Tact quality of life outcomes

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Tact quality of life outcomes

  1. 1. Embargoed for 6:02pm PT, Sunday, Nov. 4 LBCT-02- D. Mark - TACT QofL Quality of Life Outcomes: The Trial to Assess Chelation Therapy Daniel B. Mark, MD, MPH Professor of Medicine Director, Outcomes Research Duke University Medical Center Duke Clinical Research Institute e On behalf of the TACT Quality of Life (QOL) Research Team and the TACT Investigators TACT Research Program supported by NHLBI and NCCAM Financial Disclosures Consulting Research Grants Janssen Gilead Medtronic AstraZeneca Eli Lilly November 4, 2012 2
  2. 2. TACT : Background•  Disodium ethylene diamine tetra acetic acid (EDTA) binds divalent cations (e.g., lead, calcium) and permits renal excretion•  Treatment of lead toxicity with EDTA in 1951•  Report of treatment of angina in 1956 by Clarke with ↓ sx  From 1956 to the present:   Use in atherosclerotic disease expanded   Evolution of a standardized protocol that included disodium EDTA, ascorbate, B-vitamins, and other components   Used clinically by chelation practitioners   Chelation discouraged by traditional professional societies
  3. 3. TACT: Design Overview 1,708 post-MI pts • Age ≥50 134 sites • MI ≥ 6 mos prior to randomization (US, CN) double-blind 2x2 trial Chelation + high-dose vitamins Chelation placebo + high-dose vitamins Chelation + vitamin placebo Chelation placebo + vitamin placebo Mean study follow-up 55 mos1° endpoint: composite of total mortality, recurrent MI, stroke, coronary revascularization, or hospitalization for unstable angina 2° endpoints incl.: quality of life outcomes
  4. 4. TACT 1° Clinical Endpoint 0.5 Hazard Ratio 95% CI P-value EDTA:Placebo 0.82 0.69,0.99 0.035 0.4 Event Rate 0.3 Placebo EDTA Chelation 0.2 death, MI, stroke, 0.1 coronary revascularization, hospitalization for angina 0.0 0 6 12 18 24 30 36 42 48 54 60 Months since randomizationNumber at RiskEDTA Chelation 839 760 703 650 588 537 511 476 427 358 229 Placebo 869 776 701 638 566 515 475 429 384 322 205
  5. 5. TACT Quality of Life Study: Primary Objective•  To determine whether chelation therapy significantly improves physical functioning and psychological well-being in stable CAD patients with a history of MI
  6. 6. TACT QOL Study: Quality of Life (QOL) Methods Overview•  911 (53%) of 1708 main TACT pts randomly selected for QOL substudy•  QOL structured interviews at baseline, 6 mos, 12 mos, and 24 mos•  All baseline questionnaires were collected by site coordinators who were trained by DCRI Outcomes Group•  Follow-up interviews were conducted via telephone by DCRI Outcomes Group•  97% of expected QOL contacts collected
  7. 7. TACT QOL Substudy: Primary QOL Outcome Measures•  DASI - cardiac-related functional status. -  Scores: 0 (worst) to 58 (best), reflect the ability of patients to do physical activities without difficulty or assistance in 12 domains. -  For an individual pt, a clinically significant change is >4 points.•  MHI-5 - psychological well-being, including both depression and anxiety. -  Scores: normalized to 50+10. -  A clinically significant change for an individual patient is approximately > 2.5 points.•  Other measures: SAQ (frequency, stability, QOL), SF-36, EQ-5D
