Pub Date : 2024-05-07DOI: 10.1016/j.ahj.2024.05.005
Yejin Mok PhD,MPH , Yifei Lu PhD , Shoshana H. Ballew PhD , Yingying Sang MS , Anna Kucharska-Newton PhD,MPH , Mauro F. Mediano PhD , Silvia Koton PhD , Jennifer A. Schrack PhD , Priya Palta PhD , Josef Coresh MD,PhD , Wayne Rosamond PhD , Kunihiro Matsushita MD,PhD
Background
High to moderate levels of physical activity (PA) are associated with low risk of incident cardiovascular disease. However, it is unclear whether the benefits of PA in midlife extend to cardiovascular health following myocardial infarction (MI) in later life.
Methods
Among 1,111 Atherosclerosis Risk in Communities study participants with incident MI during Atherosclerosis Risk in Communities follow-up (mean age 73 [SD 9] years at MI, 54% men, 21% Black), PA on average 11.9 (SD 6.9) years prior to incident MI (premorbid PA) was evaluated as the average score of PA between visit 1 (1987-1989) and visit 3 (1993-1995) using a modified Baecke questionnaire. Total and domain-specific PA (sport, nonsport leisure, and work PA) was analyzed for associations with composite and individual outcomes of mortality, recurrent MI, and stroke after index MI using multivariable Cox models.
Results
During a median follow-up of 4.6 (IQI 1.0-10.5) years after incident MI, 823 participants (74%) developed a composite outcome. The 10-year cumulative incidence of the composite outcome was lower in the highest, as compared to the lowest tertile of premorbid total PA (56% vs. 70%, respectively). This association remained statistically significant even after adjusting for potential confounders (adjusted hazard ratio [aHR] 0.80 [0.67-0.96] for the highest vs. lowest tertile). For individual outcomes, high premorbid total PA was associated with a low risk of recurrent MI (corresponding aHR 0.64 [0.44, 0.93]). When domain-specific PA was analyzed, similar results were seen for sport and work PA. The association was strongest in the first year following MI (e.g., aHR of composite outcome 0.66 [95% CI 0.47, 0.91] for the highest vs. lowest tertile of total PA).
Conclusions
Premorbid PA was associated positively with post-MI cardiovascular health. Our results demonstrate the additional prognostic advantages of PA beyond reducing the risk of incident MI.
背景:中高水平的体力活动(PA)与心血管疾病的低发病风险有关。然而,目前还不清楚中年时进行体育锻炼的益处是否会延伸到晚年心肌梗塞(MI)后的心血管健康:在 ARIC 随访期间发生心肌梗死的 111 名 ARIC 参与者中(发生心肌梗死时平均年龄为 73 [SD 9] 岁,54% 为男性,21% 为黑人),使用改良的 Baecke 问卷对发生心肌梗死前平均 11.9(SD 6.9)年的 PA(病前 PA)进行了评估,即访问 1(1987-89 年)至访问 3(1993-95 年)期间 PA 的平均得分。使用多变量 Cox 模型分析了总 PA 和特定领域 PA(运动、非运动休闲和工作 PA)与指数心肌梗死后死亡率、复发性心肌梗死和中风的综合和个体结果的关系:在发生心肌梗死后中位随访 4.6(IQI 1.0-10.5)年期间,823 名参与者(74%)出现了综合结果。与病前总PA值最低的三等分位数相比,病前总PA值最高的三等分位数的10年累积综合结果发生率较低(分别为56%和70%)。即使在调整了潜在的混杂因素后,这种关联仍具有统计学意义(最高三分位数与最低三分位数的调整后危险比 [aHR] 为 0.80 [0.67-0.96])。就单个结果而言,病前总PA高与复发性心肌梗死的低风险相关(相应的aHR为0.64 [0.44, 0.93])。在分析特定领域的 PA 时,运动 PA 和工作 PA 的结果相似。在心肌梗死后的第一年,这种关联性最强(例如,总PA最高与最低三分位数的综合结果aHR为0.66 [95% CI 0.47, 0.91]):结论:病前 PA 与心肌梗死后的心血管健康呈正相关。我们的研究结果表明,除了降低发生心肌梗死的风险外,PA 还具有额外的预后优势。
{"title":"Premorbid physical activity and prognosis after incident myocardial infarction: The atherosclerosis risk in communities study","authors":"Yejin Mok PhD,MPH , Yifei Lu PhD , Shoshana H. Ballew PhD , Yingying Sang MS , Anna Kucharska-Newton PhD,MPH , Mauro F. Mediano PhD , Silvia Koton PhD , Jennifer A. Schrack PhD , Priya Palta PhD , Josef Coresh MD,PhD , Wayne Rosamond PhD , Kunihiro Matsushita MD,PhD","doi":"10.1016/j.ahj.2024.05.005","DOIUrl":"10.1016/j.ahj.2024.05.005","url":null,"abstract":"<div><h3>Background</h3><p>High to moderate levels of physical activity (PA) are associated with low risk of incident cardiovascular disease. However, it is unclear whether the benefits of PA in midlife extend to cardiovascular health following myocardial infarction (MI) in later life.</p></div><div><h3>Methods</h3><p>Among 1,111 Atherosclerosis Risk in Communities study participants with incident MI during Atherosclerosis Risk in Communities follow-up (mean age 73 [SD 9] years at MI, 54% men, 21% Black), PA on average 11.9 (SD 6.9) years prior to incident MI (premorbid PA) was evaluated as the average score of PA between visit 1 (1987-1989) and visit 3 (1993-1995) using a modified Baecke questionnaire. Total and domain-specific PA (sport, nonsport leisure, and work PA) was analyzed for associations with composite and individual outcomes of mortality, recurrent MI, and stroke after index MI using multivariable Cox models.</p></div><div><h3>Results</h3><p>During a median follow-up of 4.6 (IQI 1.0-10.5) years after incident MI, 823 participants (74%) developed a composite outcome. The 10-year cumulative incidence of the composite outcome was lower in the highest, as compared to the lowest tertile of premorbid total PA (56% vs. 70%, respectively). This association remained statistically significant even after adjusting for potential confounders (adjusted hazard ratio [aHR] 0.80 [0.67-0.96] for the highest vs. lowest tertile). For individual outcomes, high premorbid total PA was associated with a low risk of recurrent MI (corresponding aHR 0.64 [0.44, 0.93]). When domain-specific PA was analyzed, similar results were seen for sport and work PA. The association was strongest in the first year following MI (e.g., aHR of composite outcome 0.66 [95% CI 0.47, 0.91] for the highest vs. lowest tertile of total PA).</p></div><div><h3>Conclusions</h3><p>Premorbid PA was associated positively with post-MI cardiovascular health. Our results demonstrate the additional prognostic advantages of PA beyond reducing the risk of incident MI.</p></div>","PeriodicalId":7868,"journal":{"name":"American heart journal","volume":null,"pages":null},"PeriodicalIF":4.8,"publicationDate":"2024-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140896767","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-06DOI: 10.1016/j.ahj.2024.04.018
