk of cardiovascular disease is increased among persons with human immunodeficiency virus (HIV) infection, so data regarding primary prevention strategies in this population are needed. METHODS In this phase 3 trial, we randomly assigned 7769 participants with HIV infection with a low-to-moderate risk of cardiovascular disease who were receiving antiretroviral therapy to receive daily pitavastatin calcium (at a dose of 4 mg) or placebo. The primary outcome was the occurrence of a major adverse cardiovascular event, which was defined as a composite of cardiovascular death, myocardial infarction, hospitalization for unstable angina, stroke, transient ischemic attack, peripheral arterial ischemia, revascularization, or death from an undetermined cause. RESULTS The median age of the participants was 50 years (interquartile range, 45 to 55); the median CD4 count was 621 cells per cubic millimeter (interquartile range, 448 to 827), and the HIV RNA value was below quantification in 5250 of 5997 participants (87.5%) with available data. The trial was stopped early for efficacy after a median follow-up of 5.1 years (interquartile range, 4.3 to 5.9). The incidence of a major adverse cardiovascular event was 4.81 per 1000 person-years in the pitavastatin group and 7.32 per 1000 person-years in the placebo group (hazard ratio, 0.65; 95% confidence interval [CI], 0.48 to 0.90; P = 0.002). Muscle-related symptoms occurred in 91 participants (2.3%) in the pitavastatin group and in 53 (1.4%) in the placebo group; diabetes mellitus occurred in 206 participants (5.3%) and in 155 (4.0%), respectively. CONCLUSIONS Participants with HIV infection who received pitavastatin had a lower risk of a major adverse cardiovascular event than those who received placebo over a median follow-up of 5.1 years. (Funded by the National Institutes of Health and others; REPRIEVE ClinicalTrials.gov number, NCT02344290.).
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Affiliation(s)
- Steven K Grinspoon
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Kathleen V Fitch
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Markella V Zanni
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Carl J Fichtenbaum
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Triin Umbleja
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Judith A Aberg
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Edgar T Overton
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Carlos D Malvestutto
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Gerald S Bloomfield
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Judith S Currier
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Esteban Martinez
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Jhoanna C Roa
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Marissa R Diggs
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Evelynne S Fulda
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Kayla Paradis
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Stephen D Wiviott
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Borek Foldyna
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Sara E Looby
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Patrice Desvigne-Nickens
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Beverly Alston-Smith
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Jorge Leon-Cruz
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Sara McCallum
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Udo Hoffmann
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Michael T Lu
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Heather J Ribaudo
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
| | - Pamela S Douglas
- From the Metabolism Unit (S.K.G., K.V.F., M.V.Z., M.R.D., E.S.F., S.E.L., S.M.), the Cardiovascular Imaging Research Center, Department of Radiology (K.P., B.F., M.T.L.), and the Yvonne L. Munn Center for Nursing Research (S.E.L.), Massachusetts General Hospital and Harvard Medical School, the Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health (T.U., J.L.-C., H.J.R.), and the Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School (S.D.W.) - all in Boston; the Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati (C.J.F.), and the Division of Infectious Diseases, Ohio State University Medical Center, Columbus (C.D.M.); the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York (J.A.A.); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham (E.T.O.); the Department of Medicine, Duke Global Health Institute and Duke Clinical Research Institute, Duke University (G.S.B.), and Duke University Research Institute, Duke University School of Medicine (P.S.D.) - both in Durham, NC; the Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (J.S.C.); the Infectious Diseases Service, Hospital Clinic and University of Barcelona, Barcelona, and CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid - both in Spain (E.M.); DLH, Silver Spring (J.C.R.), and the Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute (P.D.-N.), and the Division of AIDS, National Institute of Allergy and Infectious Diseases (B.A.-S.), National Institutes of Health, Bethesda - all in Maryland; and Cleerly, Denver (U.H.)
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Wiviott SD, Berg DD. SGLT2 Inhibitors Reduce Heart Failure Hospitalization and Cardiovascular Death: Clarity and Consistency. J Am Coll Cardiol 2023; 81:2388-2390. [PMID: 37344039 DOI: 10.1016/j.jacc.2023.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Stephen D Wiviott
- TIMI (Thrombolysis In Myocardial Infarction) Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - David D Berg
- TIMI (Thrombolysis In Myocardial Infarction) Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/ddbergMD
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Berg DD, Moura FA, Bellavia A, Scirica BM, Wiviott SD, Bhatt DL, Raz I, Bohula EA, Giugliano RP, Park JG, Feinberg MW, Braunwald E, Morrow DA, Sabatine MS. Assessment of Atherothrombotic Risk in Patients With Type 2 Diabetes Mellitus. J Am Coll Cardiol 2023; 81:2391-2402. [PMID: 37344040 DOI: 10.1016/j.jacc.2023.04.031] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/22/2023] [Accepted: 04/17/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Risk of atherothrombotic events is not uniform in patients with type 2 diabetes mellitus (T2DM). Tailored risk assessment may help guide selection of pharmacotherapies for cardiovascular primary and secondary prevention. OBJECTIVES The purpose of this study was to develop a risk model for atherothrombosis in patients with T2DM. METHODS We developed and validated a risk model for myocardial infarction (MI) or ischemic stroke (IS) in a pooled cohort of 42,181 patients with T2DM from 4 TIMI (Thrombolysis In Myocardial Infarction) clinical trial cohorts. Candidate variables were assessed with multivariable Cox regression, and independent variables (P < 0.05) were retained in the final model. Discrimination and calibration were assessed. Treatment interactions with dapagliflozin (sodium-glucose cotransporter-2 inhibitor) and evolocumab (proprotein convertase subtilisin/kexin type 9 inhibitor) were explored in the DECLARE-TIMI 58 (Dapagliflozin Effect on CardiovascuLAR Events-Thrombolysis In Myocardial Infarction 58) and FOURIER (Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk) trials, respectively. RESULTS Sixteen variables were independent predictors of MI or IS. The model identified a >8-fold gradient of MI or IS rates between the top vs bottom risk quintiles in the validation cohort (3-year Kaplan-Meier rate: 14.9% vs 1.4%; P < 0.0001). C-indexes were 0.704 and 0.706 in the derivation and validation cohorts, respectively. The model was well-calibrated in both primary and secondary prevention. Absolute reduction in the rates of MI or IS tended to be greater in patients with higher baseline predicted risk for both dapagliflozin (absolute risk reduction: 2.1% vs 0.2%) and evolocumab (absolute risk reduction: 3.2% vs 1.0%). CONCLUSIONS We developed and validated a risk score for atherothrombotic events, leveraging 16 routinely assessed clinical variables in patients with T2DM. The score has the potential to improve risk assessment and inform clinical decision-making.
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Affiliation(s)
- David D Berg
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Filipe A Moura
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea Bellavia
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin M Scirica
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Itamar Raz
- Faculty of Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Erin A Bohula
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeong-Gun Park
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark W Feinberg
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Zelniker TA, Wiviott SD, Mosenzon O, Goodrich EL, Jarolim P, Cahn A, Bhatt DL, Leiter LA, McGuire DK, Wilding J, Averkov O, Budaj A, Parkhomenko A, Ray KK, Gause-Nilsson I, Langkilde AM, Fredriksson M, Raz I, Sabatine MS, Morrow DA. Association of Cardiac Biomarkers With Major Adverse Cardiovascular Events in High-risk Patients With Diabetes: A Secondary Analysis of the DECLARE-TIMI 58 Trial. JAMA Cardiol 2023; 8:503-509. [PMID: 36857035 PMCID: PMC9979005 DOI: 10.1001/jamacardio.2023.0019] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/03/2023] [Indexed: 03/02/2023]
Abstract
Importance Dapagliflozin reduces the risk of hospitalizations for heart failure and the progression of chronic kidney disease in patients with and without type 2 diabetes (T2D), whereas the effects on reducing atherosclerotic events appear less clear. Objective To explore whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hsTnT) levels can identify a subset of patients with T2D at higher risk and who might benefit more from dapagliflozin with regard to atherosclerotic events. Design, Setting, and Participants This was a secondary analysis of the DECLARE-TIMI 58 trial, a randomized clinical trial of dapagliflozin in patients with T2D and either multiple risk factors for atherosclerotic cardiovascular disease (ASCVD; approximately 60%) or established ASCVD (approximately 40%). All patients with available blood samples at randomization were included in these analyses. Data were collected from May 2013 to September 2018, and data were analyzed from May 2019 to June 2022. Interventions Dapagliflozin vs placebo. Main Outcomes and Measures Major adverse cardiovascular events (MACE), the composite of myocardial infarction, ischemic stroke, or cardiovascular death, which was one of dual primary outcomes of the main trial. Results Of 14 565 included patients, 9143 (62.8%) were male, and the mean (SD) age was 63.9 (6.8) years. When tested individually in a multivariable model for MACE risk, NT-proBNP and hsTnT were each significantly associated with the risk of MACE (adjusted hazard ratio [aHR] per 1 SD in log-transformed biomarker: NT-proBNP, 1.62; 95% CI, 1.49-1.76; hsTnT: 1.59; 95% CI, 1.46-1.74). The magnitude of the association was similar in patients with ASCVD (NT-proBNP: aHR, 1.60; 95% CI, 1.45-1.77; hsTnT: aHR, 1.62; 95% CI, 1.45-1.81) and multiple risk factors for ASCVD (NT-proBNP: aHR, 1.62; 95% CI, 1.40-1.88; hsTnT: aHR, 1.51; 95% CI, 1.29-1.77). Moreover, both biomarkers remained independently associated with MACE when both were included in the multivariable model (NT-proBNP: aHR, 1.46; 95% CI, 1.34-1.60; hsTnT: aHR, 1.39; 95% CI, 1.26-1.53). Modeled as a continuous variable, baseline biomarker levels did not modify the relative treatment effect of dapagliflozin vs placebo with MACE. However, the relative risk reduction numerically grew with higher biomarker levels, as did the baseline risk. Thus, MACE event rates were nominally lower in dapagliflozin-treated vs placebo-treated patients with biomarker concentrations in the top quartile (NT-proBNP: HR, 0.83; 95% CI, 0.71-0.97; absolute risk reduction [ARR], 2.4%; hsTnT: HR, 0.85; 95% CI, 0.72-0.99; ARR, 2.7%), whereas there was no significant treatment effect in patients with biomarkers levels in quartiles 1 to 3 (NT-proBNP: HR, 1.02; 95% CI, 0.88-1.18; ARR, 0%; hsTnT: HR, 0.97; 95% CI, 0.84-1.13; ARR, 0.2%). Conclusions and Relevance In this study, NT-proBNP and hsTnT levels were associated with the risk for future cardiovascular events in both primary and secondary prevention patients with T2D. Both cardiac biomarkers were helpful to identify patients at very high risk for atherosclerotic events that may derive reduction in risk of MACE with dapagliflozin. Trial Registration ClinicalTrials.gov Identifier: NCT01730534.
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Affiliation(s)
| | - Stephen D. Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ofri Mosenzon
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Erica L. Goodrich
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Avivit Cahn
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York
| | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K. McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | - Oleg Averkov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Andrzej Budaj
- Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | | | - Kausik K. Ray
- Imperial Centre for Cardiovascular Disease Prevention and Imperial Clinical Trials Unit, Imperial College London, London, United Kingdom
| | | | | | | | - Itamar Raz
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Marc S. Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Deputy Editor, JAMA Cardiology
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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10
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Schechter M, Wiviott SD, Raz I, Goodrich EL, Rozenberg A, Yanuv I, Murphy SA, Zelniker TA, Fredriksson M, Johansson PA, Leiter LA, Bhatt DL, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Cahn A, Langkilde AM, Sabatine MS, Mosenzon O. Effects of dapagliflozin on hospitalisations in people with type 2 diabetes: post-hoc analyses of the DECLARE-TIMI 58 trial. Lancet Diabetes Endocrinol 2023; 11:233-241. [PMID: 36878239 DOI: 10.1016/s2213-8587(23)00009-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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] [Received: 11/21/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND In people with type 2 diabetes at high risk of cardiovascular or kidney disease, sodium-glucose co-transporter 2 (SGLT2) inhibitors consistently reduce the risk of hospitalisations for heart failure. Less is known about their effects on hospitalisation from any cause, especially in people with type 2 diabetes without atherosclerotic cardiovascular disease, which includes most of the global population of people with type 2 diabetes. We aimed to assess the effect of the SGLT2 inhibitor, dapagliflozin, on the risks of hospitalisations for any cause and for specific causes in people with type 2 diabetes with and without atherosclerotic cardiovascular disease. METHODS The DECLARE-TIMI 58 trial was a double-blind, multicentre, randomised, placebo-controlled study. People with type 2 diabetes and either risk factors for or established atherosclerotic cardiovascular disease were randomly assigned (1:1) to receive oral dapagliflozin 10 mg or placebo once daily. In these post-hoc analyses, the effects of dapagliflozin on risks of first non-elective any-cause and cause-specific hospitalisation were assessed with Cox proportional hazards regression models overall and in the subset of participants without prevalent atherosclerotic cardiovascular disease. The risk of total (first plus subsequent) non-elective hospitalisations was assessed with Lin-Wei-Ying-Yang model. Investigator-reported System Organ Class terms were used to classify cause-specific hospitalisations. The trial is registered with ClinicalTrials.gov, NCT01730534. FINDINGS Between April 25, 2013, and Sept 18, 2018, 17 160 people (6422 [37·4%] women, 10 738 [62·6%] men; mean age 63·9 years [SD 6·8]) were enrolled in the original trial, of whom 10186 (59·4%) had multiple risk factors for but did not have established atherosclerotic cardiovascular disease, and 6835 (39·8%) had both no evidence of atherosclerotic cardiovascular disease and low KDIGO risk. Over a median follow-up of 4·2 years (IQR 3·9-4·4), dapagliflozin was associated with a lower risk of first non-elective hospitalisation for any cause (2779 [32·4%] of 8582 people in the dapagliflozin group vs 3036 [35·4%] of 8578 people in the placebo group; hazard ratio [HR] 0·89 [95% CI 0·85-0·94]) and total (first plus subsequent) non-elective hospitalisations for any cause (risk ratio 0·92 [95% CI 0·86-0·97]). The association between dapagliflozin use and the risk of first non-elective hospitalisation for any cause was consistent in subgroups of participants with (HR 0·92 [95% CI 0·85-0·99] and without (0·87 [0·81-0·94]) atherosclerotic cardiovascular disease at baseline (p interaction=0·31). Compared with the placebo group, the dapagliflozin group had lower risk of first hospitalisations due to cardiac disorders (HR 0·91 [95% CI 0·84-1·00]), metabolism and nutrition disorders (0·73 [0·60-0·89]), renal and urinary disorders (0·61 [0·49-0·77]), and due to any other cause excluding these three causes (0·90 [0·85-0·96]). Treatment with dapagliflozin was also associated with a lower risk of hospitalisations due to musculoskeletal and connective tissue disorders (HR 0·81 [0·67-0·99]) and infections and infastations (HR 0·86 [0·78-0·96]). INTERPRETATION Dapagliflozin reduced the risk of first and total non-elective hospitalisations for any cause in people with type 2 diabetes, regardless of the presence of atherosclerotic cardiovascular disease, including hospitalisations not directly attributed to cardiac, kidney, or metabolic causes. These findings might have implications on health-related quality of life for people with type 2 diabetes and on health-care costs attributable this condition. FUNDING AstraZeneca.
