James A. Troy, MD, MHS

 

Clinical Question: Does triple therapy (long-acting beta₂-agonist, long-acting muscarinic antagonist, and inhaled corticosteroid) reduce exacerbations in patients with symptomatic chronic obstructive pulmonary disease (COPD)?

Background: Guidelines from GOLD and NICE recommend considering a step-up to triple therapy for patients with refractory COPD symptoms or exacerbations. However, it is unknown if this reduces the long term risk of exacerbations.

Study Design: A randomized controlled trial.

Setting: Facilities consisting of 224 primary and specialty care sites in fifteen countries.

Synopsis: This study enrolled 2,691 patients with COPD, severe airflow restriction (FEV₁ less than 50%), significant symptoms (CAT score greater than or equal to 10), and at least one exacerbation in the past year. Participants were randomized to a novel three-agent inhaler (containing an extrafine formulation of beclomethasone, formoterol, and glycopyrronium), an “open triple” regimen including beclomethasone/formoterol plus tiotropium, or to tiotropium alone.

During 52 weeks of treatment, the triple therapy regimens significantly reduced moderate to severe COPD exacerbations, compared with tiotropium alone, with annualized exacerbation rates of 0.46 (95% confidence interval, 0.41-0.51), 0.45 (0.39-0.52), and 0.57 (0.52-0.63), respectively. Rates of adverse events were similar between all three groups.

Bottom Line: Triple therapy was superior to tiotropium alone for reducing exacerbations in patients with symptomatic COPD. The two triple therapy regimens studied did not significantly differ in efficacy.

Citation: Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): A double-blind, parallel group, randomized controlled trial. Lancet. 2017;389(10082):1919-29.

Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.

 

Clinical Question: Does triple therapy (long-acting beta₂-agonist, long-acting muscarinic antagonist, and inhaled corticosteroid) reduce exacerbations in patients with symptomatic chronic obstructive pulmonary disease (COPD)?

Background: Guidelines from GOLD and NICE recommend considering a step-up to triple therapy for patients with refractory COPD symptoms or exacerbations. However, it is unknown if this reduces the long term risk of exacerbations.

Study Design: A randomized controlled trial.

Setting: Facilities consisting of 224 primary and specialty care sites in fifteen countries.

Synopsis: This study enrolled 2,691 patients with COPD, severe airflow restriction (FEV₁ less than 50%), significant symptoms (CAT score greater than or equal to 10), and at least one exacerbation in the past year. Participants were randomized to a novel three-agent inhaler (containing an extrafine formulation of beclomethasone, formoterol, and glycopyrronium), an “open triple” regimen including beclomethasone/formoterol plus tiotropium, or to tiotropium alone.

During 52 weeks of treatment, the triple therapy regimens significantly reduced moderate to severe COPD exacerbations, compared with tiotropium alone, with annualized exacerbation rates of 0.46 (95% confidence interval, 0.41-0.51), 0.45 (0.39-0.52), and 0.57 (0.52-0.63), respectively. Rates of adverse events were similar between all three groups.

Bottom Line: Triple therapy was superior to tiotropium alone for reducing exacerbations in patients with symptomatic COPD. The two triple therapy regimens studied did not significantly differ in efficacy.

Citation: Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): A double-blind, parallel group, randomized controlled trial. Lancet. 2017;389(10082):1919-29.

Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.

 

Clinical Question: Does triple therapy (long-acting beta₂-agonist, long-acting muscarinic antagonist, and inhaled corticosteroid) reduce exacerbations in patients with symptomatic chronic obstructive pulmonary disease (COPD)?

Background: Guidelines from GOLD and NICE recommend considering a step-up to triple therapy for patients with refractory COPD symptoms or exacerbations. However, it is unknown if this reduces the long term risk of exacerbations.

Study Design: A randomized controlled trial.

Setting: Facilities consisting of 224 primary and specialty care sites in fifteen countries.

Synopsis: This study enrolled 2,691 patients with COPD, severe airflow restriction (FEV₁ less than 50%), significant symptoms (CAT score greater than or equal to 10), and at least one exacerbation in the past year. Participants were randomized to a novel three-agent inhaler (containing an extrafine formulation of beclomethasone, formoterol, and glycopyrronium), an “open triple” regimen including beclomethasone/formoterol plus tiotropium, or to tiotropium alone.