Giulia Corn PhD , Marie Lund MD, PhD , Niklas W. Andersson MD , Tine L. Dohlmann MSc, PhD , Mark A. Hlatky MD , Jan Wohlfahrt MSc, DrMedSci , Mads Melbye MD, DrMedSci
Background
The response of low-density lipoprotein cholesterol (LDL-C) to statin therapy is variable, and may be affected by the presence of co-morbid conditions or the use of concomitant medications. Systematic variation in the response to statins based on these factors could affect the selection of the statin treatment regimen in population subgroups. We investigated whether common comorbidities and co-medications had clinically important effects on statin responses in individual patients.
Methods
This register-based cohort study included 89,006 simvastatin or atorvastatin initiators with measurements of pre-statin and on-statin LDL-C levels, in Denmark, 2008-2018. We defined statin response as the percentage reduction in LDL-C, and used linear regression to estimate percentage reduction differences (PRD) according to 175 chronic comorbidities and 99 co-medications. We evaluated both the statistical significance (P-values corrected for multiple testing) and the clinical importance (PRD of 5 percentage points or more) of the observed associations.
Results
Concomitant use of oral blood-glucose lowering drugs, which included metformin in 96% of treated individuals, was associated with a greater response to statin therapy that was both statistically significant and clinically important, with a PRD of 5.18 (95% confidence interval: 4.79 to 5.57). No other comorbidity or co-medication reached the prespecified thresholds for a significant, clinically important effect on statin response. Overall, comorbidities and co-medications had little effect on statin response, and altogether explained only 1.7% of the total observed population variance.
Conclusion
Most of the studied comorbidities and co-medications did not have a clinically important effect on statin response, suggesting no need to modify treatment regimens. However, use of metformin was associated with a significantly enhanced LDL-C response to statins, suggesting that lower statin doses may be effective in patients taking metformin.
{"title":"Low-density lipoprotein cholesterol response to statins according to comorbidities and co-medications: A population-based study","authors":"Giulia Corn PhD , Marie Lund MD, PhD , Niklas W. Andersson MD , Tine L. Dohlmann MSc, PhD , Mark A. Hlatky MD , Jan Wohlfahrt MSc, DrMedSci , Mads Melbye MD, DrMedSci","doi":"10.1016/j.ahj.2024.04.018","DOIUrl":"10.1016/j.ahj.2024.04.018","url":null,"abstract":"<div><h3>Background</h3><p>The response of low-density lipoprotein cholesterol (LDL-C) to statin therapy is variable, and may be affected by the presence of co-morbid conditions or the use of concomitant medications. Systematic variation in the response to statins based on these factors could affect the selection of the statin treatment regimen in population subgroups. We investigated whether common comorbidities and co-medications had clinically important effects on statin responses in individual patients.</p></div><div><h3>Methods</h3><p>This register-based cohort study included 89,006 simvastatin or atorvastatin initiators with measurements of pre-statin and on-statin LDL-C levels, in Denmark, 2008-2018. We defined statin response as the percentage reduction in LDL-C, and used linear regression to estimate percentage reduction differences (PRD) according to 175 chronic comorbidities and 99 co-medications. We evaluated both the statistical significance (<em>P</em>-values corrected for multiple testing) and the clinical importance (PRD of 5 percentage points or more) of the observed associations.</p></div><div><h3>Results</h3><p>Concomitant use of oral blood-glucose lowering drugs, which included metformin in 96% of treated individuals, was associated with a greater response to statin therapy that was both statistically significant and clinically important, with a PRD of 5.18 (95% confidence interval: 4.79 to 5.57). No other comorbidity or co-medication reached the prespecified thresholds for a significant, clinically important effect on statin response. Overall, comorbidities and co-medications had little effect on statin response, and altogether explained only 1.7% of the total observed population variance.</p></div><div><h3>Conclusion</h3><p>Most of the studied comorbidities and co-medications did not have a clinically important effect on statin response, suggesting no need to modify treatment regimens. However, use of metformin was associated with a significantly enhanced LDL-C response to statins, suggesting that lower statin doses may be effective in patients taking metformin.</p></div>","PeriodicalId":7868,"journal":{"name":"American heart journal","volume":null,"pages":null},"PeriodicalIF":4.8,"publicationDate":"2024-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0002870324001054/pdfft?md5=389b47d88aa9cf0f546a6bb2530b5300&pid=1-s2.0-S0002870324001054-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140849368","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-06DOI: 10.1016/j.ahj.2024.05.001
Fengqing Zhang MD , Meice Tian MD , Xiaohu Wang MD, Haotian Zhang MD, Xingtong Zhou MD, Rui Liu MD, Rui Liu MD, Zejian Jin MD, Changwei Zhang MD, Xianqiang Wang MD
Background
Previous studies suggested only the radial artery and the No-touch (NT) technique were effective in reducing graft occlusion after coronary artery bypass grafting (CABG) surgery. However, there is no randomized trial comparing these 2 graft conduits. The optimum second conduit for CABG remains undetermined.