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Affiliation(s)
- Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephen D Wiviott
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas A Zelniker
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Martin Fredriksson
- BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden
| | - Peter A Johansson
- BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Internal Medicine, Parkland Health and Hospital System, Dallas, TX, USA
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK
| | | | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Marc S Sabatine
- TIMI Study Group and Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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11
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Small AM, Berg D, Raz I, Goodrich EL, Moura F, Mosenzon O, Cahn A, Bhatt DL, Leiter LA, McGuire DK, Wilding J, Gause-Nilsson I, Sabatine MS, Morrow DA, Wiviott SD. RELATIONSHIP BETWEEN CYSTATIN C, CREATININE-BASED EGFR, CARDIOVASCULAR EVENTS AND KIDNEY OUTCOMES IN DECLARETIMI 58. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02260-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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12
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Gaba P, O'Donoghue ML, Park JG, Wiviott SD, Atar D, Kuder JF, Im K, Murphy SA, De Ferrari GM, Gaciong ZA, Toth K, Gouni-Berthold I, Lopez-Miranda J, Schiele F, Mach F, Flores-Arredondo JH, López JAG, Elliott-Davey M, Wang B, Monsalvo ML, Abbasi S, Giugliano RP, Sabatine MS. Association Between Achieved Low-Density Lipoprotein Cholesterol Levels and Long-Term Cardiovascular and Safety Outcomes: An Analysis of FOURIER-OLE. Circulation 2023; 147:1192-1203. [PMID: 36779348 DOI: 10.1161/circulationaha.122.063399] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [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: 02/14/2023]
Abstract
BACKGROUND Low-density lipoprotein cholesterol (LDL-C) level is a well-established risk factor for atherosclerotic cardiovascular disease. However, the optimal achieved LDL-C level with regard to efficacy and safety in the long term remains unknown. METHODS In FOURIER (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk), 27 564 patients with stable atherosclerotic cardiovascular disease were randomized to evolocumab versus placebo, with a median follow-up of 2.2 years. In the open-label extension (FOURIER-OLE), 6635 of these patients were transitioned to open-label evolocumab regardless of initial treatment allocation in the parent trial and were followed up with for an additional median of 5 years. In this prespecified analysis, we examined the relationship between achieved LDL-C levels (an average of the first 2 LDL-C levels measured) in FOURIER-OLE (available in 6559 patients) and the incidence of subsequent cardiovascular and safety outcomes. We also performed sensitivity analyses evaluating cardiovascular and safety outcomes in the entire FOURIER and FOURIER-OLE patient population. Multivariable modeling was used to adjust for baseline factors associated with achieved LDL-C levels. RESULTS In FOURIER-OLE, 1604 (24%), 2627 (40%), 1031 (16%), 486 (7%), and 811 (12%) patients achieved LDL-C levels of <20, 20 to <40, 40 to <55, 55 to <70, and ≥70 mg/dL, respectively. There was a monotonic relationship between lower achieved LDL-C levels-down to very low levels <20 mg/dL-and a lower risk of the trial's primary efficacy end point (composite of cardiovascular death, myocardial infarction, stroke, or hospital admission for unstable angina or coronary revascularization) and the key secondary efficacy end point (composite of cardiovascular death, myocardial infarction, or stroke) that persisted after multivariable adjustment (adjusted Ptrend<0.0001 for both end points). No statistically significant associations existed in the primary analyses between lower achieved LDL-C levels and increased risk of the safety outcomes (serious adverse events, new or recurrent cancer, cataract-related adverse events, hemorrhagic stroke, new-onset diabetes, neurocognitive adverse events, muscle-related events, or noncardiovascular death). Similar findings were noted in the entire FOURIER and FOURIER-OLE cohort up to a maximum follow-up of 8.6 years. CONCLUSIONS In patients with atherosclerotic cardiovascular disease, long-term achievement of lower LDL-C levels, down to <20 mg/dL (<0.5 mmol/L), was associated with a lower risk of cardiovascular outcomes with no significant safety concerns. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01764633.
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Affiliation(s)
- Prakriti Gaba
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Michelle L O'Donoghue
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Jeong-Gun Park
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Dan Atar
- Division of Medicine, University of Oslo, Norway (D.A.)
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - KyungAh Im
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Gaetano M De Ferrari
- Department of Medical Sciences, University of Turin and Department of Cardiology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza, Turin, Italy (G.M.D.)
| | - Zbigniew A Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, The Medical University of Warsaw, Poland (Z.A.G.)
| | - Kalman Toth
- 1st Department of Medicine, University of Pécs, Medical School, Hungary (K.T.)
| | - Ioanna Gouni-Berthold
- University of Cologne, Center for Endocrinology, Diabetes, and Preventative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Germany (I.G.-B.)
| | - Jose Lopez-Miranda
- Lipids and Atherosclerosis Unit, Maimonides Biomedical Research Institute of Cordoba, Reina Sofia University Hospital, University of Cordoba, CIBEROBN, Spain (J.L.-M.)
| | | | - François Mach
- Cardiology Department, Geneva University Hospital, Switzerland (F.M.)
| | | | - J Antonio G López
- Amgen Inc, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., M.E.-D., B.W., M.L.M., S.A.)
| | - Mary Elliott-Davey
- Amgen Inc, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., M.E.-D., B.W., M.L.M., S.A.)
| | - Bei Wang
- Amgen Inc, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., M.E.-D., B.W., M.L.M., S.A.)
| | | | - Siddique Abbasi
- Amgen Inc, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., M.E.-D., B.W., M.L.M., S.A.)
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (P.G., M.L.O., J.-G.P., S.D.W., J.F.K., K.I., S.A.M., R.P.G., M.S.S.)
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Kato ET, Morrow DA, Guo J, Berg DD, Blazing MA, Bohula EA, Bonaca MP, Cannon CP, de Lemos JA, Giugliano RP, Jarolim P, Kempf T, Kristin Newby L, O'Donoghue ML, Pfeffer MA, Rifai N, Wiviott SD, Wollert KC, Braunwald E, Sabatine MS. Growth differentiation factor 15 and cardiovascular risk: individual patient meta-analysis. Eur Heart J 2023; 44:293-300. [PMID: 36303404 PMCID: PMC10066747 DOI: 10.1093/eurheartj/ehac577] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 08/23/2022] [Accepted: 09/29/2022] [Indexed: 01/25/2023] Open
Abstract
AIMS Levels of growth differentiation factor 15 (GDF-15), a cytokine secreted in response to cellular stress and inflammation, have been associated with multiple types of cardiovascular (CV) events. However, its comparative prognostic performance across different presentations of atherosclerotic cardiovascular disease (ASCVD) remains unknown. METHODS AND RESULTS An individual patient meta-analysis was performed using data pooled from eight trials including 53 486 patients. Baseline GDF-15 concentration was analyzed as a continuous variable and using established cutpoints (<1200 ng/L, 1200-1800 ng/L, > 1800 ng/L) to evaluate its prognostic performance for CV death/hospitalization for heart failure (HHF), major adverse cardiovascular events (MACE), and their components using Cox models adjusted for clinical variables and established CV biomarkers. Analyses were further stratified on ASCVD status: acute coronary syndrome (ACS), stabilized after recent ACS, and stable ASCVD. Overall, higher GDF-15 concentration was significantly and independently associated with an increased rate of CV death/HHF and MACE (P < 0.001 for each). However, while GDF-15 showed a robust and consistent independent association with CV death and HHF across all presentations of ASCVD, its prognostic association with future myocardial infarction (MI) and stroke only remained significant in patients stabilized after recent ACS or with stable ASCVD [hazard ratio (HR): 1.24, 95% confidence interval (CI): 1.17-1.31 and HR: 1.16, 95% CI: 1.05-1.28 for MI and stroke, respectively] and not in ACS (HR: 0.98, 95% CI: 0.90-1.06 and HR: 0.87, 95% CI: 0.39-1.92, respectively). CONCLUSION Growth differentiation factor 15 consistently adds prognostic information for CV death and HHF across the spectrum of ASCVD. GDF-15 also adds prognostic information for MI and stroke beyond clinical risk factors and cardiac biomarkers but not in the setting of ACS.
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Affiliation(s)
- Eri Toda Kato
- Department of Cardiovascular Medicine and Department of Clinical Laboratory, Kyoto University Hospital, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - David A Morrow
- TIMI Study Group, 60 Fenwood Road, 7th floor, Boston, MA 02115, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Jianping Guo
- TIMI Study Group, 60 Fenwood Road, 7th floor, Boston, MA 02115, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - David D Berg
- TIMI Study Group, 60 Fenwood Road, 7th floor, Boston, MA 02115, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Michael A Blazing
- Duke Clinical Research Institute, Duke University, 300 W. Morris Street, Durham, NC 27701, USA
| | - Erin A Bohula
- TIMI Study Group, 60 Fenwood Road, 7th floor, Boston, MA 02115, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Marc P Bonaca
- Cardiovascular Division, Department of Medicine, University of Colorado School of Medicine, 13001 East 17th PIace, Aurora, CO 80045, USA
| | - Christopher P Cannon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9003, USA
| | - Robert P Giugliano
- TIMI Study Group, 60 Fenwood Road, 7th floor, Boston, MA 02115, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Tibor Kempf
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str, 1. D-30625 Hannover, Germany
| | - L Kristin Newby
- Duke Clinical Research Institute, Duke University, 300 W. Morris Street, Durham, NC 27701, USA
| | - Michelle L O'Donoghue
- TIMI Study Group, 60 Fenwood Road, 7th floor, Boston, MA 02115, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Nader Rifai
- Department of Pathology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Stephen D Wiviott
- TIMI Study Group, 60 Fenwood Road, 7th floor, Boston, MA 02115, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Kai C Wollert
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str, 1. D-30625 Hannover, Germany
| | - Eugene Braunwald
- TIMI Study Group, 60 Fenwood Road, 7th floor, Boston, MA 02115, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Marc S Sabatine
- TIMI Study Group, 60 Fenwood Road, 7th floor, Boston, MA 02115, USA.,Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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14
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Pollack R, Raz I, Wiviott SD, Goodrich EL, Murphy SA, Yanuv I, Rozenberg A, Mosenzon O, Langkilde AM, Gause-Nilsson IAM, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Sabatine MS, Cahn A. Efficacy and Safety of Dapagliflozin by Baseline Insulin Regimen and Dose: Post Hoc Analyses From DECLARE-TIMI 58. Diabetes Care 2023; 46:156-164. [PMID: 36399721 DOI: 10.2337/dc22-1318] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The cardiorenal benefits of adding sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy for patients on insulin, particularly those on intensive regimens that include short-acting (SA) insulin, have not been explored. RESEARCH DESIGN AND METHODS In Dapagliflozin Effect on Cardiovascular Events trial (DECLARE-TIMI 58), 17,160 patients with type 2 diabetes were randomized to dapagliflozin or placebo for a median follow-up of 4.2 years. Cardiovascular (CV), renal, metabolic, and safety outcomes with dapagliflozin versus placebo by insulin dose and regimen were studied with Cox regression models. RESULTS The study included 7,013 insulin users at baseline, with 4,650 (66.3%) patients on regimens including SA insulin. Insulin doses varied, with 2,443 (34.8%) patients receiving <0.5 IU/kg, 2,795 (39.9%) 0.5 to ≤1 IU/kg, and 1,339 (19.1%) >1 IU/kg. Dapagliflozin reduced CV death/hospitalization for heart failure among overall insulin users (hazard ratio [HR] 0.82 [95% CI 0.69-0.97]) and consistently in patients on insulin regimens with or without SA insulin (0.83 [0.67-1.03] and 0.78 [0.57-1.07], respectively, Pinteraction = 0.75). No heterogeneity was observed by insulin dose (Pinteraction = 0.43). The HR for major adverse CV events with dapagliflozin among insulin users (0.84 [0.74-0.97]) was similar irrespective of regimen or dose (Pinteraction = 0.75 and 0.07). Dapagliflozin reduced the rate of adverse renal outcomes overall and consistently across subgroups of insulin users. Decreases in HbA1c, weight, and systolic blood pressure with dapagliflozin were seen regardless of insulin dose or regimen. The known safety profile of dapagliflozin was unchanged in patients on intensive insulin regimens. CONCLUSIONS The benefits and safety of dapagliflozin were maintained in high-risk patients receiving high-dose or intensive insulin regimens including SA insulin.
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Affiliation(s)
- Rena Pollack
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Erica L Goodrich
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | | | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
- Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, U.K
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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15
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Baigent C, Emberson J, Haynes R, Herrington WG, Judge P, Landray MJ, Mayne KJ, Ng SY, Preiss D, Roddick AJ, Staplin N, Zhu D, Anker SD, Bhatt DL, Brueckmann M, Butler J, Cherney DZ, Green JB, Hauske SJ, Haynes R, Heerspink HJ, Herrington WG, Inzucchi SE, Jardine MJ, Liu CC, Mahaffey KW, McCausland FR, McGuire DK, McMurray JJ, Neal B, Neuen BL, Packer M, Perkovic V, Sabatine MS, Solomon SD, Vaduganathan M, Wanner C, Wheeler DC, Wiviott SD, Zannad F. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials. Lancet 2022; 400:1788-1801. [PMID: 36351458 PMCID: PMC7613836 DOI: 10.1016/s0140-6736(22)02074-8] [Citation(s) in RCA: 200] [Impact Index Per Article: 100.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Large trials have shown that sodium glucose co-transporter-2 (SGLT2) inhibitors reduce the risk of adverse kidney and cardiovascular outcomes in patients with heart failure or chronic kidney disease, or with type 2 diabetes and high risk of atherosclerotic cardiovascular disease. None of the trials recruiting patients with and without diabetes were designed to assess outcomes separately in patients without diabetes. METHODS We did a systematic review and meta-analysis of SGLT2 inhibitor trials. We searched the MEDLINE and Embase databases for trials published from database inception to Sept 5, 2022. SGLT2 inhibitor trials that were double-blind, placebo-controlled, performed in adults (age ≥18 years), large (≥500 participants per group), and at least 6 months in duration were included. Summary-level data used for analysis were extracted from published reports or provided by trial investigators, and inverse-variance-weighted meta-analyses were conducted to estimate treatment effects. The main efficacy outcomes were kidney disease progression (standardised to a definition of a sustained ≥50% decrease in estimated glomerular filtration rate [eGFR] from randomisation, a sustained low eGFR, end-stage kidney disease, or death from kidney failure), acute kidney injury, and a composite of cardiovascular death or hospitalisation for heart failure. Other outcomes were death from cardiovascular and non-cardiovascular disease considered separately, and the main safety outcomes were ketoacidosis and lower limb amputation. This study is registered with PROSPERO, CRD42022351618. FINDINGS We identified 13 trials involving 90 413 participants. After exclusion of four participants with uncertain diabetes status, we analysed 90 409 participants (74 804 [82·7%] participants with diabetes [>99% with type 2 diabetes] and 15 605 [17·3%] without diabetes; trial-level mean baseline eGFR range 37-85 mL/min per 1·73 m2). Compared with placebo, allocation to an SGLT2 inhibitor reduced the risk of kidney disease progression by 37% (relative risk [RR] 0·63, 95% CI 0·58-0·69) with similar RRs in patients with and without diabetes. In the four chronic kidney disease trials, RRs were similar irrespective of primary kidney diagnosis. SGLT2 inhibitors reduced the risk of acute kidney injury by 23% (0·77, 0·70-0·84) and the risk of cardiovascular death or hospitalisation for heart failure by 23% (0·77, 0·74-0·81), again with similar effects in those with and without diabetes. SGLT2 inhibitors also reduced the risk of cardiovascular death (0·86, 0·81-0·92) but did not significantly reduce the risk of non-cardiovascular death (0·94, 0·88-1·02). For these mortality outcomes, RRs were similar in patients with and without diabetes. For all outcomes, results were broadly similar irrespective of trial mean baseline eGFR. Based on estimates of absolute effects, the absolute benefits of SGLT2 inhibition outweighed any serious hazards of ketoacidosis or amputation. INTERPRETATION In addition to the established cardiovascular benefits of SGLT2 inhibitors, the randomised data support their use for modifying risk of kidney disease progression and acute kidney injury, not only in patients with type 2 diabetes at high cardiovascular risk, but also in patients with chronic kidney disease or heart failure irrespective of diabetes status, primary kidney disease, or kidney function. FUNDING UK Medical Research Council and Kidney Research UK.
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16
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Bohula EA, Berg DD, Lopes MS, Connors JM, Babar I, Barnett CF, Chaudhry SP, Chopra A, Ginete W, Ieong MH, Katz JN, Kim EY, Kuder JF, Mazza E, McLean D, Mosier JM, Moskowitz A, Murphy SA, O’Donoghue ML, Park JG, Prasad R, Ruff CT, Shahrour MN, Sinha SS, Wiviott SD, Van Diepen S, Zainea M, Baird-Zars V, Sabatine MS, Morrow DA. Anticoagulation and Antiplatelet Therapy for Prevention of Venous and Arterial Thrombotic Events in Critically Ill Patients With COVID-19: COVID-PACT. Circulation 2022; 146:1344-1356. [PMID: 36036760 PMCID: PMC9624238 DOI: 10.1161/circulationaha.122.061533] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The efficacy and safety of prophylactic full-dose anticoagulation and antiplatelet therapy in critically ill COVID-19 patients remain uncertain. METHODS COVID-PACT (Prevention of Arteriovenous Thrombotic Events in Critically-ill COVID-19 Patients Trial) was a multicenter, 2×2 factorial, open-label, randomized-controlled trial with blinded end point adjudication in intensive care unit-level patients with COVID-19. Patients were randomly assigned to a strategy of full-dose anticoagulation or standard-dose prophylactic anticoagulation. Absent an indication for antiplatelet therapy, patients were additionally randomly assigned to either clopidogrel or no antiplatelet therapy. The primary efficacy outcome was the hierarchical composite of death attributable to venous or arterial thrombosis, pulmonary embolism, clinically evident deep venous thrombosis, type 1 myocardial infarction, ischemic stroke, systemic embolic event or acute limb ischemia, or clinically silent deep venous thrombosis, through hospital discharge or 28 days. The primary efficacy analyses included an unmatched win ratio and time-to-first event analysis while patients were on treatment. The primary safety outcome was fatal or life-threatening bleeding. The secondary safety outcome was moderate to severe bleeding. Recruitment was stopped early in March 2022 (≈50% planned recruitment) because of waning intensive care unit-level COVID-19 rates. RESULTS At 34 centers in the United States, 390 patients were randomly assigned between anticoagulation strategies and 292 between antiplatelet strategies (382 and 290 in the on-treatment analyses). At randomization, 99% of patients required advanced respiratory therapy, including 15% requiring invasive mechanical ventilation; 40% required invasive ventilation during hospitalization. Comparing anticoagulation strategies, a greater proportion of wins occurred with full-dose anticoagulation (12.3%) versus standard-dose prophylactic anticoagulation (6.4%; win ratio, 1.95 [95% CI, 1.08-3.55]; P=0.028). Results were consistent in time-to-event analysis for the primary efficacy end point (full-dose versus standard-dose incidence 19/191 [9.9%] versus 29/191 [15.2%]; hazard ratio, 0.56 [95% CI, 0.32-0.99]; P=0.046). The primary safety end point occurred in 4 (2.1%) on full dose and in 1 (0.5%) on standard dose (P=0.19); the secondary safety end point occurred in 15 (7.9%) versus 1 (0.5%; P=0.002). There was no difference in all-cause mortality (hazard ratio, 0.91 [95% CI, 0.56-1.48]; P=0.70). There were no differences in the primary efficacy or safety end points with clopidogrel versus no antiplatelet therapy. CONCLUSIONS In critically ill patients with COVID-19, full-dose anticoagulation, but not clopidogrel, reduced thrombotic complications with an increase in bleeding, driven primarily by transfusions in hemodynamically stable patients, and no apparent excess in mortality. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04409834.
