Problems with use of composite end points in cardiovascular trials: a systematic review.

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OBJECTIVE: To explore the extent to which components of composite end points in randomized controlled trials vary in importance to patients, the frequency of events in the more and less important components, and the extent of variability in the relative risk reductions across components.DESIGN: Systematic review of randomized controlled trials. DATA SOURCES: Cardiovascular randomized controlled trials published in the Lancet, Annals of Internal Medicine, Circulation, European Heart Journal, JAMA, and New England Journal of Medicine, from 1 January 2002 to 30 June 2003. Component end points of composite end points were categorized according to importance to patients as fatal, critical, major, moderate, or minor.RESULTS: Of 114 identified randomized controlled trials that included a composite end point of importance to patients, 68% (n=77) reported complete component data for the primary composite end point; almost all (98%; n=112) primary composite end points included a fatal end point. Of 84 composite end points for which component data were available, 54% (n=45) showed large or moderate gradients in both importance to patients and magnitude of effect across components. When analyzed by categories of importance to patients, the most important components were associated with lower event rates in the control group (medians of 3.3-3.7% for fatal, critical, and major outcomes; 12.3% for moderate outcomes; and 8.0% for minor outcomes). Components of greater importance to patients were associated with smaller treatment effects than less important ones (relative risk reduction of 8% for death and 33% for components of minor importance to patients). CONCLUSION: The use of composite end points in cardiovascular trials is frequently complicated by large gradients in importance to patients and in magnitude of the effect of treatment across component end points. Higher event rates and larger treatment effects associated with less important components may result in misleading impressions of the impact of treatment. PMID: 17403713
Title of abstract: 
Problems with use of composite end points in cardiovascular trials: systematic review of randomized controlled trials.
Author: 
Ferreira-González I, Busse JW, Heels-Ansdell D, Montori VM, Akl EA, Bryant DM, Alonso-Coello P, Alonso J, Worster A, Upadhye S, Jaeschke R, Schünemann HJ, Permanyer-Miralda G, Pacheco-Huergo V, Domingo-Salvany A, Wu P, Mills EJ, Guyatt GH.
Affiliations: 
Universitat Autònoma de Barcelona, Hospital Vall d'Hebron, Hospital General Vall d'Hebron, McMaster University, Mayo Clinic College of Medicine, University at Buffalo, Italian National Cancer Institute Regina Elena, University of Western Ontario, Hospital
Citedate: 
Sunday, December 31, 2006 - 19:00
Citation: 
BMJ, 2007;334(7597):786.

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