Materials and methods
This study is a prospective, single-center randomized clinical trial, aiming to compare the graft patency between the radial artery and the NT vein graft. All patients undergoing isolated CABG with left internal mammary artery (LIMA) plus at least 2 additional grafts will be considered eligible. About 774 cases (516 in the radial artery group and 258 in the NT vein group) will be enrolled in over 1 to 2 years. Participants will be randomized and allocated to two bypass strategies: the LIMA plus 1 radial artery and 1 conventional vein graft, or the LIMA plus 2 NT vein grafts. The primary outcome is graft occlusion at 1 year after CABG evaluated by CT angiography. The secondary outcomes include graft occlusion at 3 and 5 years and major adverse cardiac or cerebrovascular events at 1, 3, and 5 years follow-ups.
Discussion
This study will define whether or not the NT vein has a lower graft occlusion rate than the radial artery in short and mid-term follow-ups, and provide new evidence for the second conduit choice in CABG surgery.
Trial registration
ClinicalTrials.gov NCT06014047. Registered on October 15th, 2023.
{"title":"Rationale and design of a single-center randomized trial to compare the graft patency between the radial artery and the no-touch saphenous vein in coronary artery bypass grafting surgery (GRAFT-CAB Study)","authors":"Fengqing Zhang MD , Meice Tian MD , Xiaohu Wang MD, Haotian Zhang MD, Xingtong Zhou MD, Rui Liu MD, Rui Liu MD, Zejian Jin MD, Changwei Zhang MD, Xianqiang Wang MD","doi":"10.1016/j.ahj.2024.05.001","DOIUrl":"10.1016/j.ahj.2024.05.001","url":null,"abstract":"<div><h3>Background</h3><p>Previous studies suggested only the radial artery and the No-touch (NT) technique were effective in reducing graft occlusion after coronary artery bypass grafting (CABG) surgery. However, there is no randomized trial comparing these 2 graft conduits. The optimum second conduit for CABG remains undetermined.</p></div><div><h3>Materials and methods</h3><p>This study is a prospective, single-center randomized clinical trial, aiming to compare the graft patency between the radial artery and the NT vein graft. All patients undergoing isolated CABG with left internal mammary artery (LIMA) plus at least 2 additional grafts will be considered eligible. About 774 cases (516 in the radial artery group and 258 in the NT vein group) will be enrolled in over 1 to 2 years. Participants will be randomized and allocated to two bypass strategies: the LIMA plus 1 radial artery and 1 conventional vein graft, or the LIMA plus 2 NT vein grafts. The primary outcome is graft occlusion at 1 year after CABG evaluated by CT angiography. The secondary outcomes include graft occlusion at 3 and 5 years and major adverse cardiac or cerebrovascular events at 1, 3, and 5 years follow-ups.</p></div><div><h3>Discussion</h3><p>This study will define whether or not the NT vein has a lower graft occlusion rate than the radial artery in short and mid-term follow-ups, and provide new evidence for the second conduit choice in CABG surgery.</p></div><div><h3>Trial registration</h3><p>ClinicalTrials.gov NCT06014047. Registered on October 15th, 2023.</p></div>","PeriodicalId":7868,"journal":{"name":"American heart journal","volume":null,"pages":null},"PeriodicalIF":4.8,"publicationDate":"2024-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140850209","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-04DOI: 10.1016/j.ahj.2024.05.002
Stephen J. Nicholls MBBS, PhD , Adam J. Nelson MBBS, MBA, MPH, PhD , Marc Ditmarsch MD , John J.P. Kastelein MD, PhD , Christie M. Ballantyne MD , Kausik K. Ray MD, MPhil, FMedSci , Ann Marie Navar MD , Steven E. Nissen MD , Anne C. Golberg MD , Liam R. Brunham MDPhD , Danielle Curcio MBA , Erin Wuerdeman MS , Annie Neild PhD , Douglas Kling MBA , &rew Hsieh PharmD , Mary R. Dicklin PhD , Brian A. Ference MD, MPhil, MSc , Ulrich Laufs MD, PhD , Maciej Banach MD, PhD , Roxana Mehran MD , Michael H. Davidson MD
Background
Obicetrapib, a novel, selective cholesteryl ester transfer protein (CETP) inhibitor, reduces low-density lipoprotein cholesterol (LDL-C), LDL particles, apolipoprotein (Apo) B, and lipoprotein(a) [Lp(a)] and increases high-density lipoprotein cholesterol (HDL-C) when added to statins with or without ezetimibe. By substantially reducing LDL-C, obicetrapib has the potential to lower atherogenic lipoproteins in patients with atherosclerotic cardiovascular disease (ASCVD) or heterozygous familial hypercholesterolemia (HeFH) whose LDL-C levels remain high despite treatment with available maximally tolerated lipid-modifying therapies, addressing an unmet medical need in a patient population at high risk for cardiovascular events.