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Affiliation(s)
- Erin A. Bohula
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - David D. Berg
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Mathew S. Lopes
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jean M. Connors
- Hematology Division (J.M.C.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Ijlal Babar
- Singing River Health System, Ocean Springs, MS (I.B.)
| | | | | | - Amit Chopra
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, NY (A.C.)
| | - Wilson Ginete
- Essentia Health St. Mary’s Medical Center, Duluth, MN (W.G.)
| | - Michael H. Ieong
- The Pulmonary Center, Boston University School of Medicine, MA (M.H.I.)
| | - Jason N. Katz
- Division of Cardiovascular Medicine, Duke University School of Medicine, Durham, NC (J.N.K.)
| | - Edy Y. Kim
- Pulmonary and Critical Care Medicine Division (E.Y.K.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Julia F. Kuder
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Dalton McLean
- Moses H. Cone Memorial Hospital, Greensboro, NC (D.M.)
| | - Jarrod M. Mosier
- Department of Emergency Medicine and Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, The University of Arizona College of Medicine, Tucson (J.M.M.)
| | - Ari Moskowitz
- Beth Israel Deaconess Medical Center, Boston, MA (A.M.)
| | - Sabina A. Murphy
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Michelle L. O’Donoghue
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Christian T. Ruff
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA (S.S.S.)
| | - Stephen D. Wiviott
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Sean Van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.V.D.)
| | | | - Vivian Baird-Zars
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Marc S. Sabatine
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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17
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O'Donoghue ML, Giugliano RP, Wiviott SD, Atar D, Keech A, Kuder JF, Im K, Murphy SA, Flores-Arredondo JH, López JAG, Elliott-Davey M, Wang B, Monsalvo ML, Abbasi S, Sabatine MS. Long-Term Evolocumab in Patients With Established Atherosclerotic Cardiovascular Disease. Circulation 2022; 146:1109-1119. [PMID: 36031810 DOI: 10.1161/circulationaha.122.061620] [Citation(s) in RCA: 108] [Impact Index Per Article: 54.0] [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] [Indexed: 01/24/2023]
Abstract
BACKGROUND In FOURIER (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk), the proprotein convertase subtilisin-kexin type 9 inhibitor evolocumab reduced low-density lipoprotein cholesterol (LDL-C) and risk of cardiovascular events and was safe and well tolerated over a median of 2.2 years of follow-up. However, large-scale, long-term data are lacking. METHODS The parent FOURIER trial randomized 27 564 patients with atherosclerotic cardiovascular disease and LDL-C ≥70 mg/dL on statin to evolocumab versus placebo. Patients completing FOURIER at participating sites were eligible to receive evolocumab in 2 open-label extension studies (FOURIER-OLE [FOURIER Open-Label Extension]) in the United States and Europe; primary analyses were pooled across studies. The primary end point was the incidence of adverse events. Lipid values and major adverse cardiovascular events were prospectively collected. RESULTS A total of 6635 patients were enrolled in FOURIER-OLE (3355 randomized to evolocumab and 3280 to placebo in the parent study). Median follow-up in FOURIER-OLE was 5.0 years; maximum exposure to evolocumab in parent plus FOURIER-OLE was 8.4 years. At 12 weeks in FOURIER-OLE, median LDL-C was 30 mg/dL, and 63.2% of patients achieved LDL-C <40 mg/dL on evolocumab. Incidences of serious adverse events, muscle-related events, new-onset diabetes, hemorrhagic stroke, and neurocognitive events with evolocumab long term did not exceed those for placebo-treated patients during the parent study and did not increase over time. During the FOURIER-OLE follow-up period, patients originally randomized in the parent trial to evolocumab versus placebo had a 15% lower risk of cardiovascular death, myocardial infarction, stroke, or hospitalization for unstable angina or coronary revascularization (hazard ratio, 0.85 [95% CI, 0.75-0.96]; P=0.008); a 20% lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80 [95% CI, 0.68-0.93]; P=0.003); and a 23% lower risk of cardiovascular death (hazard ratio, 0.77 [95% CI, 0.60-0.99]; P=0.04). CONCLUSIONS Long-term LDL-C lowering with evolocumab was associated with persistently low rates of adverse events for >8 years that did not exceed those observed in the original placebo arm during the parent study and led to further reductions in cardiovascular events compared with delayed treatment initiation. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifiers: NCT02867813 and NCT03080935.
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Affiliation(s)
- Michelle L O'Donoghue
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Norway (D.A.)
- Institute of Clinical Medicine, University of Oslo, Norway (D.A.)
| | - Anthony Keech
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - Julia F Kuder
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - KyungAh Im
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
| | | | - J Antonio G López
- Global Development, Amgen, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., B.W., M.L.M., S.A.)
| | | | - Bei Wang
- Global Development, Amgen, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., B.W., M.L.M., S.A.)
| | - Maria Laura Monsalvo
- Global Development, Amgen, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., B.W., M.L.M., S.A.)
| | - Siddique Abbasi
- Global Development, Amgen, Thousand Oaks, CA (J.H.F.-A., J.A.G.L., B.W., M.L.M., S.A.)
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.L.O., R.P.G., S.D.W., J.F.K., K.I., S.A.M., M.S.S.)
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18
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Mosenzon O, Raz I, Wiviott SD, Schechter M, Goodrich EL, Yanuv I, Rozenberg A, Murphy SA, Zelniker TA, Langkilde AM, Gause-Nilsson IAM, Fredriksson M, Johansson PA, Wilding JPH, McGuire DK, Bhatt DL, Leiter LA, Cahn A, Dwyer JP, Heerspink HJL, Sabatine MS. Dapagliflozin and Prevention of Kidney Disease Among Patients With Type 2 Diabetes: Post Hoc Analyses From the DECLARE-TIMI 58 Trial. Diabetes Care 2022; 45:2350-2359. [PMID: 35997319 PMCID: PMC9862307 DOI: 10.2337/dc22-0382] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/05/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE In patients with moderate to severe albuminuric kidney disease, sodium-glucose cotransporter 2 inhibitors reduce the risk of kidney disease progression. These post hoc analyses assess the effects of dapagliflozin on kidney function decline in patients with type 2 diabetes (T2D), focusing on populations with low kidney risk. RESEARCH DESIGN AND METHODS In the Dapagliflozin Effect on Cardiovascular Events-Thrombolysis in Myocardial Infarction 58 (DECLARE-TIMI 58) trial, patients with T2D at high cardiovascular risk were randomly assigned to dapagliflozin versus placebo. Outcomes were analyzed by treatment arms, overall, and by Kidney Disease: Improving Global Outcomes (KDIGO) risk categories. The prespecified kidney-specific composite outcome was a sustained decline ≥40% in the estimated glomerular filtration rate (eGFR) to <60 mL/min/1.73 m2, end-stage kidney disease, and kidney-related death. Other outcomes included incidence of categorical eGFR decline of different thresholds and chronic (6 month to 4 year) or total (baseline to 4 year) eGFR slopes. RESULTS Most participants were in the low-moderate KDIGO risk categories (n = 15,201 [90.3%]). The hazard for the kidney-specific composite outcome was lower with dapagliflozin across all KDIGO risk categories (P-interaction = 0.97), including those at low risk (hazard ratio [HR] 0.54, 95% CI 0.38-0.77). Risks for categorical eGFR reductions (≥57% [in those with baseline eGFR ≥60 mL/min/1.73 m2], ≥50%, ≥40%, and ≥30%) were lower with dapagliflozin (HRs 0.52, 0.57, 0.55, and 0.70, respectively; P < 0.05). Slopes of eGFR decline favored dapagliflozin across KDIGO risk categories, including the low KDIGO risk (between-arm differences of 0.87 [chronic] and 0.55 [total] mL/min/1.73 m2/year; P < 0.0001). CONCLUSIONS Dapagliflozin mitigated kidney function decline in patients with T2D at high cardiovascular risk, including those with low KDIGO risk, suggesting a role of dapagliflozin in the early prevention of diabetic kidney disease.
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Affiliation(s)
- Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Thomas A Zelniker
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, U.K
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX.,Parkland Health and Hospital System, Dallas, TX
| | | | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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19
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Bonaca MP, Antman EM, Cunningham JW, Wiviott SD, Murphy SA, Halperin JL, Weitz JI, Grosso MA, Lanz HJ, Braunwald E, Giugliano RP, Ruff CT. Ischaemic and bleeding risk in atrial fibrillation with and without peripheral artery disease and efficacy and safety of full- and half-dose edoxaban vs. warfarin: insights from ENGAGE AF-TIMI 48. Eur Heart J Cardiovasc Pharmacother 2022; 8:695-706. [PMID: 34962979 DOI: 10.1093/ehjcvp/pvab089] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 10/13/2021] [Revised: 10/29/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
AIMS In patients with atrial fibrillation (AF), peripheral artery disease (PAD) is associated with higher rates of stroke and bleeding. Both higher dose edoxaban (60/30 mg) and lower dose edoxaban (30/15 mg) were non-inferior to warfarin for stroke and systemic embolism (SSE) and significantly reduced major bleeding in AF patients in the global study to assess the safety and effectiveness of edoxaban vs standard practice of dosing with warfarin in patients with atrial fibrillation (ENGAGE AF-TIMI 48) trial. Whether the efficacy and safety of these dosing strategies vs. warfarin are consistent in patients with AF and PAD has not been described. METHODS AND RESULTS Of 21 105 patients with AF randomized to warfarin, edoxaban 60/30 mg, or edoxaban 30/15 mg, 841 were identified with PAD. Endpoints included major adverse cardiovascular events (MACEs), SSE, and major bleeding. Patients with PAD had higher risk of MACEs [adjusted hazard ratio (HRadj) 1.33, 95% confidence interval (CI) 1.12-1.57, P = 0.001] and cardiovascular (CV) death (HRadj 1.49, 95% CI 1.21-1.83, P < 0.001) than those without PAD, but not major bleeding. The efficacy of edoxaban 60/30 mg vs. warfarin was consistent regardless of PAD (SSE HR; PAD 1.16, 95% CI 0.42-3.20; no-PAD 0.86, 95% CI 0.74-1.02, P-interaction 0.57) as was major bleeding (PAD 0.96, 95% CI 0.54-1.70; no-PAD 0.80, 95% CI 0.70-0.91, P-interaction 0.54). Edoxaban 30/15 mg was inferior for SSE, with significant heterogeneity when stratified by PAD status (P-interaction 0.039). CONCLUSION Patients with AF and PAD are at heightened risk of MACEs and CV death vs. those without PAD. The efficacy and safety of edoxaban 60/30 mg vs. warfarin in AF are consistent regardless of PAD; however, edoxaban 30/15 mg is inferior for stroke prevention in AF patients with PAD. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT00781391.
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Affiliation(s)
- Marc P Bonaca
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- CPC Clinical Research, University of Colorado School of Medicine, 13199 E. Montview Blvd., Suite 200, Aurora, CO 80045, USA
| | - Elliott M Antman
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan W Cunningham
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jonathan L Halperin
- Cardiovascular Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | | | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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20
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Oyama K, Raz I, Cahn A, Goodrich EL, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Mosenzon O, Sabatine MS, Wiviott SD. Efficacy and Safety of Dapagliflozin According to Background Use of Cardiovascular Medications in Patients With Type 2 Diabetes: A Prespecified Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol 2022; 7:914-923. [PMID: 35857296 DOI: 10.1001/jamacardio.2022.2006] [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 Dapagliflozin was shown to reduce the cardiovascular (CV) and kidney outcomes in patients with type 2 diabetes. However, data are limited on the relationship of the effect and safety with the concurrent use of CV medications in patients with type 2 diabetes. Objective To assess whether the cardiorenal efficacy and safety of dapagliflozin were consistent with and without background use of CV medications commonly used for heart failure (HF) and kidney disease in patients with type 2 diabetes. Design, Setting, and Participants This study is a prespecified secondary analysis of DECLARE-TIMI 58, which was a randomized trial of dapagliflozin vs placebo in 17 160 patients with type 2 diabetes and either atherosclerotic disease or multiple risk factors for CV disease. Patients were stratified by baseline use of the following CV medications: angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers (ACEI/ARBs), β-blockers, diuretics, and mineralocorticoid receptor antagonists (MRAs). The study was conducted from May 2013 to September 2018, and data were evaluated for this analysis from February 2021 to May 2022. Interventions Dapagliflozin or placebo. Main Outcomes and Measures The outcomes of interest were the composite of CV death or hospitalization for HF (HHF), HHF alone, and a kidney-specific composite outcome (persistent ≥40% decrease in estimated glomerular filtration rate [eGFR], end-stage kidney disease, or kidney-related death). Results Among 17 160 patients, 13 950 (81%) used ACEI/ARBs, 9030 (53%) used β-blockers, 6205 (36%) used diuretics, and 762 (4%) used MRAs at baseline. Changes in blood pressure and eGFR at 48 months with dapagliflozin compared with placebo did not differ regardless of concurrent therapy (placebo-corrected change, -1.6 mm Hg [95% CI, -4.2 to 1.0] to -2.6 mm Hg [95% CI, -3.3 to -2.9]; P > .05 for each interaction). Dapagliflozin consistently reduced the risk of CV death/HHF, HHF alone, and the kidney-specific composite outcome regardless of background use of selected medications (hazard ratio [HR] range: HR, 0.50; 95% CI, 0.39-0.63; to HR, 0.82; 95% CI, 0.72-0.95; P > .05 for each interaction). In patients receiving ACEI/ARBs + β-blockers + diuretics (n = 4243), dapagliflozin reduced the risk of CV death/HHF and of the kidney-specific outcome by 24% (HR, 0.76; 95% CI, 0.62-0.93) and 38% (HR, 0.62; 95% CI, 0.44-0.87), respectively. There were no significant treatment interactions with the concomitant CV medications for adverse events of volume depletion, acute kidney injury, or hyperkalemia (range: HR, 0.12; 95% CI, 0.02-0.99; to HR, 1.04; 95% CI, 0.83-1.32; P > .05 for each interaction). Conclusions and Relevance Dapagliflozin consistently reduced the risk of CV and kidney outcomes irrespective of background use of various CV medications without any treatment interaction for key safety events. These data show the clinical benefit and safety of dapagliflozin in a broad range of patients with type 2 diabetes regardless of background therapy. Trial Registration ClinicalTrials.gov Identifier: NCT01730534.
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Affiliation(s)
- Kazuma Oyama
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, United Kingdom
| | | | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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21
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Neuen BL, Oshima M, Agarwal R, Arnott C, Cherney DZ, Edwards R, Langkilde AM, Mahaffey KW, McGuire DK, Neal B, Perkovic V, Pong A, Sabatine MS, Raz I, Toyama T, Wanner C, Wheeler DC, Wiviott SD, Zinman B, Heerspink HJL. Sodium-Glucose Cotransporter 2 Inhibitors and Risk of Hyperkalemia in People With Type 2 Diabetes: A Meta-Analysis of Individual Participant Data From Randomized, Controlled Trials. Circulation 2022; 145:1460-1470. [PMID: 35394821 DOI: 10.1161/circulationaha.121.057736] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [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: 12/12/2022]
Abstract
BACKGROUND Hyperkalemia increases risk of cardiac arrhythmias and death and limits the use of renin-angiotensin-aldosterone system inhibitors and mineralocorticoid receptor antagonists, which improve clinical outcomes in people with chronic kidney disease or systolic heart failure. Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of cardiorenal events in people with type 2 diabetes at high cardiovascular risk or with chronic kidney disease. However, their effect on hyperkalemia has not been systematically evaluated. METHODS A meta-analysis was conducted using individual participant data from randomized, double-blind, placebo-controlled clinical outcome trials with SGLT2 inhibitors in people with type 2 diabetes at high cardiovascular risk or with chronic kidney disease in whom serum potassium levels were routinely measured. The primary outcome was time to serious hyperkalemia, defined as central laboratory-determined serum potassium ≥6.0 mmol/L, with other outcomes including investigator-reported hyperkalemia events and hypokalemia (serum potassium ≤3.5 mmol/L). Cox regression analyses were performed to estimate treatment effects from each trial with hazards ratios and corresponding 95% CIs pooled with random-effects models to obtain summary treatment effects, overall and across key subgroups. RESULTS Results from 6 trials were included comprising 49 875 participants assessing 4 SGLT2 inhibitors. Of these, 1754 participants developed serious hyperkalemia, and an additional 1119 investigator-reported hyperkalemia events were recorded. SGLT2 inhibitors reduced the risk of serious hyperkalemia (hazard ratio, 0.84 [95% CI, 0.76-0.93]), an effect consistent across studies (Pheterogeneity=0.71). The incidence of investigator-reported hyperkalemia was also lower with SGLT2 inhibitors (hazard ratio, 0.80 [95% CI, 0.68-0.93]; Pheterogeneity=0.21). Reductions in serious hyperkalemia were observed across a range of subgroups, including baseline kidney function, history of heart failure, and use of renin-angiotensin-aldosterone system inhibitor, diuretic, and mineralocorticoid receptor antagonist. SGLT2 inhibitors did not increase the risk of hypokalemia (hazard ratio, 1.04 [95% CI, 0.94-1.15]; Pheterogeneity=0.42). CONCLUSIONS SGLT2 inhibitors reduce the risk of serious hyperkalemia in people with type 2 diabetes at high cardiovascular risk or with chronic kidney disease without increasing the risk of hypokalemia.
