Archive
Journal Club 17 June 2015
Paper
Presenter
KC
Summary
BACKGROUND
Patients receiving oral anticoagulation (OAC) who undergo drug-eluting stent (DES) implantation
require additional dual antiplatelet therapy with aspirin and clopidogrel. Such triple therapy confers an elevated bleeding
risk, and its optimal duration is not known.
OBJECTIVES
The goal of this study was to evaluate whether shortening the duration of clopidogrel therapy from
6 months to 6 weeks after DES implantation was associated with a superior net clinical outcome in patients receiving
concomitant aspirin and OAC.
METHODS
In this randomized, open-label trial, we enrolled patients receiving OAC who underwent DES implantation at
3 European centers between September 2008 and December 2013. A total of 614 patients receiving concomitant aspirin
and OAC were randomized to either 6-week clopidogrel therapy (n ¼ 307) or 6-month clopidogrel therapy (n ¼ 307). The
primary endpoint was a composite of death, myocardial infarction (MI), definite stent thrombosis, stroke, or Thrombolysis
In Myocardial Infarction (TIMI) major bleeding at 9 months.
RESULTS
The primary endpoint occurred in 30 patients (9.8%) in the 6-week group compared with 27 patients (8.8%)
in the 6-month group (hazard ratio [HR]: 1.14; 95% CI: 0.68 to 1.91; p ¼ 0.63). There were no significant differences
for the secondary combined ischemic endpoint of cardiac death, MI, definite stent thrombosis, and ischemic stroke
(12 [4.0%] vs. 13 [4.3%]; HR: 0.93; 95% CI: 0.43 to 2.05; p ¼ 0.87) or the secondary bleeding endpoint of TIMI major
bleeding (16 [5.3%] vs. 12 [4.0%]; HR: 1.35; 95% CI: 0.64 to 2.84; p ¼ 0.44).
CONCLUSIONS
Six weeks of triple therapy was not superior to 6 months with respect to net clinical outcomes. These
results suggest that physicians should weigh the trade-off between ischemic and bleeding risk when choosing the shorter
or longer duration of triple therapy.
Journal Club 10 June 2015
Paper
Presenter
KL
Summary
BACKGROUND
Hemodialysis patients are high absorbers of intestinal cholesterol; they benefit less than other patient
groups from statin therapy, which inhibits cholesterol synthesis.
OBJECTIVES
This study sought to investigate whether the individual cholesterol absorption rate affects atorvastatin’s
effectiveness to reduce cardiovascular risk in hemodialysis patients.
METHODS
This post-hoc analysis included 1,030 participants in the German Diabetes and Dialysis Study (4D) who were
randomized to either 20 mg of atorvastatin (n ¼ 519) or placebo (n ¼ 511). The primary endpoint was a composite of
major cardiovascular events. Secondary endpoints included all-cause mortality and all cardiac events. Tertiles of the
cholestanol-to-cholesterol ratio, which is an established biomarker of cholesterol absorption, were used to identify high
and low cholesterol absorbers.
RESULTS
A total of 454 primary endpoints occurred. On multivariate time-to-event analyses, the interaction term
between tertiles and treatment with atorvastatin was significantly associated with the risk of reaching the primary
endpoint. Stratified analysis by cholestanol-to-cholesterol ratio tertiles confirmed this effect modification: atorvastatin
reduced the risk of reaching the primary endpoint in the first tertile (hazard ratio [HR]: 0.72; p ¼ 0.049), but not the
second (HR: 0.79; p ¼ 0.225) or third tertiles (HR: 1.21; p ¼ 0.287). Atorvastatin consistently significantly reduced allcause
mortality and the risk of all cardiac events in only the first tertile.
CONCLUSIONS
Intestinal cholesterol absorption, as reflected by cholestanol-to-cholesterol ratios, predicts the
effectiveness of atorvastatin to reduce cardiovascular risk in hemodialysis patients. Those with low cholesterol absorption
appear to benefit from treatment with atorvastatin, whereas those with high absorption do not benefit.
Supplementary Material
The editorial is available here.
Journal Club 3 June 2015
Paper
Randomized Trial of Four Financial- Incentive Programs for Smoking Cessation
Presenter
Summary
BACKGROUND
Financial incentives promote many health behaviors, but effective ways to deliver
health incentives remain uncertain.
METHODS
We randomly assigned CVS Caremark employees and their relatives and friends to
one of four incentive programs or to usual care for smoking cessation. Two of the
incentive programs targeted individuals, and two targeted groups of six participants.
One of the individual-oriented programs and one of the group-oriented
programs entailed rewards of approximately $800 for smoking cessation; the others
entailed refundable deposits of $150 plus $650 in reward payments for successful
participants. Usual care included informational resources and free smokingcessation
aids.
RESULTS
Overall, 2538 participants were enrolled. Of those assigned to reward-based programs,
90.0% accepted the assignment, as compared with 13.7% of those assigned
to deposit-based programs (P<0.001). In intention-to-treat analyses, rates of sustained
abstinence from smoking through 6 months were higher with each of the
four incentive programs (range, 9.4 to 16.0%) than with usual care (6.0%) (P<0.05
for all comparisons); the superiority of reward-based programs was sustained
through 12 months. Group-oriented and individual-oriented programs were associated
with similar 6-month abstinence rates (13.7% and 12.1%, respectively;
P = 0.29). Reward-based programs were associated with higher abstinence rates
than deposit-based programs (15.7% vs. 10.2%, P<0.001). However, in instrumental-
variable analyses that accounted for differential acceptance, the rate of abstinence
at 6 months was 13.2 percentage points (95% confidence interval, 3.1 to
22.8) higher in the deposit-based programs than in the reward-based programs
among the estimated 13.7% of the participants who would accept participation in
either type of program.
CONCLUSIONS
Reward-based programs were much more commonly accepted than deposit-based
programs, leading to higher rates of sustained abstinence from smoking. Grouporiented
incentive programs were no more effective than individual-oriented
programs.
Phoenix Cardiology 