Methods and results
BROADWAY (NCT05142722) and BROOKLYN (NCT05425745) are ongoing placebo-controlled, double-blind, randomized Phase III trials designed to examine the efficacy, safety, and tolerability of obicetrapib as an adjunct to dietary intervention and maximally tolerated lipid-modifying therapies in participants with a history of ASCVD and/or underlying HeFH whose LDL-C is not adequately controlled. The primary efficacy endpoint was the percent change in LDL-C from baseline to day 84. Other endpoints included changes in Apo B, non-HDL-C, HDL-C, Apo A1, Lp(a), and triglycerides in addition to parameters evaluating safety, tolerability, and pharmacokinetics. BROADWAY also included an adjudicated assessment of major adverse cardiovascular events, measurements of glucose homeostasis, and an ambulatory blood pressure monitoring substudy. A total of 2,532 participants were randomized in BROADWAY and 354 in BROOKLYN to receive obicetrapib 10 mg or placebo (2:1) for 365 days with follow-up through 35 days after the last dose. Results from both trials are anticipated in 2024.
Conclusion
These trials will provide safety and efficacy data to support the potential use of obicetrapib among patients with ASCVD or HeFH with elevated LDL-C for whom existing therapies are not sufficiently effective or well-tolerated.
{"title":"Obicetrapib on top of maximally tolerated lipid‐modifying therapies in participants with or at high risk for atherosclerotic cardiovascular disease: rationale and designs of BROADWAY and BROOKLYN","authors":"Stephen J. Nicholls MBBS, PhD , Adam J. Nelson MBBS, MBA, MPH, PhD , Marc Ditmarsch MD , John J.P. Kastelein MD, PhD , Christie M. Ballantyne MD , Kausik K. Ray MD, MPhil, FMedSci , Ann Marie Navar MD , Steven E. Nissen MD , Anne C. Golberg MD , Liam R. Brunham MDPhD , Danielle Curcio MBA , Erin Wuerdeman MS , Annie Neild PhD , Douglas Kling MBA , &rew Hsieh PharmD , Mary R. Dicklin PhD , Brian A. Ference MD, MPhil, MSc , Ulrich Laufs MD, PhD , Maciej Banach MD, PhD , Roxana Mehran MD , Michael H. Davidson MD","doi":"10.1016/j.ahj.2024.05.002","DOIUrl":"10.1016/j.ahj.2024.05.002","url":null,"abstract":"<div><h3>Background</h3><p>Obicetrapib, a novel, selective cholesteryl ester transfer protein (CETP) inhibitor, reduces low-density lipoprotein cholesterol (LDL-C), LDL particles, apolipoprotein (Apo) B, and lipoprotein(a) [Lp(a)] and increases high-density lipoprotein cholesterol (HDL-C) when added to statins with or without ezetimibe. By substantially reducing LDL-C, obicetrapib has the potential to lower atherogenic lipoproteins in patients with atherosclerotic cardiovascular disease (ASCVD) or heterozygous familial hypercholesterolemia (HeFH) whose LDL-C levels remain high despite treatment with available maximally tolerated lipid-modifying therapies, addressing an unmet medical need in a patient population at high risk for cardiovascular events.</p></div><div><h3>Methods and results</h3><p>BROADWAY (NCT05142722) and BROOKLYN (NCT05425745) are ongoing placebo-controlled, double-blind, randomized Phase III trials designed to examine the efficacy, safety, and tolerability of obicetrapib as an adjunct to dietary intervention and maximally tolerated lipid-modifying therapies in participants with a history of ASCVD and/or underlying HeFH whose LDL-C is not adequately controlled. The primary efficacy endpoint was the percent change in LDL-C from baseline to day 84. Other endpoints included changes in Apo B, non-HDL-C, HDL-C, Apo A1, Lp(a), and triglycerides in addition to parameters evaluating safety, tolerability, and pharmacokinetics. BROADWAY also included an adjudicated assessment of major adverse cardiovascular events, measurements of glucose homeostasis, and an ambulatory blood pressure monitoring substudy. A total of 2,532 participants were randomized in BROADWAY and 354 in BROOKLYN to receive obicetrapib 10 mg or placebo (2:1) for 365 days with follow-up through 35 days after the last dose. Results from both trials are anticipated in 2024.</p></div><div><h3>Conclusion</h3><p>These trials will provide safety and efficacy data to support the potential use of obicetrapib among patients with ASCVD or HeFH with elevated LDL-C for whom existing therapies are not sufficiently effective or well-tolerated.</p></div>","PeriodicalId":7868,"journal":{"name":"American heart journal","volume":null,"pages":null},"PeriodicalIF":4.8,"publicationDate":"2024-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0002870324001169/pdfft?md5=2f77ee2270a5f61edfb6acafea45fd22&pid=1-s2.0-S0002870324001169-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140847637","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-02DOI: 10.1016/j.ahj.2024.04.020
Herbert I. Weisberg PhD , Megan Dailey Higgs PhD
Clinicians often suspect that a treatment effect can vary across individuals. However, they usually lack “evidence-based” guidance regarding potential heterogeneity of treatment effects (HTE). Potentially actionable HTE is rarely discovered in clinical trials and is widely believed (or rationalized) by researchers to be rare. Conventional statistical methods to test for possible HTE are extremely conservative and tend to reinforce this belief. In truth, though, there is no realistic way to know whether a common, or average, effect estimated from a clinical trial is relevant for all, or even most, patients. This absence of evidence, misinterpreted as evidence of absence, may be resulting in sub-optimal treatment for many individuals. We first summarize the historical context in which current statistical methods for randomized controlled trials (RCTs) were developed, focusing on the conceptual and technical limitations that shaped, and restricted, these methods. In particular, we explain how the common-effect assumption came to be virtually unchallenged. Second, we propose a simple graphical method for exploratory data analysis that can provide useful visual evidence of possible HTE. The basic approach is to display the complete distribution of outcome data rather than relying uncritically on simple summary statistics. Modern graphical methods, unavailable when statistical methods were initially formulated a century ago, now render fine-grained interrogation of the data feasible. We propose comparing observed treatment-group data to “pseudo data” engineered to mimic that which would be expected under a particular HTE model, such as the common-effect model. A clear discrepancy between the distributions of the common-effect pseudo data and the actual treatment-effect data provides prima facie evidence of HTE to motivate additional confirmatory investigation. Artificial data are used to illustrate implications of ignoring heterogeneity in practice and how the graphical method can be useful.