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Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., C.A.)
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Japan (M.O., T.T.)
| | - Rajiv Agarwal
- Indiana University School of Medicine and VA Medical Center, Indianapolis (R.A.)
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (B.L.N., C.A.).,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.A.).,Sydney Medical School, University of Sydney, Australia (C.A.)
| | - David Z Cherney
- Department of Medicine and Department of Physiology, Division of Nephrology, University Health Network, University of Toronto, Ontario, Canada (D.Z.C.)
| | | | | | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Darren K McGuire
- Department of Internal Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas (D.K.M.)
| | - Bruce Neal
- The Charles Perkins Centre, University of Sydney, Australia (B.N.).,Department of Epidemiology and Biostatistics, Imperial College London, UK (B.N.)
| | - Vlado Perkovic
- Faculty of Medicine, University of New South Wales, Sydney, Australia (V.P.)
| | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (M.S.S., S.D.W.)
| | - Itamar Raz
- Diabetes Unit, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel (I.R.)
| | | | - Christoph Wanner
- Division of Nephrology, Department of Medicine, Würzburg University Clinic, Germany (C.W.)
| | - David C Wheeler
- Department of Renal Medicine, UCL Medical School, London, UK (D.C.W.)
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (M.S.S., S.D.W.)
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Ontario, Canada (B.Z.)
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, the Netherlands (H.J.L.H.)
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22
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Furtado RHM, Raz I, Goodrich EL, Murphy SA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Aylward P, Dalby AJ, Dellborg M, Dimulescu D, Nicolau JC, Oude Ophuis AJM, Cahn A, Mosenzon O, Gause-Nilsson I, Langkilde AM, Sabatine MS, Wiviott SD. Efficacy and Safety of Dapagliflozin in Type 2 Diabetes According to Baseline Blood Pressure: Observations From DECLARE-TIMI 58 Trial. Circulation 2022; 145:1581-1591. [PMID: 35510542 DOI: 10.1161/circulationaha.121.058103] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 11/16/2022]
Abstract
Background: Dapagliflozin improved heart failure and kidney outcomes in patients with type 2 diabetes mellitus (T2DM) with or at high risk for cardiovascular disease in the DECLARE-TIMI 58 trial. Here, the aim was to analyze efficacy and safety of dapagliflozin stratified according to baseline systolic blood pressure (SBP). Methods: The DECLARE-TIMI 58 trial randomized patients with T2DM and either prior atherosclerotic cardiovascular disease (ASCVD) or ASCVD risk factors to dapagliflozin or placebo. Patients were categorized by baseline SBP levels: < 120, 120-129, 130-139, 140-159 and ≥ 160 mmHg (respectively, normal, elevated, stage 1, stage 2 and severe hypertension). Efficacy outcomes of interest were hospitalization for heart failure (HHF) and a renal-specific composite outcome (sustained decrease in estimated glomerular filtration rate by 40%, progression to end-stage renal disease or renal death). Safety outcomes included symptoms of volume depletion, lower extremity amputations and acute kidney injury. Results: The trial comprised 17,160 patients; mean age of 64.0 ± 6.8 years ; 37.4% women; median duration of T2DM 11 years; 40.6% with prevalent CVD. Overall, dapagliflozin reduced SBP by 2.4 mmHg (95% CI 1.9-2.9; p < 0.0001) compared with placebo at 48 months. The beneficial effects of dapagliflozin on HHF and renal outcomes were consistent across all baseline SBP categories, with no evidence of modification of treatment effect (p-interactions = 0.28 and 0.52, respectively). Among normotensive patients, the HR´s were 0.66 (95% CI 0.42-1.05) and 0.39 (95% CI 0.19-0.78), respectively for HHF and the renal specific outcome. Events of volume depletion, amputation and acute kidney injury did not differ with dapagliflozin overall or within any baseline SBP group. Conclusions: In patients with T2DM with or at high ASCVD risk, dapagliflozin reduced risk for HHF and renal outcomes regardless of baseline systolic blood pressure, with no difference in adverse events of interest at any level of baseline SBP. These results indicate that dapagliflozin provides important cardiorenal benefit in patients with T2DM at high ASCVD risk, independent of baseline blood pressure.
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Affiliation(s)
- Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil; TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Philip Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | | | - Mikael Dellborg
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Doina Dimulescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - José C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA
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Bergmark BA, Marston NA, Bramson CR, Curto M, Ramos V, Jevne A, Kuder JF, Park JG, Murphy SA, Verma S, Wojakowski W, Terra SG, Sabatine MS, Wiviott SD. Effect of Vupanorsen on Non-High-Density Lipoprotein Cholesterol Levels in Statin-Treated Patients With Elevated Cholesterol: TRANSLATE-TIMI 70. Circulation 2022; 145:1377-1386. [PMID: 35369705 PMCID: PMC9047643 DOI: 10.1161/circulationaha.122.059266] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Genetic loss-of-function variants in ANGPTL3 are associated with lower levels of plasma lipids. Vupanorsen is a hepatically targeted antisense oligonucleotide that inhibits Angiopoietin-like 3 (ANGPTL3) protein synthesis.
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Affiliation(s)
- Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nicholas A Marston
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | | | - Alexandra Jevne
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jeong-Gun Park
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Subodh Verma
- Department of Surgery, University of Toronto, Toronto, Canada
| | | | | | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Cahn A, Wiviott SD, Mosenzon O, Goodrich EL, Murphy SA, Yanuv I, Rozenberg A, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Langkilde AM, Sabatine MS, Raz I. Association of Baseline HbA1c With Cardiovascular and Renal Outcomes: Analyses From DECLARE-TIMI 58. Diabetes Care 2022; 45:938-946. [PMID: 35015847 DOI: 10.2337/dc21-1744] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 08/19/2021] [Accepted: 11/28/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Current guidelines recommend prescribing SGLT2 inhibitors to patients with type 2 diabetes and established or at high risk for atherosclerotic cardiovascular disease (ASCVD), irrespective of HbA1c levels. We studied the association of HbA1c with cardiovascular and renal outcomes and whether the benefit of dapagliflozin varies by baseline HbA1c. RESEARCH DESIGN AND METHODS In the Dapagliflozin Effect on Cardiovascular Events trial (DECLARE-TIMI 58), 17,160 patients with type 2 diabetes were randomly assigned to dapagliflozin or placebo for a median follow-up of 4.2 years. Cardiovascular and renal outcomes by baseline HbA1c in the overall population and with dapagliflozin versus placebo in HbA1c subgroups were studied by Cox regression models. RESULTS In the overall population, higher baseline HbA1c was associated with a higher risk of cardiovascular death or hospitalization for heart failure (HHF); major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction, and ischemic stroke; and cardiorenal outcomes (adjusted hazard ratios 1.12 [95% CI 1.06-1.19], 1.08 [1.04-1.13], and 1.17 [1.11-1.24] per 1% higher level, respectively). Elevated HbA1c was associated with a greater increased risk for MACE and cardiorenal outcomes in patients with multiple risk factors (MRF) than in established ASCVD (P-interaction = 0.0064 and 0.0093, respectively). Compared with placebo, dapagliflozin decreased the risk of cardiovascular death/HHF, HHF, and cardiorenal outcomes, with no heterogeneity by baseline HbA1c (P-interaction > 0.05). CONCLUSIONS Higher HbA1c levels were associated with greater cardiovascular and renal risk, particularly in the MRF population, yet the benefits of dapagliflozin were observed in all subgroups irrespective of baseline HbA1c, including patients with HbA1c <7%.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, U.K
| | | | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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25
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Berg D, Wiviott SD, Raz I, Jarolim P, Goodrich EL, Mosenzon O, Cahn A, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson I, Hammarstedt A, Oscarsson J, Sabatine MS, Morrow DA. FIBROBLAST GROWTH FACTOR-23, CARDIORENAL OUTCOMES, AND EFFICACY OF DAPAGLIFLOZIN IN PATIENTS WITH TYPE 2 DIABETES MELLITUS: AN ANALYSIS FROM DECLARE-TIMI 58. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02517-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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26
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Kolkailah AA, Wiviott SD, Raz I, Murphy SA, Mosenzon O, Bhatt DL, Leiter LA, Wilding JPH, Gause-Nilsson I, Sabatine MS, McGuire DK. Effect of Dapagliflozin on Hematocrit in Patients With Type 2 Diabetes at High Cardiovascular Risk: Observations From DECLARE-TIMI 58. Diabetes Care 2022; 45:e27-e29. [PMID: 35020832 PMCID: PMC8914433 DOI: 10.2337/dc21-1668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 08/10/2021] [Accepted: 11/01/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Ahmed A Kolkailah
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Itamar Raz
- Department of Medicine, Hadassah Hebrew University, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- La Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, U.K
| | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX.,Parkland Health and Hospital System, Dallas, TX
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27
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Berg DD, Wiviott SD, Scirica BM, Zelniker TA, Goodrich EL, Jarolim P, Mosenzon O, Cahn A, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Johanson P, Langkilde AM, Raz I, Braunwald E, Sabatine MS, Morrow DA. A Biomarker-Based Score for Risk of Hospitalization for Heart Failure in Patients With Diabetes. Diabetes Care 2021; 44:2573-2581. [PMID: 34535469 PMCID: PMC8546278 DOI: 10.2337/dc21-1170] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/25/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Heart failure (HF) is an impactful complication of type 2 diabetes mellitus (T2DM). We aimed to develop and validate a risk score for hospitalization for HF (HHF) incorporating biomarkers and clinical factor(s) in patients with T2DM. RESEARCH DESIGN AND METHODS We derived a risk score for HHF using clinical data, high-sensitivity troponin T (hsTnT), and N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) from 6,106 placebo-treated patients with T2DM in SAVOR-TIMI 53 (Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus-Thrombolysis in Myocardial Infarction 53). Candidate variables were assessed using Cox regression. The strongest indicators of HHF risk were included in the score using integer weights. The score was externally validated in 7,251 placebo-treated patients in DECLARE-TIMI 58 (Dapagliflozin Effect on CardiovascuLAR Events-Thrombolysis in Myocardial Infarction 58). The effect of dapagliflozin on HHF was assessed by risk category in DECLARE-TIMI 58. RESULTS The strongest indicators of HHF risk were NT-proBNP, prior HF, and hsTnT (each P < 0.001). A risk score using these three variables identified a gradient of HHF risk (P-trend <0.001) in the derivation and validation cohorts, with C-indices of 0.87 (95% CI, 0.84-0.89) and 0.84 (0.81-0.86), respectively. Whereas there was no significant effect of dapagliflozin versus placebo on HHF in the low-risk group (hazard ratio [HR] 0.98 [95% CI 0.50-1.92]), dapagliflozin significantly reduced HHF in the intermediate-, high-, and very-high-risk groups (HR 0.64 [0.43-0.95], 0.63 [0.43-0.94], and 0.72 [0.54-0.96], respectively). Correspondingly, absolute risk reductions (95% CI) increased across these latter 3 groups: 1.0% (0.0-1.9), 3.0% (0.7-5.3), and 4.4% (-0.2 to 8.9) (P-trend <0.001). CONCLUSIONS We developed and validated a risk score for HHF in T2DM that incorporated NT-proBNP, prior HF, and hsTnT. The risk score identifies patients at higher risk of HHF who derive greater absolute benefit from dapagliflozin.
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Affiliation(s)
- David D Berg
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin M Scirica
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Thomas A Zelniker
- Division of Cardiology, Vienna General Hospital and Medical University of Vienna, Austria
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ofri Mosenzon
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Avivit Cahn
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Darren K McGuire
- University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Aintree University Hospital, University of Liverpool, Liverpool, U.K
| | | | | | - Itamar Raz
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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28
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Oyama K, Raz I, Cahn A, Kuder J, Murphy SA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Park KS, Goudev A, Diaz R, Špinar J, Gause-Nilsson IAM, Mosenzon O, Sabatine MS, Wiviott SD. Obesity and effects of dapagliflozin on cardiovascular and renal outcomes in patients with type 2 diabetes mellitus in the DECLARE-TIMI 58 trial. Eur Heart J 2021; 43:2958-2967. [PMID: 34427295 DOI: 10.1093/eurheartj/ehab530] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/11/2021] [Accepted: 08/02/2021] [Indexed: 01/03/2023] Open
Abstract
AIMS We investigated the associations between obesity, cardiorenal events, and benefits of dapagliflozin in patients with type 2 diabetes mellitus (T2DM). METHODS AND RESULTS DECLARE-TIMI 58 randomized patients with T2DM and either atherosclerotic cardiovascular (CV) disease or multiple risk factors to dapagliflozin vs. placebo. Patients were stratified by body mass index (BMI, kg/m2): normal (18.5 to <25), overweight (25 to <30), moderately obese (30 to <35), severely obese (35 to <40), and very-severely obese (≥40). Outcomes analysed were CV death, hospitalization for heart failure (HHF), renal-specific composite outcome, and atrial fibrillation or flutter (AF/AFL). Of 17 134 patients, 9.0% had a normal BMI, 31.5% were overweight, 32.4% were moderately, 17.2% severely, and 9.8% were very-severely obese. Higher BMI was associated with a higher adjusted risk of HHF and AF/AFL (hazard ratio 1.30 and 1.28, respectively, per 5 kg/m2; P < 0.001 for all). Dapagliflozin reduced body weight by similar relative amounts consistently across BMI categories (percent difference: -1.9 to -2.4%). Although relative risk reductions in CV and renal-specific composite outcomes with dapagliflozin did not significantly differ across the range of BMI (P for interaction ≥0.20 for all outcomes), obese patients (BMI ≥ 30 kg/m2) tended to derive greater absolute risk reduction in HHF and AF/AFL (P for interaction 0.02 and 0.09, respectively) than non-obese patients. CONCLUSIONS In DECLARE-TIMI 58, patients with T2DM and higher BMI were more likely to have HHF and AF/AFL. Whereas relative risk reductions in CV and renal outcomes with dapagliflozin were generally consistent across the range of BMI, absolute risk reduction in obesity-related outcomes including HHF and AF/AFL tended to be larger in obese patients with T2DM. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01730534.
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Affiliation(s)
- Kazuma Oyama
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Kiryat Hadassah 12000, Jerusalem 91200, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Kiryat Hadassah 12000, Jerusalem 91200, Israel
| | - Julia Kuder
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, 36 Queen St. East, Toronto, ON M5B 1W8, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, 5323 Harry Hines Blvd. Dallas, TX 75390, USA
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Kyong-Soo Park
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu Seoul 03080, Republic of Korea
| | - Assen Goudev
- Department of Cardiology, Queen Giovanna University Hospital, 8# Bialo More street, Sofia 1527, Bulgaria
| | - Rafael Diaz
- Estudios Clínicos Latino America, Paraguay 160, Rosario, Santa Fe 2000, Argentina
| | - Jindřich Špinar
- Internal Cardiology Department, St. Ann University Hospital, Masaryk University, Pekařská 53 Brno 65691, Czech Republic
| | | | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Kiryat Hadassah 12000, Jerusalem 91200, Israel
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
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29
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Mosenzon O, Wiviott SD, Heerspink HJL, Dwyer JP, Cahn A, Goodrich EL, Rozenberg A, Schechter M, Yanuv I, Murphy SA, Zelniker TA, Gause-Nilsson IAM, Langkilde AM, Fredriksson M, Johansson PA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Sabatine MS, Raz I. The Effect of Dapagliflozin on Albuminuria in DECLARE-TIMI 58. Diabetes Care 2021; 44:1805-1815. [PMID: 34233928 PMCID: PMC8385472 DOI: 10.2337/dc21-0076] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/14/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve albuminuria in patients with high cardiorenal risk. We report albuminuria change in the Dapagliflozin Effect on Cardiovascular Events (DECLARE-TIMI 58) cardiovascular outcome trial, which included populations with lower cardiorenal risk. RESEARCH DESIGN AND METHODS DECLARE-TIMI 58 randomized 17,160 patients with type 2 diabetes, creatinine clearance >60 mL/min, and either atherosclerotic cardiovascular disease (CVD; 40.6%) or risk-factors for CVD (59.4%) to dapagliflozin or placebo. Urinary albumin-to-creatinine ratio (UACR) was tested at baseline, 6 months, 12 months, and yearly thereafter. The change in UACR over time was measured as a continuous and categorical variable (≤15, >15 to <30, ≥30 to ≤300, and >300 mg/g) by treatment arm. The composite cardiorenal outcome was a ≥40% sustained decline in the estimated glomerular filtration rate (eGFR) to <60 mL/min/1.73 m2, end-stage kidney disease, and cardiovascular or renal death; specific renal outcome included all except cardiovascular death. RESULTS Baseline UACR was available for 16,843 (98.15%) participants: 9,067 (53.83%) with ≤15 mg/g, 2,577 (15.30%) with >15 to <30 mg/g, 4,030 (23.93%) with 30-300 mg/g, and 1,169 (6.94%) with >300 mg/g. Measured as a continuous variable, UACR improved from baseline to 4.0 years with dapagliflozin, compared with placebo, across all UACR and eGFR categories (all P < 0.0001). Sustained confirmed ≥1 category improvement in UACR was more common in dapagliflozin versus placebo (hazard ratio 1.45 [95% CI 1.35-1.56], P < 0.0001). Cardiorenal outcome was reduced with dapagliflozin for subgroups of UACR ≥30 mg/g (P < 0.0125, P interaction = 0.033), and the renal-specific outcome was reduced for all UACR subgroups (P < 0.05, P interaction = 0.480). CONCLUSIONS In DECLARE-TIMI 58, dapagliflozin demonstrated a favorable effect on UACR and renal-specific outcome across baseline UACR categories, including patients with normal albumin excretion. The results suggest a role for SGLT2i also in the primary prevention of diabetic kidney disease.