During 52 weeks of treatment, the triple therapy regimens significantly reduced moderate to severe COPD exacerbations, compared with tiotropium alone, with annualized exacerbation rates of 0.46 (95% confidence interval, 0.41-0.51), 0.45 (0.39-0.52), and 0.57 (0.52-0.63), respectively. Rates of adverse events were similar between all three groups.

Bottom Line: Triple therapy was superior to tiotropium alone for reducing exacerbations in patients with symptomatic COPD. The two triple therapy regimens studied did not significantly differ in efficacy.

Citation: Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): A double-blind, parallel group, randomized controlled trial. Lancet. 2017;389(10082):1919-29.

Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.

 

Clinical Question: Can the HEART score risk stratify emergency department patients with chest pain?

Background: Many patients with chest pain are subjected to unnecessary admission and testing. The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score can accurately predict outcomes in chest pain patients, though it has undergone limited evaluation in real world settings.

Study Design: A cluster randomized trial.

Setting: Nine emergency departments in the Netherlands.

Synopsis: All sites started by providing usual care, then sequentially switched over to use of the HEART score to guide treatment. HEART care recommended early discharge if low risk (HEART score, 0-3), admission and further testing if intermediate risk (4-6), and early invasive testing if high risk (7-10).

The study included 3,648 adults presenting with chest pain. The HEART score was noninferior to usual care for the safety outcome of major adverse cardiovascular events (MACE) within 6 weeks. Only 2.0% of low risk patients experienced MACE, though 41% of these patients were still admitted or sent for further testing, and reduction in health care cost was minimal.

Bottom Line: The HEART score accurately predicted risk in patients with chest pain, but a significant portion of low risk patients underwent further testing anyway.

Citation: Poldervaart JM, Reitsma JB, Backus BE, et al. Effect of using the HEART score in patients with chest pain in the emergency department. Ann Intern Med. 2017 May 16;166(10):689-97.

Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.

 

Clinical Question: Can the HEART score risk stratify emergency department patients with chest pain?

Background: Many patients with chest pain are subjected to unnecessary admission and testing. The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score can accurately predict outcomes in chest pain patients, though it has undergone limited evaluation in real world settings.

Study Design: A cluster randomized trial.

Setting: Nine emergency departments in the Netherlands.

Synopsis: All sites started by providing usual care, then sequentially switched over to use of the HEART score to guide treatment. HEART care recommended early discharge if low risk (HEART score, 0-3), admission and further testing if intermediate risk (4-6), and early invasive testing if high risk (7-10).

The study included 3,648 adults presenting with chest pain. The HEART score was noninferior to usual care for the safety outcome of major adverse cardiovascular events (MACE) within 6 weeks. Only 2.0% of low risk patients experienced MACE, though 41% of these patients were still admitted or sent for further testing, and reduction in health care cost was minimal.

Bottom Line: The HEART score accurately predicted risk in patients with chest pain, but a significant portion of low risk patients underwent further testing anyway.

Citation: Poldervaart JM, Reitsma JB, Backus BE, et al. Effect of using the HEART score in patients with chest pain in the emergency department. Ann Intern Med. 2017 May 16;166(10):689-97.

Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.

 

Clinical Question: Can the HEART score risk stratify emergency department patients with chest pain?

Background: Many patients with chest pain are subjected to unnecessary admission and testing. The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score can accurately predict outcomes in chest pain patients, though it has undergone limited evaluation in real world settings.

Study Design: A cluster randomized trial.

Setting: Nine emergency departments in the Netherlands.

Synopsis: All sites started by providing usual care, then sequentially switched over to use of the HEART score to guide treatment. HEART care recommended early discharge if low risk (HEART score, 0-3), admission and further testing if intermediate risk (4-6), and early invasive testing if high risk (7-10).

The study included 3,648 adults presenting with chest pain. The HEART score was noninferior to usual care for the safety outcome of major adverse cardiovascular events (MACE) within 6 weeks. Only 2.0% of low risk patients experienced MACE, though 41% of these patients were still admitted or sent for further testing, and reduction in health care cost was minimal.

Bottom Line: The HEART score accurately predicted risk in patients with chest pain, but a significant portion of low risk patients underwent further testing anyway.

Citation: Poldervaart JM, Reitsma JB, Backus BE, et al. Effect of using the HEART score in patients with chest pain in the emergency department. Ann Intern Med. 2017 May 16;166(10):689-97.

Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.