{"title":"Lifting the veil off treatment effect heterogeneity","authors":"Herbert I. Weisberg PhD , Megan Dailey Higgs PhD","doi":"10.1016/j.ahj.2024.04.020","DOIUrl":"10.1016/j.ahj.2024.04.020","url":null,"abstract":"<div><p>Clinicians often suspect that a treatment effect can vary across individuals. However, they usually lack “evidence-based” guidance regarding potential heterogeneity of treatment effects (HTE). Potentially actionable HTE is rarely discovered in clinical trials and is widely believed (or rationalized) by researchers to be rare. Conventional statistical methods to test for possible HTE are extremely conservative and tend to reinforce this belief. In truth, though, there is no realistic way to know whether a common, or average, effect estimated from a clinical trial is relevant for all, or even most, patients. This absence of evidence, misinterpreted as evidence of absence, may be resulting in sub-optimal treatment for many individuals. We first summarize the historical context in which current statistical methods for randomized controlled trials (RCTs) were developed, focusing on the conceptual and technical limitations that shaped, and restricted, these methods. In particular, we explain how the common-effect assumption came to be virtually unchallenged. Second, we propose a simple graphical method for exploratory data analysis that can provide useful visual evidence of possible HTE. The basic approach is to display the complete distribution of outcome data rather than relying uncritically on simple summary statistics. Modern graphical methods, unavailable when statistical methods were initially formulated a century ago, now render fine-grained interrogation of the data feasible. We propose comparing observed treatment-group data to “pseudo data” engineered to mimic that which would be expected under a particular HTE model, such as the common-effect model. A clear discrepancy between the distributions of the common-effect pseudo data and the actual treatment-effect data provides prima facie evidence of HTE to motivate additional confirmatory investigation. Artificial data are used to illustrate implications of ignoring heterogeneity in practice and how the graphical method can be useful.</p></div>","PeriodicalId":7868,"journal":{"name":"American heart journal","volume":null,"pages":null},"PeriodicalIF":4.8,"publicationDate":"2024-05-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140850099","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.ahj.2024.04.011
Yuchao Guo MD , Xianbao Liu MD , Ranxi Li BM , Stella Ng BM , Qiong Liu PhD , Lihan Wang MMed , Po Hu MMed , Kaida Ren MD , Jubo Jiang MMed , Jiaqi Fan MD , Yuxin He MD , Qifeng Zhu MD , Xinping Lin MMed , Huajun Li MMed , Jian'an Wang MD
Background
There has not been a consensus on the prothesis sizing strategy in type 0 bicuspid aortic stenosis (AS) patients undergoing transcatheter aortic valve replacement (TAVR). Modifications to standard annular sizing strategies might be required due to the distinct anatomical characteristics. We have devised a downsizing strategy for TAVR using a self-expanding valve specifically for patients with type 0 bicuspid AS. The primary aim of this study is to compare the safety and efficacy of downsizing strategy with the Standard Annulus Sizing Strategy in TAVR for patients with type 0 bicuspid AS.
Trial design
It is a prospective, multi-center, superiority, single-blinded, randomized controlled trial comparing the Down Sizing and Standard Annulus Sizing Strategy in patients with type 0 bicuspid aortic stenosis undergoing transcatheter aortic valve replacement. Eligible participants will include patients with severe type 0 bicuspid AS, as defined by criteria such as mean gradient across aortic valve ≥40 mmHg, peak aortic jet velocity ≥4.0 m/s, aortic valve area (AVA) ≤1.0 cm², or AVA index ≤0.6 cm2/m2. These patients will be randomly assigned, in a 1:1 ratio, to either the Down Sizing Strategy group or the Standard Sizing Strategy group. In the Down Sizing Strategy group, a valve one size smaller will be implanted if the “waist sign” manifests along with less than mild regurgitation during balloon pre-dilatation. The primary end point of the study is a composite of VARC-3 defined device success, absence of both permanent pacemaker implantation due to high-degree atrioventricular block and new-onset complete left bundle branch block.
Conclusion
This study will compare the safety and efficacy of Down Sizing Strategy with the Standard Annulus Sizing Strategy and provide valuable insights into the optimal approach for sizing in TAVR patients with type 0 bicuspid AS. We hypothesize that the Down Sizing Strategy will demonstrate superiority when compared to the Standard Annulus Sizing Strategy. (Down Sizing Strategy (HANGZHOU Solution) vs Standard Sizing Strategy TAVR in Bicuspid Aortic Stenosis (Type 0) (TAILOR-TAVR), NCT05511792).