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Affiliation(s)
- Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel .,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Hiddo J L Heerspink
- University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Thomas A Zelniker
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX.,Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, U.K
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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30
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Zelniker TA, Raz I, Mosenzon O, Dwyer JP, Heerspink HHJL, Cahn A, Goodrich EL, Im K, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson I, Langkilde AM, Sabatine MS, Wiviott SD. Effect of Dapagliflozin on Cardiovascular Outcomes According to Baseline Kidney Function and Albuminuria Status in Patients With Type 2 Diabetes: A Prespecified Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol 2021; 6:801-810. [PMID: 33851953 DOI: 10.1001/jamacardio.2021.0660] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 12/24/2022]
Abstract
Importance Sodium-glucose cotransporter 2 inhibitors, such as dapagliflozin, promote renal glucose excretion and reduce cardiovascular (CV) deaths and hospitalizations for heart failure (HHF) among patients with type 2 diabetes. The relative CV efficacy and safety of dapagliflozin according to baseline kidney function and albuminuria status are unknown. Objective To assess the CV efficacy and safety of dapagliflozin according to baseline estimated glomerular filtration rate (eGFR) and urinary albumin to creatinine ratio (UACR). Design, Setting, and Participants This secondary analysis of the randomized clinical trial Dapagliflozin Effect on Cardiovascular Events-Thrombolysis in Myocardial Infarction 58 compared dapagliflozin vs placebo in 17 160 patients with type 2 diabetes and a baseline creatinine clearance of 60 mL/min or higher. Patients were categorized according to prespecified subgroups of baseline eGFR (<60 vs ≥60 mL/min/1.73 m2), urinary albumin to creatinine ratio (UACR; <30 vs ≥30 mg/g), and of chronic kidney disease (CKD) markers using these subgroups (0, 1, or 2). The study was conducted from May 2013 to September 2018. Interventions Dapagliflozin vs placebo. Main Outcomes and Measures The dual primary end points were major adverse cardiovascular events (myocardial infarction, stroke, and CV death) and the composite of CV death or HHF. Results At baseline, 1265 patients (7.4%) had an eGFR below 60 mL/min/1.73 m2, and 5199 patients (30.9%) had albuminuria. Among patients having data for both eGFR and UACR, 10 958 patients (65.1%) had an eGFR equal to or higher than 60 mL/min/1.73 m2 and an UACR below 30 mg/g (mean [SD] age, 63.7 [6.7] years; 40.1% women), 5336 patients (31.7%) had either an eGFR below 60 mL/min/1.73 m2 or albuminuria (mean [SD] age, 64.1 [7.1] years; 32.6% women), and 548 patients (3.3%) had both (mean [SD] age, 66.8 [6.9] years; 30.5% women). In the placebo group, patients with more CKD markers had higher event rates at 4 years as assessed using the Kaplan-Meier approach for the composite of CV death or HHF (3.9% for 0 markers, 8.3% for 1 marker, and 17.4% for 2 markers) and major adverse cardiovascular events (7.5% for 0 markers, 11.6% for 1 marker, and 18.9% for 2 markers). Estimates for relative risk reductions for the composite of CV death or HHF and for major adverse cardiovascular events were generally consistent across subgroups (both P > .24 for interaction), although greater absolute risk reductions were observed with more markers of CKD. The absolute risk difference for the composite of CV death or HHF was greater for patients with more markers of CKD (0 markers, -0.5%; 1 marker, -1.0%; and 2 markers, -8.3%; P = .02 for interaction). The numbers of amputations, cases of diabetic ketoacidosis, fractures, and major hypoglycemic events were balanced or numerically lower with dapagliflozin compared with placebo for patients with an eGFR below 60 mL/min/1.73 m2 and an UACR of 30 mg/g or higher. Conclusions and Relevance The effect of dapagliflozin on the relative risk for CV events was consistent across eGFR and UACR groups, with the greatest absolute benefit for the composite of CV death or HHF observed among patients with both reduced eGFR and albuminuria. Trial Registration ClinicalTrials.gov Identifier: NCT01730534.
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Affiliation(s)
- Thomas A Zelniker
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Itamar Raz
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Ofri Mosenzon
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Jamie P Dwyer
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hiddo H J L Heerspink
- University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,The George Institute for International Health, Sydney, Australia
| | - Avivit Cahn
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Erica L Goodrich
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Jerusalem, Israel
| | - Kyungah Im
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, The University of Texas Southwestern Medical Center, Dallas
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | | | | | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Wiviott SD, Giugliano RP, Sabatine MS. Myocardial Infarction and Evolocumab-Reply. JAMA Cardiol 2021; 6:1222-1223. [PMID: 34160553 DOI: 10.1001/jamacardio.2021.2000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Deputy Editor, JAMA Cardiology
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O'Donoghue ML, Kato ET, Mosenzon O, Murphy SA, Cahn A, Herrera M, Tankova T, Šmahelová A, Merlini P, Gause-Nilsson I, Langkilde AM, McGuire DK, Wilding JPH, Leiter LA, Bhatt DL, Raz I, Sabatine MS, Wiviott SD. The efficacy and safety of dapagliflozin in women and men with type 2 diabetes mellitus. Diabetologia 2021; 64:1226-1234. [PMID: 33611623 DOI: 10.1007/s00125-021-05399-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 10/22/2020] [Accepted: 12/09/2020] [Indexed: 01/24/2023]
Abstract
AIMS/HYPOTHESIS Women remain underrepresented in clinical trials and those with type 2 diabetes mellitus are at high risk for cardiovascular (CV) events. The sodium-glucose cotransporter 2 (SGLT2) inhibitor dapagliflozin reduces the risk of CV death or heart failure hospitalisations in individuals with type 2 diabetes. Here, we performed a pre-specified analysis to examine whether sex modifies these effects. METHODS The DECLARE-TIMI 58 trial randomised 17,160 patients with type 2 diabetes with or at risk for atherosclerotic disease to dapagliflozin or placebo (median follow-up 4.2 years). The dual efficacy outcomes were CV death or heart failure hospitalisations, and major adverse cardiovascular events (MACE; CV death, myocardial infarction or ischaemic stroke). The renal-specific composite outcome was a sustained ≥40% drop in eGFR to <60 ml min-1 [1.73 m]-2, new end-stage renal disease or renal death. Cox models were run separately by sex with treatment-by-sex interaction testing for each outcome. RESULTS At baseline, women (n = 6422, 37.4%) had higher HbA1c, longer type 2 diabetes duration, and were on fewer glucose-lowering medications. There was no evidence of modification of the effect of dapagliflozin by sex for (1) CV death or heart failure hospitalisations: women (3.8% vs 4.5%; HR 0.84, 95% CI 0.66, 1.07) and men (5.3% vs 6.4%; HR 0.83, 95% CI 0.71, 0.96; pinteraction = 0.90); (2) MACE: women (6.3% vs 6.8%; HR 0.93, 95% CI 0.77, 1.12) and men (10.0% vs 10.7%; HR 0.93, 95% CI 0.83, 1.05; pinteraction = 0.99); or (3) renal-specific composite: women (1.4% vs 2.8%; HR 0.50, 95% CI 0.35, 0.70) and men (1.5% vs 2.5%; HR 0.55, 95% CI 0.42, 0.73; pinteraction = 0.64). The overall safety profile of dapagliflozin was similar for women and men. CONCLUSIONS/INTERPRETATION Dapagliflozin offers comparable CV and renal benefits and a comparable safety profile in women and men. FUNDING AstraZeneca. TRIAL REGISTRATION clinicaltrials.gov NCT01730534.
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Affiliation(s)
- Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA.
| | - Eri T Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ofri Mosenzon
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Avivit Cahn
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | | | | | - Alena Šmahelová
- Faculty Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Piera Merlini
- 2nd Division of Cardiology, Ca' Granda Niguarda Hospital, Milan, Italy
| | | | | | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, TX, USA
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Larry A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Itamar Raz
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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Cahn A, Raz I, Leiter LA, Mosenzon O, Murphy SA, Goodrich EL, Yanuv I, Rozenberg A, Bhatt DL, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Langkilde AM, Sabatine MS, Wiviott SD. Cardiovascular, Renal, and Metabolic Outcomes of Dapagliflozin Versus Placebo in a Primary Cardiovascular Prevention Cohort: Analyses From DECLARE-TIMI 58. Diabetes Care 2021; 44:1159-1167. [PMID: 33653824 DOI: 10.2337/dc20-2492] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 10/08/2020] [Accepted: 01/31/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE International guidelines propose prescribing sodium-glucose cotransporter 2 (SGLT2) inhibitors to patients with type 2 diabetes (T2D) as secondary prevention in patients with established atherosclerotic cardiovascular disease (ASCVD) or for primary prevention of cardiovascular events in high-risk patients with multiple risk factors (MRF) for ASCVD. The current analyses expand on the cardiovascular renal and metabolic effects of SGLT2 inhibitors in MRF patients. RESEARCH DESIGN AND METHODS In DECLARE-TIMI 58, 17,160 patients with T2D and MRF (59.4%) or established ASCVD (40.6%) were randomized to dapagliflozin versus placebo; patients were followed for a median of 4.2 years. The cardiovascular and renal outcomes in the MRF cohort were studied across clinically relevant subgroups for treatment effect and subgroup-based treatment interaction. RESULTS Among patients with MRF, the reduction with dapagliflozin in risk of cardiovascular death or hospitalization for heart failure (CVD/HHF) (hazard ratio [HR] 0.84, 95% CI 0.67-1.04) and the renal-specific outcome (HR 0.51, 95% CI 0.37-0.69) did not differ from that for patients with ASCVD (P interaction 0.99 and 0.72, respectively). The effect on CVD/HHF was entirely driven by a reduction in HHF (HR 0.64, 95% CI 0.46-0.88). The benefits of dapagliflozin on HHF and on the renal-specific outcome, among the subset with MRF, were directionally consistent across clinically relevant subgroups. At 48 months, HbA1c, weight, systolic blood pressure, and urinary albumin-to-creatinine ratio were lower with dapagliflozin versus placebo and estimated glomerular filtration rate was higher (P < 0.001). CONCLUSIONS In patients with T2D and MRF, dapagliflozin reduced the risk of HHF and adverse renal outcomes regardless of baseline characteristics. These analyses support the benefit of dapagliflozin for important outcomes in a broad primary prevention population.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, and The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.,Parkland Health and Hospital System, Dallas, TX
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, U.K
| | | | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Lau ES, Braunwald E, Morrow DA, Giugliano RP, Antman EM, Gibson CM, Scirica BM, Bohula EA, Wiviott SD, Bhatt DL, Bonaca MP, Cannon CP, Im K, Guo J, Sabatine MS, O'Donoghue ML. Sex, Permanent Drug Discontinuation, and Study Retention in Clinical Trials: Insights From the TIMI trials. Circulation 2021; 143:685-695. [PMID: 33587654 DOI: 10.1161/circulationaha.120.052339] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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: 12/19/2022]
Abstract
BACKGROUND Women are underrepresented across cardiovascular clinical trials. Whether women are more likely than men to prematurely discontinue study drug or withdraw consent once enrolled in a clinical trial is unknown. METHODS Eleven phase 3/4 TIMI (Thrombolysis in Myocardial Infarction) trials were included (135 879 men and 51 812 women [28%]). The association between sex and premature study drug discontinuation and withdrawal of consent were examined by multivariable logistic regression after adjusting for potential confounders in each individual trial and combining the individual point estimates in random effects models. RESULTS After adjusting for baseline differences, women had 22% higher odds of premature drug discontinuation (adjusted odds ratio [ORadj], 1.22 [95% CI, 1.16-1.28]; P<0.001) compared with men. Qualitatively consistent results were observed for women versus men in the placebo arms (ORadj, 1.20 [95% CI, 1.13-1.27]) and active therapy arms (ORadj, 1.23 [95% CI, 1.17-1.30)]; there was some evidence for regional heterogeneity (P interaction <0.001). Of those who stopped study drug prematurely, a similar proportion of men and women in the active arm stopped because of an adverse event (36% for both; P=0.60). Women were also more likely to withdraw consent compared with men (ORadj, 1.26 [95% CI, 1.17-1.36]; P<0.001). CONCLUSIONS Women were more likely than men to prematurely discontinue study drug and withdraw consent across cardiovascular outcome trials. Premature study drug discontinuation was not explained by baseline differences by sex or a higher proportion of adverse events. Future trials should better capture reasons for drug discontinuation and withdrawal of consent to understand barriers to continued study drug use and clinical trial participation, particularly among women.
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Affiliation(s)
- Emily S Lau
- Cardiology Division, Massachusetts General Hospital, Boston, MA (E.S.L.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - Elliott M Antman
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | | | - Benjamin M Scirica
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - Erin A Bohula
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (D.L.B., C.P.C.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - Marc P Bonaca
- CPC Clinical Research, Cardiovascular Division, University of Colorado School of Medicine, Denver, CO (M.P.B.)
| | - Christopher P Cannon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (D.L.B., C.P.C.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - KyungAh Im
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - Jianping Guo
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
| | - Michelle L O'Donoghue
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D.).,Harvard Medical School, Boston, MA (E.S.L., E.B., D.A.M., R.P.G., E.M.A., B.M.S., E.A.B., S.D.W., K.I., J.G., M.S.S., M.O.D., D.L.B., C.P.C.)
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Marston NA, Bonaca MP, Jarolim P, Goodrich EL, Bhatt DL, Steg PG, Cohen M, Storey RF, Johanson P, Wiviott SD, Braunwald E, Sabatine MS, Morrow DA. Clinical Application of High-Sensitivity Troponin Testing in the Atherosclerotic Cardiovascular Disease Framework of the Current Cholesterol Guidelines. JAMA Cardiol 2021; 5:1255-1262. [PMID: 32756916 DOI: 10.1001/jamacardio.2020.2981] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 12/20/2022]
Abstract
Importance The 2018 American Heart Association/American College of Cardiology (AHA/ACC) cholesterol management guidelines identified 2 distinct groups of patients with atherosclerotic cardiovascular disease (ASCVD) prompting different treatment recommendations. Objective To investigate whether the addition of high-sensitivity troponin (hsTn) testing to guideline-derived ASCVD risk can improve risk classification and downstream treatment recommendations. Design, Setting, and Participants A prospective cohort biomarker substudy was performed that included 8635 patients enrolled in the Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis in Myocardial Infarction 54 (PEGASUS-TIMI 54) trial. Patients were assigned to risk groups of either very high-risk ASCVD or lower-risk ASCVD based on their cardiovascular history and comorbidities, in line with the 2018 AHA/ACC cholesterol management guidelines criteria. Patients were also classified on the basis of hsTnI level (ARCHITECT assay; Abbott) using cut points of 2 ng/L (limit of detection) and 6 ng/L (risk threshold), followed by joint classification on the basis of clinical features and hsTnI level. The setting was a nested prospective cohort study in a completed multinational trial. Participants were all patients who had a myocardial infarction 1 to 3 years before enrollment, were at least 50 years of age, and had at least 1 high-risk feature. The study dates were October 2010 to December 2014. The dates of analysis were June 2019 to January 2020. Main Outcomes and Measures The primary end point was a composite of cardiovascular death, myocardial infarction, or stroke. Results Among 8635 patients enrolled in the PEGASUS-TIMI 54 trial, the median age was 65 years (interquartile range, 58-71 years), and 6614 (76.6%) were men; 8340 (96.6%) were White individuals and 176 (2.0%) were Black individuals. Patients meeting clinical criteria for the very high-risk ASCVD group had a primary end point 3-year event rate of 8.8% compared with 5.0% in the lower-risk ASCVD group (hazard ratio, 2.01; 95% CI, 1.58-2.57; P < .001). When patients in the very high-risk ASCVD group were further risk stratified by hsTnI level, 614 of 6789 patients (9.0%) with an undetectable hsTnI level had a 3-year event rate of 2.7% (<1% per year), which was less than the overall rate in the lower-risk ASCVD group. Analogously, in the lower-risk ASCVD group, 417 of 1846 patients (22.6%) with an hsTnI level exceeding 6 ng/L had an event rate of 9.1%, comparable to the overall rate in the very high-risk ASCVD group. The addition of hsTnI to guideline-derived ASCVD risk led to a net reclassification index at event rate of 0.15 (95% CI, 0.10-0.21). Overall, use of hsTnI reclassified 1031 of 8635 patients (11.9%) (1 in 11 with very high-risk ASCVD and 1 in 4 with lower-risk ASCVD). Conclusions and Relevance The findings of this cohort substudy suggest that a strategy incorporating hsTn into a guideline-derived ASCVD risk algorithm provides enhanced risk stratification and reclassifies 11.9% of patients into a more appropriate risk group. This application of hsTn testing might be used to optimize the care of patients with ASCVD.
