- Email: [email protected]
Dual antiplatelet therapy duration and mortality
Correspondence
Age 0–49 years Age 50–69 years Age 0–69 years Change in age-standardised mortality in 2000–10, by cause Communicable, perinatal, and maternal causes
–31%
–25%
–30%
Non-communicable diseases
–15%
–14%
–14%
Injuries (ie, external causes)
–14%
–9%
–13%
All causes of death
–24%
–15%
–19%
Millions of deaths in projected 2030 population If 2010 death rates remain unchanged*
21·2
22·7
43·9
If 2000–10 changes persist*
13·0
16·7
29·7
With the UN-targeted mortality improvements†
10·7
14·9
25·6
*Stratified for age and World Bank country income group to the 2030 world population at ages 0–69 years. †Two-thirds lower child, maternal, HIV, tuberculosis, and malaria mortality; and one-third lower mortality compared with mortality caused by other diseases and injuries.
Table: Proportional decreases in global mortality in 2000–10, and numbers of deaths in the projected 2030 population under various assumptions about 2010–30 proportional decreases
We agree that premature death is not the only thing that matters, but we note that changes in mortality at ages 0–69 years will correlate closely with changes in life expectancy, or in healthy life expectancy.3 We also note that health-adjusted life expectancy can be estimated surprisingly accurately just from all-cause age-specific death rates; indeed, the age-specific ratios of healthy life to total life depend strongly on age but hardly at all on sex or level of economic development. Our SDG target is transparent and easily understood. To characterise either the inter nationally agreed NCD goals or our proposed SDGs (or the original MDGs) as ageist is not appropriate. At present, 30 million people aged 0–69 years die every year—ie, almost 100 000 per day— and this number is likely to continue roughly unchanged for many years, as population growth counterbalances falling age-specific death rates. Hence, the avoidance of premature death should continue to be one of the world’s priorities. KA is the Minister of Health of Ethiopia. All other authors declare no competing interests.
*Ole Frithjof Norheim, Prabhat Jha, Kesetebirhan Admasu, Dean T Jamison, *Richard Peto [email protected]; rpeto@ctsu. ox.ac.uk
www.thelancet.com Vol 385 May 30, 2015
Department of Global Public Health and Primary Care, University of Bergen, Bergen, 5018, Norway (OFN); Centre for Global Health Research, St Michael’s Hospital, University of Toronto, ON, Canada (PJ); Ministry of Health, Addis Ababa, Ethiopia (KA); Global Health Sciences, University of California, San Francisco, CA, USA (DTJ); and Nuffield Department of Population Health Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK (RP) 1
2
3
WHO. Sixty-fifth world health assembly: Resolution A65/54. May 25, 2012. http://apps. who.int/gb/ebwha/pdf_files/WHA65/A65_54en.pdf (accessed June 23, 2013). Norheim OF, Jha P, Admasu K, et al. Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health. Lancet 2015; 385: 239–52. Institute of Health Metrics and Evaluation. 2015. http://vizhub.healthdata.org/gbdcompare (accessed April 1, 2015).
Dual antiplatelet therapy duration and mortality
12 months after coronary stenting was associated with an increase in the risk of non-cardiovascular death. Additionally, findings of another meta-analysis of DAPT after drug-eluting stent implantation 3 suggested a numerically higher all-cause mortality with extended duration DAPT. The meta-analysis by Sammy Elmariah and colleagues1 has some limitations, including different DAPT durations and different drug-eluting stent generations between studies. Thus, extension of DAPT duration beyond 6 or 12 months requires careful assessment of the balance between risk of ischaemic and bleeding complications.4,5 JA declares grants and personal fees from AstraZeneca and Daiichi Sankyo. RB declares personal fees from Boehringer Ingelheim, Bayer, and AstraZeneca. FG declares grants from AstraZeneca and Daiichi Sankyo.
*Johann Auer, Robert Berent, Franz Gurtner [email protected] Cardiology and Intensive Care, General Hospital Braunau, Braunau, Austria (JA, FG); and HerzReha, Bad Ischl, Austria (RB) 1
2
3
4 5
We read with great interest the Review and meta-analysis by Sammy Elmariah and colleagues (Feb 28, p 792),1 in which they suggest that prolonged duration dual antiplatelet therapy (DAPT) is not associated with a difference in the risk of cardiovascular or non-cardiovascular death, compared with aspirin alone or short duration DAPT. In contrast, results of the 2014 DAPT Study by Laura Mauri and colleagues2 showed that continuation of DAPT beyond
Elmariah S, Mauri L, Doros G, et al. Extended duration dual antiplatelet therapy and mortality: a systematic review and meta-analysis. Lancet 2015; 385: 792–98. Mauri L, Kereiakes DJ, Yeh RW, et al. Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med 2014; 371: 2155–66. Giustino G, Baber U, Sartori S, et al. Duration of dual antiplatelet therapy following drug-eluting stent implantation: a systematic review and meta-analysis of randomized controlled trials. J Am Coll Cardiol 2015; 114: 236–42. Auer J, Berent R. Dual antiplatelet therapy after stenting. Lancet 2015; 385: 325–26. Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/ EACTS Guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35: 2541–619.