背景:对于接受经导管主动脉瓣置换术(TAVR)的0型双尖瓣主动脉瓣狭窄(AS)患者的人工瓣膜尺寸策略尚未达成共识。由于其独特的解剖学特征,可能需要对标准瓣环尺寸策略进行修改。我们专门为 0 型双尖瓣 AS 患者设计了一种使用自扩张瓣膜进行 TAVR 的向下尺寸调整策略。本研究的主要目的是比较 "缩小瓣膜尺寸策略 "与 "标准瓣环尺寸策略 "在 0 型双尖瓣强直性脊柱炎患者 TAVR 中的安全性和有效性:这是一项前瞻性、多中心、优越性、单盲、随机对照试验,在接受经导管主动脉瓣置换术的 0 型双尖瓣主动脉瓣狭窄患者中比较 Down Sizing 策略和 Standard Annulus Sizing 策略。符合条件的参与者将包括重度 0 型双尖瓣 AS 患者,其标准包括主动脉瓣平均梯度≥40 mmHg、主动脉喷射速度峰值≥4.0 m/s、主动脉瓣面积 (AVA) ≤1.0 cm²,或 AVA 指数≤0.6 cm2/m²。这些患者将按 1:1 的比例随机分配到 "缩小尺寸策略 "组或 "标准尺寸策略 "组。在缩小尺寸策略组中,如果在球囊预扩张过程中出现 "腰围征 "并伴有轻度以下反流,则植入小一号的瓣膜。研究的主要终点是 VARC-3 定义的设备成功率、没有因高度房室传导阻滞和新发完全左束支传导阻滞而植入永久起搏器:这项研究将比较 "向下尺寸选择策略 "与 "标准瓣环尺寸选择策略 "的安全性和有效性,并为 0 型双尖瓣 AS TAVR 患者的最佳尺寸选择方法提供有价值的见解。我们假设,与标准瓣环大小策略相比,向下大小策略将显示出优越性。(双尖瓣主动脉瓣狭窄(0 型)TAVR 的向下尺寸策略(杭州方案)与标准尺寸策略(TAILOR-TAVR),NCT05511792)。
{"title":"Comparison of downsizing strategy (HANGZHOU Solution) and standard annulus sizing strategy in type 0 bicuspid aortic stenosis patients undergoing transcatheter aortic valve replacement: Rationale and design of a randomized clinical trial","authors":"Yuchao Guo MD , Xianbao Liu MD , Ranxi Li BM , Stella Ng BM , Qiong Liu PhD , Lihan Wang MMed , Po Hu MMed , Kaida Ren MD , Jubo Jiang MMed , Jiaqi Fan MD , Yuxin He MD , Qifeng Zhu MD , Xinping Lin MMed , Huajun Li MMed , Jian'an Wang MD","doi":"10.1016/j.ahj.2024.04.011","DOIUrl":"10.1016/j.ahj.2024.04.011","url":null,"abstract":"<div><h3>Background</h3><p>There has not been a consensus on the prothesis sizing strategy in type 0 bicuspid aortic stenosis (AS) patients undergoing transcatheter aortic valve replacement (TAVR). Modifications to standard annular sizing strategies might be required due to the distinct anatomical characteristics. We have devised a downsizing strategy for TAVR using a self-expanding valve specifically for patients with type 0 bicuspid AS. The primary aim of this study is to compare the safety and efficacy of downsizing strategy with the Standard Annulus Sizing Strategy in TAVR for patients with type 0 bicuspid AS.</p></div><div><h3>Trial design</h3><p>It is a prospective, multi-center, superiority, single-blinded, randomized controlled trial comparing the Down Sizing and Standard Annulus Sizing Strategy in patients with type 0 bicuspid aortic stenosis undergoing transcatheter aortic valve replacement. Eligible participants will include patients with severe type 0 bicuspid AS, as defined by criteria such as mean gradient across aortic valve ≥40 mmHg, peak aortic jet velocity ≥4.0 m/s, aortic valve area (AVA) ≤1.0 cm², or AVA index ≤0.6 cm<sup>2</sup>/m<sup>2</sup>. These patients will be randomly assigned, in a 1:1 ratio, to either the Down Sizing Strategy group or the Standard Sizing Strategy group. In the Down Sizing Strategy group, a valve one size smaller will be implanted if the “waist sign” manifests along with less than mild regurgitation during balloon pre-dilatation. The primary end point of the study is a composite of VARC-3 defined device success, absence of both permanent pacemaker implantation due to high-degree atrioventricular block and new-onset complete left bundle branch block.</p></div><div><h3>Conclusion</h3><p>This study will compare the safety and efficacy of Down Sizing Strategy with the Standard Annulus Sizing Strategy and provide valuable insights into the optimal approach for sizing in TAVR patients with type 0 bicuspid AS. We hypothesize that the Down Sizing Strategy will demonstrate superiority when compared to the Standard Annulus Sizing Strategy. (Down Sizing Strategy (HANGZHOU Solution) vs Standard Sizing Strategy TAVR in Bicuspid Aortic Stenosis (Type 0) (TAILOR-TAVR), NCT05511792).</p></div>","PeriodicalId":7868,"journal":{"name":"American heart journal","volume":null,"pages":null},"PeriodicalIF":4.8,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140847378","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-30DOI: 10.1016/j.ahj.2024.03.011
Marco Spagnolo MD, Davide Capodanno MD, PhD
Despite a perceived increase in attention to gender differences in medicine, a comprehensive assessment of gender equality research, particularly in cardiology, remains underexplored. This observational retrospective study, focusing on documents related to “Gender Equality” according to the Sustainable Development Goals, reveals cardiology as a significant area for gender equality research, albeit with a decline in publications post-2018. The analysis highlighted a concentrated effort in the United States and a considerable impact gap between gender-focused and general cardiology research. The global academic community must intensify research into gender disparities, which is essential for achieving professional gender equality and addressing the burden of cardiovascular diseases.