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Affiliation(s)
- Nicholas A Marston
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc P Bonaca
- Colorado Prevention Center (CPC) Clinical Research, Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Philippe G Steg
- Division of Cardiology, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Marc Cohen
- Newark Beth Israel Medical Center, Rutgers New Jersey Medical School, Newark
| | - Robert F Storey
- Division of Cardiology, The University of Sheffield, Sheffield, United Kingdom
| | | | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Wiviott SD, Giugliano RP, Morrow DA, De Ferrari GM, Lewis BS, Huber K, Kuder JF, Murphy SA, Forni DM, Kurtz CE, Honarpour N, Keech AC, Sever PS, Pedersen TR, Sabatine MS. Effect of Evolocumab on Type and Size of Subsequent Myocardial Infarction: A Prespecified Analysis of the FOURIER Randomized Clinical Trial. JAMA Cardiol 2021; 5:787-793. [PMID: 32347885 DOI: 10.1001/jamacardio.2020.0764] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 12/12/2022]
Abstract
Importance The PCSK9 inhibitor evolocumab reduced major vascular events in the Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk (FOURIER) trial, yet the types and sizes of myocardial outcomes in FOURIER have not been previously explored. Objective To assess the types and sizes of myocardial infarction (MI) and the effect of evolocumab on MI by subtype. Design, Setting, and Participants A prespecified analysis of a multicenter double-blind randomized clinical trial. Patients were randomized to evolocumab or placebo and followed up for a median of 2.2 years. The study included 27 564 patients with stable atherosclerotic disease receiving statin therapy. Clinical end points were evaluated by the Thrombolysis in Myocardial Infarction clinical events committee. Rates presented are 3-year Kaplan-Meier estimates. Data were collected from 2013 to 2016 and analyzed from June 2017 to December 2019. Main Outcomes and Measures Myocardial infarction was defined based on the third universal MI definition, and further classified according to MI type (universal MI subclass, ST-segment elevation myocardial infarction [STEMI] vs non-STEMI) and by MI size (determined by peak troponin level). Results A total of 27 564 patients were randomized, with a mean (SD) age of 62.5 (9.0) years, and 20 795 (75%) were male. Of these, 1107 patients experienced a total of 1288 MIs. Most MIs (68%) were atherothrombotic (type 1), with 15% from myocardial oxygen supply-demand mismatch (type 2) and 15% percutaneous coronary intervention-related (type 4). Sudden death (type 3) and coronary artery bypass grafting-related (type 5) accounted for a total of 21 MIs (<2%). Evolocumab significantly reduced the risk of first MI by 27% (4.4% vs 6.3%; hazard ratio [HR], 0.73; 95% CI, 0.65-0.82; P < .001), type 1 by 32% (2.9% vs 4.5%; HR, 0.68; 95% CI, 0.59-0.79; P < .001), and type 4 by 35% (0.8% vs 1.1%; HR, 0.65; 95% CI, 0.48-0.87; P = .004), with no effect on type 2 (0.9% vs 0.8%; HR, 1.09; 95% CI, 0.82-1.45; P = .56). Most MIs (688 [59.8%]) had troponin levels greater than or equal to 10 times the upper limit of normal. The benefit was highly significant and consistent regardless of the size of MI with a 34% reduction in MIs with troponin level greater than or equal to 10 times the upper limit of normal (2.6% vs 3.7%; HR, 0.66; 95% CI, 0.56-0.77; P < .001) and a 36% reduction in the risk of STEMI (1.0% vs 1.5%; HR, 0.64; 95% CI, 0.49-0.84; P < .001). Conclusions and Relevance Low-density lipoprotein cholesterol lowering with evolocumab was highly effective in reducing the risk of MI. This reduction with evolocumab included benefit across multiple subtypes of MI related to plaque rupture, smaller and larger MIs, and both STEMI and non-STEMI. These data are consistent with the known benefit of low-density lipoprotein cholesterol lowering and underscore the reduction in clinically meaningful events. Trial Registration ClinicalTrials.gov Identifier: NCT01764633.
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Affiliation(s)
- Stephen D Wiviott
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Robert P Giugliano
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.,Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David A Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gaetano M De Ferrari
- Department of Medical Sciences, University of Torino, Cardiology AOU Città della Salute e della Scienza, Torino, Italy
| | | | | | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sabina A Murphy
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.,Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danielle M Forni
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - Anthony C Keech
- Sydney Medical School, National Health and Medical Research Council Clinical Trials Center, University of Sydney, Sydney Australia
| | - Peter S Sever
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Terje R Pedersen
- Oslo University Hospital, Ulleval and Medical Faculty, University of Oslo, Oslo Norway
| | - Marc S Sabatine
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.,Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Deputy Editor
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Dillinger JG, Ducrocq G, Elbez Y, Cohen M, Bode C, Pollack C, Petrauskiene B, Henry P, Dorobantu M, French WJ, Wiviott SD, Sabatine MS, Mehta SR, Steg PG. Sex Differences in Ischemic and Bleeding Outcomes in Patients With Non-ST-Segment-Elevation Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: Insights From the TAO Trial. Circ Cardiovasc Interv 2021; 14:e009759. [PMID: 33430604 DOI: 10.1161/circinterventions.120.009759] [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 Previous studies have observed poorer outcomes in females with myocardial infarction, but older age and lower use of percutaneous coronary intervention in females are factors that potentially explain the worse outcome. This study sought to determine if female sex is an independent factor of ischemic and bleeding outcomes in non-ST-segment-elevation acute coronary syndrome treated with a systematic invasive approach. METHODS The TAO trial (Treatment of Acute Coronary Syndrome With Otamixaban) randomized patients with non-ST-segment-elevation acute coronary syndrome treated invasively to heparin plus eptifibatide versus otamixaban. In this post hoc analysis, the primary ischemic end point (all-cause death, myocardial infarction within 180 days) and the primary safety end point (Thrombolysis in Myocardial Infarction major or minor bleeding within 30 days) were analyzed according to sex. RESULTS Of 13 229 randomized patients, 3980 (30.1%) were females and 9249 (69.9%) were males. Females were older (64.8±11.0 versus 60.7±11.1 years), had more comorbidities, received less peri-procedural antithrombotic therapy, and underwent less frequently revascularization. Overall, females experienced a higher risk of ischemic (10.2% versus 9.1%; odds ratio [OR], 1.15 [1.01-1.30]) and bleeding events (4.2% versus 3.4%; OR, 1.23 [1.02-1.49]) than males. After multivariate analysis, the risk of ischemic outcomes (OR, 1.04 [0.90-1.19]), death (OR, 1.00 [0.75-1.23]), or bleeding (OR, 1.05 [0.85-1.28]), were similar between females and males. Only, noncoronary artery bypass graft related Thrombolysis in Myocardial Infarction major bleeding were increased in females (OR, 1.69 [1.11-2.56]). CONCLUSIONS In patients with non-ST-segment-elevation acute coronary syndrome with systematic invasive management, ischemic outcomes, bleeding events, and mortality were higher in females. After multivariate analyses, female sex was not an independent predictor of ischemic and bleeding events although noncoronary artery bypass graft related Thrombolysis in Myocardial Infarction major bleeding was higher in females. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01076764.
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Affiliation(s)
| | - Gregory Ducrocq
- Université de Paris, AP-HP, FACT, FHU APOLLO, Hôpital Bichat, Inserm U-1148, Paris, France (G.D., Y.E., P.G.S.)
| | - Yedid Elbez
- Université de Paris, AP-HP, FACT, FHU APOLLO, Hôpital Bichat, Inserm U-1148, Paris, France (G.D., Y.E., P.G.S.)
| | - Marc Cohen
- Newark Beth Israel Medical Center, Rutgers-New Jersey Medical School (M.C.)
| | - Christoph Bode
- Medizinische Universitatsklinik, Freiburg, Germany (C.B.)
| | - Charles Pollack
- University of Mississippi School of Medicine, Jackson (C.P.)
| | | | - Patrick Henry
- Université de Paris, Hôpital Lariboisière, AP-HP, Inserm U-942, Paris, France (J.-G.D., P.H.)
| | | | - William J French
- Harbor-University of California, Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Stephen D Wiviott
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (S.D.W., M.S.S.)
| | - Marc S Sabatine
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (S.D.W., M.S.S.)
| | - Shamir R Mehta
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada (S.R.M.)
| | - Philippe Gabriel Steg
- Université de Paris, AP-HP, FACT, FHU APOLLO, Hôpital Bichat, Inserm U-1148, Paris, France (G.D., Y.E., P.G.S.).,Royal Brompton Hospital, Imperial College, London, United Kingdom (P.G.S.)
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38
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Cahn A, Wiviott SD, Mosenzon O, Murphy SA, Goodrich EL, Yanuv I, Rozenberg A, Wilding JPH, Leiter LA, Bhatt DL, McGuire DK, Litwak L, Kooy A, Gause-Nilsson IAM, Fredriksson M, Langkilde AM, Sabatine MS, Raz I. Cardiorenal outcomes with dapagliflozin by baseline glucose-lowering agents: Post hoc analyses from DECLARE-TIMI 58. Diabetes Obes Metab 2021; 23:29-38. [PMID: 32844557 DOI: 10.1111/dom.14179] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 05/26/2020] [Revised: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
AIM To assess the associations between baseline glucose-lowering agents (GLAs) and cardiorenal outcomes with dapagliflozin versus placebo in the DECLARE-TIMI 58 study. MATERIALS AND METHODS DECLARE-TIMI 58 assessed the cardiorenal outcomes of dapagliflozin versus placebo in patients with type 2 diabetes. This post hoc analysis elaborates the efficacy and safety outcomes by baseline GLA for treatment effect and GLA-based treatment interaction. RESULTS At baseline, 14 068 patients (82.0%) used metformin, 7322 (42.7%) sulphonylureas, 2888 (16.8%) dipeptidyl peptidase-4 inhibitors, 750 (4.4%) glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and 7013 (40.9%) insulin. Dapagliflozin reduced the composite of cardiovascular death (CVD) and hospitalization for heart failure (HHF) versus placebo regardless of baseline GLA, with greater benefit in the small group of patients with baseline use of GLP-1 RAs (HR [95% CI] 0.37 [0.18, 0.78] vs. 0.86 [0.75, 0.98] in GLP-1 RA users vs. non-users, Pinteraction = .03). The overall HR for major adverse cardiovascular events (CVD, myocardial infarction or ischaemic stroke) was 0.93 (95% CI 0.84, 1.03) with dapagliflozin versus placebo, with no interaction by baseline GLA (Pinteraction > .05). The renal-specific outcome was reduced with dapagliflozin versus placebo in the overall cohort (HR [95%CI] 0.53[0.43-0.66]), with no interaction by baseline GLA (Pinteraction > .05). All of these outcomes were similar in those with versus those without baseline metformin use. CONCLUSIONS The effects of dapagliflozin on cardiorenal outcomes were generally consistent regardless of baseline GLA, with consistent benefits regardless of baseline metformin use. The potential clinical benefit of combining sodium-glucose co-transporter-2 inhibitors with GLP-1 RAs, given some evidence of cardiovascular risk reduction with both classes, should be explored further.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Stephen D Wiviott
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Sabina A Murphy
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Erica L Goodrich
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Lawrence A Leiter
- Department of Medicine, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas
| | - Leon Litwak
- Endocrinology Unit, Diabetes Section, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Adriaan Kooy
- University Medical Center Groningen and Bethesda Diabetes Research Center, Groningen, the Netherlands
| | | | | | | | - Marc S Sabatine
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Israel
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Zelniker TA, Morrow DA, Mosenzon O, Goodrich EL, Jarolim P, Murphy SA, Bhatt DL, Leiter LA, McGuire DK, Wilding J, Bode C, Lewis BS, Gause-Nilsson I, Langkilde AM, Fredriksson M, Raz I, Sabatine MS, Wiviott SD. Relationship between baseline cardiac biomarkers and cardiovascular death or hospitalization for heart failure with and without sodium-glucose co-transporter 2 inhibitor therapy in DECLARE-TIMI 58. Eur J Heart Fail 2020; 23:1026-1036. [PMID: 33269486 DOI: 10.1002/ejhf.2073] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022] Open
Abstract
AIMS Dapagliflozin reduced the risk of the composite of cardiovascular (CV) death or hospitalization for heart failure (HHF) in patients with type 2 diabetes mellitus in DECLARE-TIMI 58. We hypothesized that baseline N-terminal pro B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hsTnT) levels would help identify patients who are at higher baseline risk and we describe the treatment effects of dapagliflozin in patients according to their baseline NT-proBNP and hsTnT levels. METHODS AND RESULTS This was a pre-specified biomarker study from DECLARE-TIMI 58, a randomized, double-blind, placebo-controlled CV outcomes trial of dapagliflozin. Baseline NT-proBNP and hsTnT levels were measured in the TIMI Clinical Trials Laboratory in 14 565 patients. Among the included patients, 9143 patients (62.8%) were male, 1464 (10.1%) had a history of heart failure and the mean age was 63.9 years. The median baseline NT-proBNP and hsTnT levels were 75 pg/mL [interquartile range (IQR) 35-165] and 10.2 pg/mL (IQR 6.9-15.5), respectively. Patients with higher NT-proBNP and hsTnT quartiles had higher rates of CV death/HHF (Q4 vs. Q1: NT-proBNP: 4-year Kaplan-Meier event rates 13.7% vs. 1.0%; hsTnT: 11.8% vs. 1.4%; P-trend <0.001). Dapagliflozin consistently reduced the relative risk of CV death/HHF regardless of baseline NT-proBNP (P-interaction 0.72) or hsTnT quartiles (P-interaction 0.93). Given their higher baseline risk, patients with NT-proBNP and/or hsTnT levels above the median derived larger absolute risk reductions with dapagliflozin (NT-proBNP 1.9% vs. 0%, P-interaction 0.010; hsTnT 1.8% vs. 0.1%, P-interaction 0.026). CONCLUSION Patients with type 2 diabetes mellitus and higher NT-proBNP or hsTnT levels are at increased risk of CV death and HHF. Dapagliflozin reduced the relative risk of CV death/HHF irrespective of NT-proBNP and hsTnT levels, with greater absolute risk reductions seen in patients with higher baseline biomarker levels.
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Affiliation(s)
- Thomas A Zelniker
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Technion-Israel Institute of Technology, Haifa, Israel
| | | | | | | | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Popovic B, Sorbets E, Abtan J, Cohen M, Pollack CV, Bode C, Wiviott SD, Sabatine MS, Mehta SR, Ruzyllo W, Rao SV, French WJ, Kerkar P, Kiss RG, Estrada JLN, Elbez Y, Ducrocq G, Steg PG. Outcomes in non-ST-segment elevation myocardial infarction patients according to heart failure at admission: Insights from a large trial with systematic early invasive strategy. Eur Heart J Acute Cardiovasc Care 2020; 10:2048872619896205. [PMID: 33081496 DOI: 10.1177/2048872619896205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 12/02/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Previous studies published before the era of systematic early invasive strategy have reported a higher mortality in non-ST-segment elevation myocardial infarction patients with heart failure. The aim of our study was to compare the clinical characteristics, outcomes and causes of death of patients according to their heart failure status at admission in a large non-ST-segment elevation myocardial infarction population with planned early invasive management. METHODS We performed a post-hoc analysis of the Treatment of Acute Coronary Syndrome with Otamixaban randomised trial which included non-ST-segment elevation myocardial infarction patients with systematic coronary angiography within 72 h. Patients were categorised according to presence or absence of heart failure (Killip grade ≥2) at admission. RESULTS A total of 13,172 patients were enrolled, of whom 944 (7.2%) had heart failure. At day 30, death occurred in 213 patients (1.6%) and cardiovascular death was the dominant cause of death in both groups ((with vs without heart failure) 78.8% vs 78.4%, p = 0.94). At six months, death occurred in 90/944 (9.5%) patients with heart failure and 258/12228 patients without heart failure (2.1%) (p < 0.001). After adjustment on Global Registry of Acute Coronary Events risk score, heart failure was an independent predictor of all-cause mortality at day 30 (odds ratio: 1.58; 95% confidence interval, 1.06-2.36, p = 0.02) and at day 180 (odds ratio: 1.77; 95% confidence interval, 1.3-2.42, p < 0.001) as well as of ischaemic complications (cardiovascular death, myocardial infarction, stent thrombosis or stroke at day 30 (odds ratio: 1.28; 95% confidence interval, 1.01-1.62, p = 0.04). CONCLUSION Non-ST-segment elevation myocardial infarction patients with heart failure at admission still have worse outcomes than those without heart failure, even with systematic early invasive strategy. Further efforts are needed to improve the prognosis of these high risk patients.