  8. 8. TACT QOL: Analysis Methods•  All primary comparisons by intention to treat•  Follow-up QOL comparison p values adjusted for vitamin group and baseline QOL scores•  No adjustment was made in significance levels for multiple comparisons.
  9. 9. TACT QOL Baseline Characteristics Chelation Placebo (n=451) (n=460)Age (median) 64 (58 to 71) 65 (58 to 72)Female 19% 19%Race, nonwhite 6% 8%Current NYHA Class None 80% 80% I 12% 12% II 7% 7% III 1% 2%Current CCS Angina Class 79% 79% None 10% 9% I 7% 10% II 3% 2% III <1% <1% IVDiabetes 32% 35%
  10. 10. TACT QOL Outcomes DASI p= 0.50 0.12 0.2750 difference 0.7 1.6 0.540 29.1 27 29.4 27.1 25.130 24.6 23.5 26.32010 0 Baseline 6 months 12 months 24 months Chelation Placebo
  11. 11. TACT QOL Outcomes SF-36 MHI-5100 90 p= 0.50 0.08 0.07 80 difference 0.4 1.2 1.3 70 60 52.1 51.5 52.1 51 52.5 51.3 50 50.1 50 40 30 20 10 0 Baseline 6 months 12 months 24 months Chelation Placebo Scaled to a norm of 50, SD 10
  12. 12. TACT QOL OutcomesSeattle Angina Questionnaire – Anginal Frequency p= 0.31 0.99 0.29 difference -1.4 0.0 1.4 100 89.8 90.2 92.6 91.8 92.9 91.2 86.3 86 80 60 40 20 0 Baseline 6 months 12 months 24 months Chelation Placebo Higher scores = less frequent angina
  13. 13. TACT QOL Outcomes Seattle Angina Questionnaire – Quality of Life p= 0.52 0.62 0.92 difference -1.1 -0.9 0.2100 79.4 79.6 80.5 80.8 79.4 78.980 69.8 69.4604020 0 Baseline 6 months 12 months 24 months Chelation Placebo Higher scores = better quality of life
  14. 14. TACT QOL Outcomes: Subgroup Analyses•  None of the prespecified subgroups showed a treatment effect on QOL•  Pts with angina sx at baseline showed a tx effect at 1 year in favor of chelation therapy (4.99 points, p=0.019), but not at other time points or overall•  No tx effect was seen in pts with heart failure sx at baseline
  15. 15. TACT QOL Outcomes: Caveats•  Trial population was largely asymptomatic at baseline (ceiling effect for some measures incl. anginal QOL)•  QOL assessment follow-up was limited to 2 years, 1° clinical outcomes show continued divergence favoring chelation out to 5 years
  16. 16. TACT QOL Outcomes: Summary•  In a population of stable, predominantly asymptomatic CAD patients with a history of prior MI, the use of EDTA chelation therapy did not produce a consistent sustained improvement in any domain of health-related quality of life.
  17. 17. TACT QOL Outcomes SF-36 Physical Component Summary100 p= 0.91 0.50 0.47 difference -0.1 0.4 0.58060 42.8 41.7 44.7 43.1 45.6 43.6 44.7 434020 0 Baseline 6 months 12 months 24 months CABG + MED MED Alone Scaled to a norm of 50, SD 10
  18. 18. TACT QOL Outcomes SF-36 Mental Component Summary100 p= 0.57 0.71 0.2680 difference -0.4 0.3 0.860 50.7 50.4 53.2 53.1 53.2 52.6 53.5 52.34020 0 Baseline 6 months 12 months 24 months Chelation Placebo Scaled to a norm of 50, SD 10
  19. 19. TACT QOL Outcomes EQ-5D Single Summary Index p= 0.87 0.18 0.002100 difference 0.3 2.1 5.2 78.2 76.1 81 77.7 81.880 74.9 73.9 75.5604020 0 Baseline 6 months 12 months 24 months Chelation Placebo Relative desirability of patient s current health status
  20. 20. TACT QOL Outcomes: Clinically Significant Improvement in DASI from Baseline100% p= 0.44 0.26 0.0680%60% 46.7% 44.0% 46.2% 42.2% 43.5% 36.9%40%20% 0% 6 months 12 months 24 months Chelation Placebo

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