{"title":"Gender equality in medical research: A cardiology-informed examination","authors":"Marco Spagnolo MD, Davide Capodanno MD, PhD","doi":"10.1016/j.ahj.2024.03.011","DOIUrl":"https://doi.org/10.1016/j.ahj.2024.03.011","url":null,"abstract":"<div><p>Despite a perceived increase in attention to gender differences in medicine, a comprehensive assessment of gender equality research, particularly in cardiology, remains underexplored. This observational retrospective study, focusing on documents related to “Gender Equality” according to the Sustainable Development Goals, reveals cardiology as a significant area for gender equality research, albeit with a decline in publications post-2018. The analysis highlighted a concentrated effort in the United States and a considerable impact gap between gender-focused and general cardiology research. The global academic community must intensify research into gender disparities, which is essential for achieving professional gender equality and addressing the burden of cardiovascular diseases.</p></div>","PeriodicalId":7868,"journal":{"name":"American heart journal","volume":null,"pages":null},"PeriodicalIF":4.8,"publicationDate":"2024-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0002870324000723/pdfft?md5=a976c910811f39488207e71e4c185896&pid=1-s2.0-S0002870324000723-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140824435","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-28DOI: 10.1016/j.ahj.2024.04.016
Jafna Cox , Laura Hamilton , Lehana Thabane , Gary Foster , James MacKillop , Feng Xie , Antonio Ciaccia , Shurjeel Choudhri , Joanna Nemis-White , Ratika Parkash , IMPACT-AF Investigators
Background
Despite guidelines supporting antithrombotic therapy use in atrial fibrillation (AF), under-prescribing persists. We assessed whether computerized clinical decision support (CDS) would enable guideline-based antithrombotic therapy for AF patients in primary care.
Methods
This cluster randomized trial of CDS versus usual care (UC) recruited participants from primary care practices across Nova Scotia, following them for 12 months. The CDS tool calculated bleeding and stroke risk scores and provided recommendations for using oral anticoagulants (OAC) per Canadian guidelines.
Results
From June 14, 2014 to December 15, 2016, 203 primary care providers (99 UC, 104 CDS) with access to high-speed Internet were recruited, enrolling 1,145 eligible patients (543 UC, 590 CDS) assigned to the same treatment arm as their provider. Patient mean age was 72.3 years; most were male (350, 64.5% UC, 351, 59.5% CDS) and from a rural area (298, 54.9% UC, 315, 53.4% CDS). At baseline, a higher than anticipated proportion of patients were receiving guideline-based OAC therapy (373, 68.7% UC, 442, 74.9% CDS; relative risk [RR] 0.97 (95% confidence interval [CI], 0.87-1.07; P = .511)). At 12 months, prescription data were available for 538 usual care and 570 CDS patients, and significantly more CDS patients were managed according to guidelines (415, 77.1% UC, 479, 84.0% CDS; RR 1.08 (95% CI, 1.01-1.15; P = .024)).
Conclusion
Notwithstanding high baseline rates, primary care provider access to the CDS over 12 months further optimized the prescribing of OAC therapy per national guidelines to AF patients potentially eligible to receive it. This suggests that CDS can be effective in improving clinical process of care.
{"title":"Computerized clinical decision support to improve stroke prevention therapy in primary care management of atrial fibrillation: a cluster randomized trial","authors":"Jafna Cox , Laura Hamilton , Lehana Thabane , Gary Foster , James MacKillop , Feng Xie , Antonio Ciaccia , Shurjeel Choudhri , Joanna Nemis-White , Ratika Parkash , IMPACT-AF Investigators","doi":"10.1016/j.ahj.2024.04.016","DOIUrl":"10.1016/j.ahj.2024.04.016","url":null,"abstract":"<div><h3>Background</h3><p>Despite guidelines supporting antithrombotic therapy use in atrial fibrillation (AF), under-prescribing persists. We assessed whether computerized clinical decision support (CDS) would enable guideline-based antithrombotic therapy for AF patients in primary care.</p></div><div><h3>Methods</h3><p>This cluster randomized trial of CDS versus usual care (UC) recruited participants from primary care practices across Nova Scotia, following them for 12 months. The CDS tool calculated bleeding and stroke risk scores and provided recommendations for using oral anticoagulants (OAC) per Canadian guidelines.</p></div><div><h3>Results</h3><p>From June 14, 2014 to December 15, 2016, 203 primary care providers (99 UC, 104 CDS) with access to high-speed Internet were recruited, enrolling 1,145 eligible patients (543 UC, 590 CDS) assigned to the same treatment arm as their provider. Patient mean age was 72.3 years; most were male (350, 64.5% UC, 351, 59.5% CDS) and from a rural area (298, 54.9% UC, 315, 53.4% CDS). At baseline, a higher than anticipated proportion of patients were receiving guideline-based OAC therapy (373, 68.7% UC, 442, 74.9% CDS; relative risk [RR] 0.97 (95% confidence interval [CI], 0.87-1.07; <em>P</em> = .511)). At 12 months, prescription data were available for 538 usual care and 570 CDS patients, and significantly more CDS patients were managed according to guidelines (415, 77.1% UC, 479, 84.0% CDS; RR 1.08 (95% CI, 1.01-1.15; <em>P</em> = .024)).</p></div><div><h3>Conclusion</h3><p>Notwithstanding high baseline rates, primary care provider access to the CDS over 12 months further optimized the prescribing of OAC therapy per national guidelines to AF patients potentially eligible to receive it. This suggests that CDS can be effective in improving clinical process of care.</p></div><div><h3>Trial Registration</h3><p>Clinical Trials NCT01927367. <span>https://clinicaltrials.gov/ct2/show/NCT01927367?term=NCT01927367&draw=2&rank=1</span><svg><path></path></svg></p></div>","PeriodicalId":7868,"journal":{"name":"American heart journal","volume":null,"pages":null},"PeriodicalIF":4.8,"publicationDate":"2024-04-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0002870324001030/pdfft?md5=2c7f150ebb0ecb857422db1687c6e14b&pid=1-s2.0-S0002870324001030-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140849449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Atrial fibrillation (AF) is common in patients with heart failure (HF) and is associated with worse clinical outcomes. We evaluated the relationship between AF and longitudinal changes in health-related quality of life (HRQoL) measured by Kansas City Cardiomyopathy Questionnaire (KCCQ) in both HF with preserved (HFpEF) and reduced ejection fraction (HFrEF).