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Affiliation(s)
- Batric Popovic
- Université de Lorraine, CHRU de Nancy, Département de cardiologie, Nancy, France
| | - Emmanuel Sorbets
- Université de Paris, puis APHP, Hotel Dieu, Centre de diagnostic et de Thérapeutique; French Alliance for Cardiovascular Trials (FACT); INSERM LVTS-U1148
| | - Jeremie Abtan
- Université de Paris, puis APHP, Hotel Dieu, Centre de diagnostic et de Thérapeutique; French Alliance for Cardiovascular Trials (FACT); INSERM LVTS-U1148
| | - Marc Cohen
- APHP, Department of cardiology, Hôpital Bichat, France; French Alliance for Cardiovascular Trials (FACT); INSERM LVTS-U1148; DHU FIRE, University of Paris
| | - Charles V Pollack
- Division of Cardiology, Newark Beth Israel Medical Center, Mount Sinai School of Medicine, Newark, New Jersey, USA
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, USA
| | | | | | | | - Shamir R Mehta
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, North Carolina, USA
| | - William J French
- David Geffen School of Medicine at UCLA, Torrance, California, USA
| | | | - Robert G Kiss
- Department of Cardiology, Military Hospital, Budapest, Hungary
| | | | - Yedid Elbez
- Université de Paris, puis APHP, Hotel Dieu, Centre de diagnostic et de Thérapeutique; French Alliance for Cardiovascular Trials (FACT); INSERM LVTS-U1148
| | - Gregory Ducrocq
- Université de Paris, puis APHP, Hotel Dieu, Centre de diagnostic et de Thérapeutique; French Alliance for Cardiovascular Trials (FACT); INSERM LVTS-U1148
| | - Philippe Gabriel Steg
- Université de Paris, puis APHP, Hotel Dieu, Centre de diagnostic et de Thérapeutique; French Alliance for Cardiovascular Trials (FACT); INSERM LVTS-U1148
- NHLI Imperial College, ICMS Royal Brompton Hospital London, United Kingdom
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Xu H, Yang Y, Wang C, Yang J, Li W, Zhang X, Ye Y, Dong Q, Fu R, Sun H, Yan X, Gao X, Wang Y, Jia X, Sun Y, Wu Y, Zhang J, Zhao W, Sabatine MS, Wiviott SD. Association of Hospital-Level Differences in Care With Outcomes Among Patients With Acute ST-Segment Elevation Myocardial Infarction in China. JAMA Netw Open 2020; 3:e2021677. [PMID: 33095249 PMCID: PMC7584928 DOI: 10.1001/jamanetworkopen.2020.21677] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
IMPORTANCE The incidence of acute myocardial infarction has increased over the past decades in China, and management challenges include an unbalanced economy, disparate resources, and variable access to medical care across the nation. OBJECTIVE To examine the variations in care and outcomes of patients with ST-segment elevation myocardial infarction among 3 levels of hospitals in the typical Chinese public hospital model. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the China Acute Myocardial Infarction Registry to compare the differences in care and outcomes among patients at 108 hospitals from 31 provinces and municipalities throughout mainland China. Participants included patients with ST-segment elevation myocardial infarction directly admitted to hospitals between January 2013 and September 2014. Data analyses were performed from June 2015 to June 2019. EXPOSURES Care in province-level, prefecture-level, or county-level hospitals in China. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. Secondary outcomes included presentation, treatments, and major complications. RESULTS A total of 12 695 patients (9593 men [75.6%]; median [interquartile range] age, 63 [54-72] years) were included; 3985 were at province-level hospitals, 6731 were at prefecture-level hospitals, and 1979 were at county-level hospitals. Compared with patients admitted to province-level hospitals, those admitted to prefecture-level and county-level hospitals were older (median [interquartile range] age, 61 [52-70] years vs 63 [54-72] years and 65 [57-75] years) and more likely to be women (815 women [20.5%] vs 1620 women [24.1%] and 667 women [33.7%]). Patients in prefecture-level and county-level hospitals were less likely to use ambulances compared with patients at province-level hospitals (11.6% [95% CI, 10.8%-12.4%] and 12.0% [95% CI, 10.6%-13.5%] vs 19.4% [95% CI, 18.1%-20.7%]; P < .001) and were less likely to experience early presentation, with onset-to-arrival times less than 12 hours for 75.3% (95% CI, 73.9%-76.6%) of patients at province-level hospitals, 70.8% (95% CI, 69.7%-71.9%) of patients at prefecture-level hospitals, and 69.8% (95% CI, 67.7%-71.8%) of patients at county-level hospitals (P < .001). The rates of reperfusion therapy were significantly lower in low-level hospitals (54.3% [95% CI, 53.1%-55.5%] for prefecture-level hospitals and 45.8% [95% CI, 43.6%-48.1%] for county-level hospitals) compared with province-level hospitals (69.4% [95% CI, 67.9%-70.8%]; P < .001). There was a progressively higher rate of in-hospital mortality at the 3 levels of hospitals: 3.1% (95% CI, 2.6%-3.7%) for province-level hospitals, 5.3% (95% CI, 4.8%-5.9%) for prefecture-level hospitals, and 10.2% (95% CI, 8.9%-11.7%) for county-level hospitals (P for trend < .001). After adjustment for patient characteristics, presentation, hospital facility, and treatments, the odds of death remained higher in prefecture-level (odds ratio, 1.39 [95% CI, 1.06-1.84]) and county-level (odds ratio, 1.43 [95% CI, 0.97-2.11]) hospitals compared with province-level hospitals (P for trend = .04). CONCLUSIONS AND RELEVANCE These findings suggest that there are significant variations in care and outcomes of patients among the 3 levels of hospitals in China. More efforts should be made to address the identified gaps, particularly in the prefecture-level and county-level hospitals. This work can inform national quality improvements efforts in China and in other developing countries.
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Affiliation(s)
- Haiyan Xu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuejin Yang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Chuangshi Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jingang Yang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Li
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xuan Zhang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yunqing Ye
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qiuting Dong
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Rui Fu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hui Sun
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xinxin Yan
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaojin Gao
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xuan Jia
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yi Sun
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuan Wu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jun Zhang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Zhao
- Information Technology Center, Fuwai Hospital, Beijing, China
| | - Marc S. Sabatine
- Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen D. Wiviott
- Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Zelniker TA, Raz I, Sabatine MS, Wiviott SD. Response by Zelniker et al to Letter Regarding Article, "Effect of Dapagliflozin on Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus: Insights From the DECLARE-TIMI 58 Trial". Circulation 2020; 142:e129-e130. [PMID: 32897752 DOI: 10.1161/circulationaha.120.049841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas A Zelniker
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria (T.A.Z.)
| | - Itamar Raz
- The Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Israel (I.R.)
| | - Marc S Sabatine
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.S.S., S.D.W.)
| | - Stephen D Wiviott
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.S.S., S.D.W.)
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43
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Giugliano RP, Gencer B, Wiviott SD, Park JG, Fuchs CS, Goessling W, Musliner TA, Tershakovec AM, Blazing MA, Califf R, Cannon CP, Braunwald E. Prospective Evaluation of Malignancy in 17,708 Patients Randomized to Ezetimibe Versus Placebo: Analysis From IMPROVE-IT. JACC CardioOncol 2020; 2:385-396. [PMID: 34396246 PMCID: PMC8352126 DOI: 10.1016/j.jaccao.2020.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND An increased risk of malignancy was reported with simvastatin/ezetimibe in 1,873 patients in the SEAS (Simvastatin and Ezetimibe in Aortic Stenosis) trial. OBJECTIVES The purpose of this study was to clarify this unexpected finding in a larger sample size of patients stabilized after acute coronary syndrome, we conducted a prospective systematic analysis of malignancy events in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial). METHODS Within IMPROVE-IT, 17,708 patients post-acute coronary syndrome were randomized to either ezetimibe 10 mg or matching placebo on a background of simvastatin 40 mg who took ≥1 dose of the study drug. Suspected tumors (benign and malignant) reported by investigators or identified from a review of adverse events were adjudicated by oncologists without knowledge of drug assignment. The primary malignancy endpoint included new, relapsing, or progressive malignancies (excluding nonmelanotic skin malignancies). The secondary endpoint was death due to malignancy. RESULTS In this trial, 1,470 patients developed the primary malignancy endpoint during a median 6 years of follow-up. The most common malignancy locations were prostate (18.9%), lung (16.8%), and bladder (8.8%) with no differences by treatment group (p > 0.05 for each location). Kaplan-Meier 7-year rates of malignancies were similar with ezetimibe and placebo (10.2% vs. 10.3%; hazard ratio: 1.03; 95% confidence interval: 0.93 to 1.14; p = 0.56), as were the rates for malignancy death (3.8% vs. 3.6%; hazard ratio: 1.04; 95% confidence interval: 0.88 to 1.23; p = 0.68). CONCLUSIONS Among 17,708 patients receiving simvastatin 40 mg daily, those randomized to ezetimibe 10 mg daily had a similar incidence of malignancy and deaths due to malignancy compared with those receiving placebo during a median follow-up of 6 years (96,377 patient-years). (IMPROVE-IT: Examining Outcomes in Subjects With Acute Coronary Syndrome: Vytorin [Ezetimibe/Simvastatin] vs Simvastatin [P04103]; NCT00202878).
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Key Words
- ACS, acute coronary syndrome
- BMI, body mass index
- CI, confidence interval
- HR, hazard ratio
- KM, Kaplan-Meier
- LDL-C, low-density lipoprotein cholesterol
- PCSK9, proprotein convertase subtilisin kexin 9
- PH, proportional hazard
- RR, risk ratio
- acute coronary syndromes
- cancer
- ezetimibe
- hs-CRP, high-sensitive C-reactive protein
- lipid-lowering therapy
- lipids
- malignancy
- statin
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Affiliation(s)
- Robert P. Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Baris Gencer
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen D. Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeong-Gun Park
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Charles S. Fuchs
- Smilow Cancer Hospital at Yale New Haven, New Haven, Connecticut, USA
| | - Wolfram Goessling
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | | | - Robert Califf
- Verily Life Sciences and Google Health, South San Francisco, California, USA
| | - Christopher P. Cannon
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Bonaca MP, Wiviott SD, Zelniker TA, Mosenzon O, Bhatt DL, Leiter LA, McGuire DK, Goodrich EL, De Mendonca Furtado RH, Wilding JPH, Cahn A, Gause-Nilsson IAM, Johanson P, Fredriksson M, Johansson PA, Langkilde AM, Raz I, Sabatine MS. Dapagliflozin and Cardiac, Kidney, and Limb Outcomes in Patients With and Without Peripheral Artery Disease in DECLARE-TIMI 58. Circulation 2020; 142:734-747. [PMID: 32795086 DOI: 10.1161/circulationaha.119.044775] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [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 Patients with peripheral artery disease (PAD) are at heightened risk of cardiovascular complications. The sodium-glucose cotransporter 2 inhibitor dapagliflozin reduces the risk for hospitalization for heart failure (HHF) and kidney events in patients with type 2 diabetes mellitus. An increased risk of amputation has been observed with canagliflozin in 1 previous trial. We examined cardiovascular and kidney efficacy and the risk of limb-related events in patients with and without PAD in an exploratory analysis. METHODS A total of 17 160 patients with type 2 diabetes mellitus, including 1025 (6%) with PAD, were randomized. Key efficacy outcomes were MACE (cardiovascular [CV] death, myocardial infarction, stroke), CV death/HHF, and progression of kidney disease. Amputations, peripheral revascularization, and limb ischemic adverse events were site-reported and categorized by a blinded reviewer. RESULTS Patients in the placebo arm with PAD versus those without tended to have higher adjusted risk of CV death, myocardial infarction, or stroke (adjusted hazard ratio [HR], 1.23 [95% CI, 0.97-1.56], P=0.094) and significantly higher adjusted risk of CV death/HHF (adjusted HR, 1.60 [95% CI, 1.21-2.12], P=0.0010) and progression of kidney disease (adjusted HR, 1.51 [95% CI, 1.13 - 2.03], P=0.0058), and limb adverse events (adjusted HR, 8.37, P<0.001). The relative risk reductions with dapagliflozin for CV death/HHF (HR, 0.86, PAD; HR, 0.82, no-PAD; P-interaction=0.79) and progression of kidney disease (HR, 0.78, PAD; HR, 0.76, no-PAD; P-interaction=0.84) were consistent regardless of PAD. There were 560 patients who had at least 1 limb ischemic event, 454 patients with at least 1 peripheral revascularization, and 236 patients with at least 1 amputation, with a total of 407 amputations reported. Overall, there were no significant differences in any limb outcome with dapagliflozin versus placebo including limb ischemic adverse events (HR, 1.07 [95% CI, 0.90-1.26]) and amputation (HR, 1.09 [95% CI, 0.84-1.40]), with no significant interactions by a history of PAD versus not (P-interactions=0.30 and 0.093, respectively). CONCLUSIONS Patients with versus without PAD are at a higher risk of CV death of CV death, HHF, and kidney outcomes, and have a consistent benefits for CV death/HHF and progression of kidney disease with dapagliflozin. Patients with PAD had a higher risk of limb events, with no consistent pattern of incremental risk observed with dapagliflozin. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01730534.
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Affiliation(s)
- Marc P Bonaca
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
| | - Stephen D Wiviott
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
| | - Thomas A Zelniker
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
| | - Ofri Mosenzon
- Diabetes Unit, Hadassah Medical Center, Hebrew University of Jerusalem, Israel (O.M., A.C., I.R.)
| | - Deepak L Bhatt
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Ontario, Canada (L.A.L.)
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Erica L Goodrich
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
| | - Remo Holanda De Mendonca Furtado
- Hospital Albert Einstein and Instituto do Coracao da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil (R.H.D.M.F.)
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, United Kingdom (J.P.H.W.)
| | - Avivit Cahn
- Diabetes Unit, Hadassah Medical Center, Hebrew University of Jerusalem, Israel (O.M., A.C., I.R.)
| | | | - Per Johanson
- AstraZeneca Gothenburg, Mölndal, Sweden (I.A.M.G.-N., P.J., M.F., P.A.J., A.M.L.)
| | - Martin Fredriksson
- AstraZeneca Gothenburg, Mölndal, Sweden (I.A.M.G.-N., P.J., M.F., P.A.J., A.M.L.)
| | - Peter A Johansson
- AstraZeneca Gothenburg, Mölndal, Sweden (I.A.M.G.-N., P.J., M.F., P.A.J., A.M.L.)
| | - Anna Maria Langkilde
- AstraZeneca Gothenburg, Mölndal, Sweden (I.A.M.G.-N., P.J., M.F., P.A.J., A.M.L.)
| | - Itamar Raz
- Diabetes Unit, Hadassah Medical Center, Hebrew University of Jerusalem, Israel (O.M., A.C., I.R.)
| | - Marc S Sabatine
- TIMI (Thrombolysis in Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Harvard Medical School, Boston, MA (M.P.B., S.D.W., T.A.Z., D.L.B., E.L.G., M.S.S.)