Authors’ reply We thank Johann Auer and colleagues for their interest in our meta-analysis, in which we assessed the association between extended 2149
Age 0–49 years Age 50–69 years Age 0–69 years Change in age-standardised mortality in 2000–10, by cause Communicable, perinatal, and maternal causes
–31%
–25%
–30%
Non-communicable diseases
–15%
–14%
–14%
Injuries (ie, external causes)
–14%
–9%
–13%
All causes of death
–24%
–15%
–19%
Millions of deaths in projected 2030 population If 2010 death rates remain unchanged*
21·2
22·7
43·9
If 2000–10 changes persist*
13·0
16·7
29·7
With the UN-targeted mortality improvements†
10·7
14·9
25·6
*Stratified for age and World Bank country income group to the 2030 world population at ages 0–69 years. †Two-thirds lower child, maternal, HIV, tuberculosis, and malaria mortality; and one-third lower mortality compared with mortality caused by other diseases and injuries.
Table: Proportional decreases in global mortality in 2000–10, and numbers of deaths in the projected 2030 population under various assumptions about 2010–30 proportional decreases
We agree that premature death is not the only thing that matters, but we note that changes in mortality at ages 0–69 years will correlate closely with changes in life expectancy, or in healthy life expectancy.3 We also note that health-adjusted life expectancy can be estimated surprisingly accurately just from all-cause age-specific death rates; indeed, the age-specific ratios of healthy life to total life depend strongly on age but hardly at all on sex or level of economic development. Our SDG target is transparent and easily understood. To characterise either the inter nationally agreed NCD goals or our proposed SDGs (or the original MDGs) as ageist is not appropriate. At present, 30 million people aged 0–69 years die every year—ie, almost 100 000 per day— and this number is likely to continue roughly unchanged for many years, as population growth counterbalances falling age-specific death rates. Hence, the avoidance of premature death should continue to be one of the world’s priorities. KA is the Minister of Health of Ethiopia. All other authors declare no competing interests.
*Ole Frithjof Norheim, Prabhat Jha, Kesetebirhan Admasu, Dean T Jamison, *Richard Peto [email protected]; rpeto@ctsu. ox.ac.uk
www.thelancet.com Vol 385 May 30, 2015
Department of Global Public Health and Primary Care, University of Bergen, Bergen, 5018, Norway (OFN); Centre for Global Health Research, St Michael’s Hospital, University of Toronto, ON, Canada (PJ); Ministry of Health, Addis Ababa, Ethiopia (KA); Global Health Sciences, University of California, San Francisco, CA, USA (DTJ); and Nuffield Department of Population Health Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK (RP) 1
2
3
WHO. Sixty-fifth world health assembly: Resolution A65/54. May 25, 2012. http://apps. who.int/gb/ebwha/pdf_files/WHA65/A65_54en.pdf (accessed June 23, 2013). Norheim OF, Jha P, Admasu K, et al. Avoiding 40% of the premature deaths in each country, 2010–30: review of national mortality trends to help quantify the UN Sustainable Development Goal for health. Lancet 2015; 385: 239–52. Institute of Health Metrics and Evaluation. 2015. http://vizhub.healthdata.org/gbdcompare (accessed April 1, 2015).
Dual antiplatelet therapy duration and mortality
12 months after coronary stenting was associated with an increase in the risk of non-cardiovascular death. Additionally, findings of another meta-analysis of DAPT after drug-eluting stent implantation 3 suggested a numerically higher all-cause mortality with extended duration DAPT. The meta-analysis by Sammy Elmariah and colleagues1 has some limitations, including different DAPT durations and different drug-eluting stent generations between studies. Thus, extension of DAPT duration beyond 6 or 12 months requires careful assessment of the balance between risk of ischaemic and bleeding complications.4,5 JA declares grants and personal fees from AstraZeneca and Daiichi Sankyo. RB declares personal fees from Boehringer Ingelheim, Bayer, and AstraZeneca. FG declares grants from AstraZeneca and Daiichi Sankyo.
*Johann Auer, Robert Berent, Franz Gurtner [email protected] Cardiology and Intensive Care, General Hospital Braunau, Braunau, Austria (JA, FG); and HerzReha, Bad Ischl, Austria (RB) 1
2
3
4 5
We read with great interest the Review and meta-analysis by Sammy Elmariah and colleagues (Feb 28, p 792),1 in which they suggest that prolonged duration dual antiplatelet therapy (DAPT) is not associated with a difference in the risk of cardiovascular or non-cardiovascular death, compared with aspirin alone or short duration DAPT. In contrast, results of the 2014 DAPT Study by Laura Mauri and colleagues2 showed that continuation of DAPT beyond
Elmariah S, Mauri L, Doros G, et al. Extended duration dual antiplatelet therapy and mortality: a systematic review and meta-analysis. Lancet 2015; 385: 792–98. Mauri L, Kereiakes DJ, Yeh RW, et al. Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med 2014; 371: 2155–66. Giustino G, Baber U, Sartori S, et al. Duration of dual antiplatelet therapy following drug-eluting stent implantation: a systematic review and meta-analysis of randomized controlled trials. J Am Coll Cardiol 2015; 114: 236–42. Auer J, Berent R. Dual antiplatelet therapy after stenting. Lancet 2015; 385: 325–26. Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/ EACTS Guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35: 2541–619.
Authors’ reply We thank Johann Auer and colleagues for their interest in our meta-analysis, in which we assessed the association between extended 2149