Methods
This is a post-hoc analysis of the TOPCAT and HF-ACTION trials. The effect of AF on KCCQ overall summary scores (OSS), in both trials, was examined using a mixed effects regression model. Patients were divided into 3 groups according to AF status at baseline: patients with a history of AF but no AF detected on ECG at enrollment (Hx AF group), patients with history of AF and AF detected on ECG at enrollment (ECG AF group) and patients with post-randomization new-onset AF (New AF group).
Results
In TOPCAT, among 1,710 patients with KCCQ data available, AF was associated with a significantly lower KCCQ-OSS (-3.98; 95% CI −7.21: −0.74) at 48 months, with a significant AF status by time interaction (P = .03). In HF-ACTION, among 1,814 patients with available KCCQ data, AF was associated with a significantly lower KCCQ-OSS (-3.67; 95% CI −6.21: −1.41) at 24 months but there was no significant AF status by time interaction. In both trials, the type of AF was not associated with significant changes in KCCQ-OSS score.
Conclusion
Ιn patients with both HFpEF and HFrEF, AF was independently associated with worse HRQoL measured by KCCQ.
背景:心房颤动(AF)在心力衰竭(HF)患者中很常见,并且与较差的临床预后有关。我们评估了在射血分数保留型心力衰竭(HFpEF)和射血分数降低型心力衰竭(HFrEF)患者中,房颤与堪萨斯城心肌病问卷(KCCQ)测量的健康相关生活质量(HRQoL)纵向变化之间的关系:这是对 TOPCAT 和 HF-ACTION 试验的事后分析。在这两项试验中,房颤对 KCCQ 总体总分(OSS)的影响均采用混合效应回归模型进行检验。根据基线时的房颤状态将患者分为三组:有房颤病史但入选时心电图未检测到房颤的患者(Hx AF 组)、有房颤病史且入选时心电图检测到房颤的患者(ECG AF 组)和随机化后新发房颤的患者(New AF 组):在 TOPCAT 中,1710 名有 KCCQ 数据的患者中,房颤与 48 个月时 KCCQ-OSS 的显著降低相关(-3.98;95% CI -7.21:-0.74),房颤状态与时间的交互作用显著(P=0.03)。在 HF-ACTION 试验中,在 1814 名有 KCCQ 数据的患者中,房颤与 24 个月时 KCCQ-OSS 的显著降低相关(-3.67;95% CI -6.21:-1.41),但房颤状态与时间之间没有显著的交互作用。在这两项试验中,房颤类型与 KCCQ-OSS 评分的显著变化无关:结论:在 HFpEF 和 HFrEF 患者中,心房颤动与 KCCQ 测量的 HRQoL 差异无关。
{"title":"Association between atrial fibrillation and heart failure patient reported outcomes across the ejection fraction spectrum","authors":"Khaled Elkholey , Zain Ul Abideen Asad , Esraa Shehata , Irina Mustafina , Marat Fudim , Stavros Stavrakis","doi":"10.1016/j.ahj.2024.04.017","DOIUrl":"10.1016/j.ahj.2024.04.017","url":null,"abstract":"<div><h3>Background</h3><p>Atrial fibrillation (AF) is common in patients with heart failure (HF) and is associated with worse clinical outcomes. We evaluated the relationship between AF and longitudinal changes in health-related quality of life (HRQoL) measured by Kansas City Cardiomyopathy Questionnaire (KCCQ) in both HF with preserved (HFpEF) and reduced ejection fraction (HFrEF).</p></div><div><h3>Methods</h3><p>This is a post-hoc analysis of the TOPCAT and HF-ACTION trials. The effect of AF on KCCQ overall summary scores (OSS), in both trials, was examined using a mixed effects regression model. Patients were divided into 3 groups according to AF status at baseline: patients with a history of AF but no AF detected on ECG at enrollment (Hx AF group), patients with history of AF and AF detected on ECG at enrollment (ECG AF group) and patients with post-randomization new-onset AF (New AF group).</p></div><div><h3>Results</h3><p>In TOPCAT, among 1,710 patients with KCCQ data available, AF was associated with a significantly lower KCCQ-OSS (-3.98; 95% CI −7.21: −0.74) at 48 months, with a significant AF status by time interaction (<em>P</em> = .03). In HF-ACTION, among 1,814 patients with available KCCQ data, AF was associated with a significantly lower KCCQ-OSS (-3.67; 95% CI −6.21: −1.41) at 24 months but there was no significant AF status by time interaction. In both trials, the type of AF was not associated with significant changes in KCCQ-OSS score.</p></div><div><h3>Conclusion</h3><p>Ιn patients with both HFpEF and HFrEF, AF was independently associated with worse HRQoL measured by KCCQ.</p></div>","PeriodicalId":7868,"journal":{"name":"American heart journal","volume":null,"pages":null},"PeriodicalIF":4.8,"publicationDate":"2024-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140849842","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}