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Cahn A, Raz I, Bonaca M, Mosenzon O, Murphy SA, Yanuv I, Rozenberg A, Wilding JPH, Bhatt DL, McGuire DK, Gause-Nilsson IAM, Fredriksson M, Johansson PA, Jermendy G, Hadjadj S, Langkilde AM, Sabatine MS, Wiviott SD, Leiter LA. Safety of dapagliflozin in a broad population of patients with type 2 diabetes: Analyses from the DECLARE-TIMI 58 study. Diabetes Obes Metab 2020; 22:1357-1368. [PMID: 32239659 DOI: 10.1111/dom.14041] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023]
Abstract
AIMS To evaluate comprehensively the safety of dapagliflozin in patients with type 2 diabetes (T2DM), with emphasis placed on potential safety concerns related to the sodium-glucose co-transporter-2 inhibitor class. METHODS In the Dapagliflozin Effect on Cardiovascular Events - Thrombolysis in Myocardial Infarction 58 (DECLARE-TIMI 58) study, 17 160 patients with T2DM were randomized to dapagliflozin or placebo and followed for a median of 4.2 years. Safety was evaluated in 17 143 patients receiving at least one dose of study drug. RESULTS Acute kidney injury occurred less frequently with dapagliflozin, and adverse events suggestive of volume depletion were balanced between treatment groups, both irrespective of baseline estimated glomerular filtration rate, blood pressure, diuretic or loop diuretic use (interaction P values >0.05). Fractures and malignancies were balanced between the groups, irrespective of sex, diabetes duration or smoking (interaction P values >0.05) and fewer cases of bladder cancer occurred in the dapagliflozin versus the placebo group. Diabetic ketoacidosis was very rare, but more frequent with dapagliflozin versus placebo (27 vs. 12 patients with events; P = 0.02), yet signs, symptoms and contributing factors were similar in the two groups. Major hypoglycaemia occurred less frequently with dapagliflozin versus placebo, regardless of baseline use of either insulin or sulphonylureas (interaction P values >0.05). There were more adverse events of genital infections leading to discontinuation of study drug in the dapagliflozin versus the placebo group, but serious genital infections were few and balanced between treatment groups. Urinary tract infections, acute pyelonephritis and urosepsis were also balanced between treatment groups. CONCLUSIONS Dapagliflozin was well tolerated. The long duration and large number of patient-years in DECLARE-TIMI 58 comprehensively addressed previous safety questions, confirming the robust safety profile of dapagliflozin.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Endocinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Endocinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Marc Bonaca
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocinology and Metabolism, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, Faculty of Health and Life Science, University of Liverpool, Liverpool, UK
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Centre, Dallas, Texas
| | | | | | | | - Gyorgy Jermendy
- 3rd Medical Department, Bajcsy-Zsilinszky Teaching Hospital, Budapest, Hungary
| | - Samy Hadjadj
- L'institut du thorax, INSERM, CNRS, UNIV Nantes, CHU Nantes, Department of Endocrinology, Diabetes and Nutrition, Nantes, France
| | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Canada
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Bajaj HS, Raz I, Mosenzon O, Murphy SA, Rozenberg A, Yanuv I, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Sabatine MS, Wiviott SD, Cahn A. Cardiovascular and renal benefits of dapagliflozin in patients with short and long-standing type 2 diabetes: Analysis from the DECLARE-TIMI 58 trial. Diabetes Obes Metab 2020; 22:1122-1131. [PMID: 32090404 DOI: 10.1111/dom.14011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/15/2020] [Accepted: 02/18/2020] [Indexed: 01/07/2023]
Abstract
AIM To investigate whether the cardiovascular and renal benefits observed with dapagliflozin in the DECLARE-TIMI 58 trial are also observed in patients with short and long-standing diabetes. MATERIALS AND METHODS This post hoc analysis studied the dual primary efficacy endpoints, a composite of cardiovascular death or hospitalization for heart failure (CVD/HHF) and major adverse cardiovascular events (MACE; CVD, myocardial infarction [MI], ischaemic stroke) by diabetes duration. RESULTS Of the 17 160 patients, 3836 had diabetes duration of ≤5 years, 4731 >5-10 years, 3952 >10-15 years, 2433 >15-20 years and 2206 >20 years. Dapagliflozin reduced the risk of CVD/HHF by a similar amount across diabetes duration subgroups, ranging from HR 0.79 (0.58-1.06) in patients with diabetes duration of ≤5 years to 0.75 (0.55-1.03) in those patients with diabetes duration of >20 years (interaction trend P-value 0.76). Hazard ratios (HRs) for MACE ranged from 1.08 (0.87-1.35) in patients with diabetes duration of ≤5 years to 0.67 (0.52-0.86) in those patients with diabetes duration of >20 years (interaction trend P-value 0.004). This was driven by greater reductions in the risk of MI and ischaemic stroke with dapagliflozin in patients with long-standing diabetes (interaction trend P-values 0.019 and 0.015, respectively). The duration-based MACE heterogeneity was apparent in those with or without a history of prior MI and in those with multiple risk factors. The renal-specific outcome was reduced with dapagliflozin with HRs ranging from 0.79 (0.47-1.34) in patients with diabetes duration of ≤5 years to 0.42 (0.25-0.72) in those patients with diabetes duration of >20 years (interaction trend P-value 0.084). CONCLUSIONS Dapagliflozin reduced the risk of CVD/HHF consistently, regardless of diabetes duration, whereas the treatment effect for MACE differed by duration subgroups, with significant reductions with dapagliflozin in patients with long-standing diabetes.
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Affiliation(s)
- Harpreet S Bajaj
- LMC Diabetes and Endocrinology, Brampton, Ontario, Canada
- Leadership Sinai Center for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Itamar Raz
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Deepak L Bhatt
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | | | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Deharo P, Ducrocq G, Bode C, Cohen M, Cuisset T, Mehta SR, Pollack CV, Wiviott SD, Rao SV, Jukema JW, Erglis A, Moccetti T, Elbez Y, Steg PG. Blood transfusion and ischaemic outcomes according to anemia and bleeding in patients with non-ST-segment elevation acute coronary syndromes: Insights from the TAO randomized clinical trial. Int J Cardiol 2020; 318:7-13. [PMID: 32590084 DOI: 10.1016/j.ijcard.2020.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/01/2020] [Accepted: 06/12/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND The benefits and risks of blood transfusion in patients with acute myocardial infarction who are anemic or who experience bleeding are debated. We sought to study the association between blood transfusion and ischemic outcomes according to haemoglobin nadir and bleeding status in patients with NST-elevation myocardial infarction (NSTEMI). METHODS The TAO trial randomized patients with NSTEMI and coronary angiogram scheduled within 72h to heparin plus eptifibatide versus otamixaban. After exclusion of patients who underwent coronary artery bypass surgery, patients were categorized according to transfusion status considering transfusion as a time-varying covariate. The primary ischemic outcome was the composite of all-cause death or MI within 180 days of randomization. Subgroup analyses were performed according to pre-transfusion hemoglobin nadir and bleeding status. RESULTS 12,547 patients were enrolled. Among these, blood transfusion was used in 489 (3.9%) patients. Patients who received transfusion had a higher rate of death or MI (29.9% vs. 8.1%, p<0.01). This excess risk persisted after adjustment on GRACE score and nadir of hemoglobin (HR 3.36 95%CI 2.63-4.29 p<0.01). Subgroup analyses showed that blood transfusion was associated with a higher risk in patients without overt bleeding (adjusted HR 6.25 vs. 2.85; p-interaction 0.001) as well as in those with hemoglobin nadir > 9.0 g/dl (HR 4.01; p-interaction<0.0001). CONCLUSION In patients with NSTEMI, blood transfusion was associated with an overall increased risk of ischaemic events. However, this was mainly driven by patients without overt bleeding and those hemoglobin nadir > 9.0g/dl. This suggests possible harm of transfusion in those groups.
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Affiliation(s)
- P Deharo
- Département de Cardiologie, CHU Timone, Marseille F-13385, France; Aix Marseille Univ, Inserm, Inra, C2VN, Marseille, France; Aix-Marseille Université, Faculté de Médecine, F-13385 Marseille, France
| | - G Ducrocq
- Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France; French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Université de Paris, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - C Bode
- Heart Center Freiburg University, Cardiology and Angiology I, Faculty of Medicine, Freiburg, Germany
| | - M Cohen
- Rutgers-New Jersey medical school, Newark, New Jersey, USA; Newark Beth Israel medical centre, Newark, New Jersey, USA
| | - T Cuisset
- Département de Cardiologie, CHU Timone, Marseille F-13385, France
| | - S R Mehta
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - C V Pollack
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - S D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - S V Rao
- Department of Cardiology, Duke Clinical Research Institute, Durham, NC, USA
| | - J W Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; The Netherlands Heart Institute, Utrecht, the Netherlands
| | - A Erglis
- University of Latvia, Pauls Stradins Clinical University Hospita, Riga, Latvia
| | - T Moccetti
- Electrophysiology Unit, Department of Cardiology, Fondazione Cardiocentro Ticino, via Tesserete 48, 6900 Lugano, Switzerland
| | - Y Elbez
- Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France; French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Université de Paris, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - P G Steg
- Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France; French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Université de Paris, Institut National de la Santé et de la Recherche Médicale, Paris, France; National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, UK.
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48
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Murphy SA, Pedersen TR, Gaciong ZA, Ceska R, Ezhov MV, Connolly DL, Jukema JW, Toth K, Tikkanen MJ, Im K, Wiviott SD, Kurtz CE, Honarpour N, Giugliano RP, Keech AC, Sever PS, Sabatine MS. Effect of the PCSK9 Inhibitor Evolocumab on Total Cardiovascular Events in Patients With Cardiovascular Disease: A Prespecified Analysis From the FOURIER Trial. JAMA Cardiol 2020; 4:613-619. [PMID: 31116355 DOI: 10.1001/jamacardio.2019.0886] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [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: 01/14/2023]
Abstract
Importance The PCSK9 inhibitor evolocumab reduced low-density lipoprotein cholesterol and first cardiovascular events in the Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk (FOURIER) trial, but patients remain at high risk of recurrent cardiovascular events. Objective To evaluate the effect of evolocumab on total cardiovascular events, given the importance of total number of cardiovascular events to patients, clinicians, and health economists. Design, Setting, and Participants Secondary analysis of a randomized, double-blind clinical trial. The FOURIER trial compared evolocumab or matching placebo and followed up patients for a median of 2.2 years. The study included 27 564 patients with stable atherosclerotic disease receiving statin therapy. Data were analyzed between May 2017 and February 2019. Main Outcomes and Measures The primary end point (PEP) was time to first cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization; the key secondary end point was time to first cardiovascular death, myocardial infarction, or stroke. In a prespecified analysis, total cardiovascular events were evaluated between treatment arms. Results The mean age of patients was 63 years, 69% of patients were taking high-intensity statin therapy, and the median LDL-C at baseline was 92 mg/dL (to convert to millimoles per liter, multiply by 0.0259). There were 2907 first PEP events and 4906 total PEP events during the trial. Evolocumab reduced total PEP events by 18% (incidence rate ratio [RR], 0.82; 95% CI, 0.75-0.90; P < .001) including both first events (hazard ratio, 0.85; 95% CI, 0.79-0.92; P < .001) and subsequent events (RR, 0.74; 95% CI, 0.65-0.85). There were 2192 total primary events in the evolocumab group and 2714 total events in the placebo group. For every 1000 patients treated for 3 years, evolocumab prevented 22 first PEP events and 52 total PEP events. Reductions in total events were driven by fewer total myocardial infarctions (RR, 0.74; 95% CI, 0.65-0.84; P < .001), strokes (RR, 0.77; 95% CI, 0.64-0.93; P = .007), and coronary revascularizations (RR, 0.78; 95% CI, 0.71-0.87; P < .001). Conclusions and Relevance The addition of the PCSK9 inhibitor evolocumab to statin therapy improved clinical outcomes, with significant reductions in total PEP events, driven by decreases in myocardial infarction, stroke, and coronary revascularization. More than double the number of events were prevented with evolocumab vs placebo as compared with the analysis of only first events. These data provide further support for the benefit of continuing aggressive lipid-lowering therapy to prevent recurrent cardiovascular events. Trial Registration ClinicalTrials.gov identifier: NCT01764633.
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Affiliation(s)
- Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Masschusetts
| | - Terje R Pedersen
- Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo, Norway
| | - Zbigniew A Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, The Medical University of Warsaw, Warsaw, Poland
| | - Richard Ceska
- Center for Preventive Cardiology, 3rd Internal Medicine Clinic, University General Hospital and Charles University 1st Medical Faculty, Prague, Czech Republic
| | | | - Derek L Connolly
- Birmingham City and Sandwell Hospitals and the Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, England
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Kalman Toth
- First Department of Medicine, University of Pecs, Medical School, Pecs, Hungary
| | - Matti J Tikkanen
- Folkhälsan Research Center, University of Helsinki, Helsinki, Finland
| | - Kyungah Im
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Masschusetts
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Masschusetts
| | | | | | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Masschusetts
| | - Anthony C Keech
- Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
| | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Masschusetts.,Deputy Editor
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49
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Koren MJ, Sabatine MS, Giugliano RP, Langslet G, Wiviott SD, Ruzza A, Ma Y, Hamer AW, Wasserman SM, Raal FJ. Long-Term Efficacy and Safety of Evolocumab in Patients With Hypercholesterolemia. J Am Coll Cardiol 2020; 74:2132-2146. [PMID: 31648705 DOI: 10.1016/j.jacc.2019.08.1024] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 07/16/2019] [Accepted: 08/04/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Evolocumab and other anti-PCSK9 antibodies reduced adverse cardiovascular outcomes in clinical trials of high-risk patients over <3 years median treatment duration. OBJECTIVES The OSLER-1 trial (Open Label Study of Long Term Evaluation Against LDL-C Trial) evaluated longer-term effects of evolocumab during open-label hypercholesterolemia treatment for up to 5 years. METHODS Patients randomized to standard of care (SOC) or evolocumab 420 mg monthly (evolocumab + SOC) for year 1. After year 1, patients could enter the all-evolocumab period and receive evolocumab + SOC for an additional 4 years. The authors analyzed the persistence of lipid effects and exposure-dependent safety focusing on yearly rates of adverse events (AEs) and anti-drug antibodies over 4.951 patient-years of observation. RESULTS A total of 1,255 patients (safety analysis population) randomized into the year 1 SOC-controlled period and received ≥1 evolocumab dose (mean ± SD age 57 ± 12 years; 53% female). A total of 1,151 patients (efficacy analysis population) progressed to the all-evolocumab period (year 2 and beyond). Evolocumab + SOC persistently lowered mean ± SE low-density lipoprotein cholesterol (LDL-C) by 56% ± 0.6% (n = 1,071), 57% ± 0.8% (n = 1,001), 56% ± 0.8% (n = 943), and 56% ± 0.8% (n = 803) after approximately 2, 3, 4, and 5 years, respectively, from randomization. Mean baseline LDL-C decreased from 140 to 61 mg/dl on treatment. Yearly serious AE rates during evolocumab + SOC ranged from 6.9% to 7.9%, comparable to the 6.8% rate in SOC patients during year 1. Evolocumab discontinuation due to AEs occurred in 5.7% of patients. Two SOC and 2 evolocumab + SOC patients developed new, transient, binding anti-drug antibodies; no neutralizing antibodies were observed. CONCLUSIONS The OSLER-1 trial demonstrated consistently excellent LDL-C-lowering efficacy, tolerance, and safety of evolocumab, with no neutralizing antibodies detected, throughout the longest-duration study of a PCSK9 inhibitor reported to date. (Open Label Study of Long Term Evaluation Against LDL-C Trial [OSLER-1]; NCT01439880).
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Affiliation(s)
- Michael J Koren
- Jacksonville Center for Clinical Research, Jacksonville, Florida.
| | - Marc S Sabatine
- Thrombolysis In Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert P Giugliano
- Thrombolysis In Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Stephen D Wiviott
- Thrombolysis In Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrea Ruzza
- Amgen, One Amgen Center Drive, Thousand Oaks, California
| | - Yuhui Ma
- Amgen, One Amgen Center Drive, Thousand Oaks, California
| | - Andrew W Hamer
- Amgen, One Amgen Center Drive, Thousand Oaks, California
| | | | - Frederick J Raal
- The Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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50
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Sun MT, Huang S, Wiviott SD, Antman EM, Roe MT, Ohman EM, Neely M, Wallentin L, Wong CX. Meta-Analysis of Intraocular Bleeding With Dual Antiplatelet Therapy Using P2Y12 Inhibitors Prasugrel or Ticagrelor. Am J Cardiol 2020; 125:1280-1283. [PMID: 32081368 DOI: 10.1016/j.amjcard.2020.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/04/2020] [Accepted: 01/10/2020] [Indexed: 10/25/2022]
Abstract
Intraocular bleeding is a devastating clinical event due to its potentially blinding nature. It is not known if determine if dual antiplatelet therapy using aspirin and potent P2Y12 inhibitors increases this risk. We searched MEDLINE and ClinicalTrials.gov for randomized controlled trials that were phase III, randomly assigned patients to dual antiplatelet therapy with either aspirin and a potent P2Y12 inhibitor or aspirin and clopidogrel, had follow-up of 6 months, and at least 200 patients. Corresponding authors were contacted for intraocular bleeding data. Inverse-variance, weighted, fixed-effects meta-analysis was undertaken, with random-effects meta-analysis performed as a sensitivity analysis. Four trials enrolling 42,850 patients were included. The median follow-up ranged from 12 to 14 months. There was overall low risk of bias. Pooled analysis demonstrated no statistically significant increase in the risk of intraocular bleeding with dual antiplatelet therapy using potent P2Y12 inhibitors compared with clopidogrel (risk ratio 0.89, 95% confidence interval 0.58 to 1.36). There was no significant heterogeneity observed across trials (I2 statistic 0%, p = 0.98). The use of random-effects meta-analysis did not change the effect estimate or confidence intervals, and the results appeared similar when stratified by potent P2Y12 inhibitor (p = 0.97). In conclusion, this collaborative meta-analysis of dual antiplatelet trials does not suggest that the risk of intraocular bleeding is increased with the use of potent P2Y12 inhibitors compared with clopidogrel. Our results suggest that these potent P2Y12 inhibitors may continue to be used cautiously where indicated as part of dual antiplatelet therapy, even in those at high risk of spontaneous intraocular bleeding.
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