Cardiovascular Outcomes According to Urinary Albumin and Kidney Disease in Patients With Type 2 Diabetes at High Cardiovascular Risk: Observations From the SAVOR-TIMI 53 Trial

Question  What is the incremental prognostic value of urinary albumin excretion for cardiovascular risk assessment in patients with diabetes with and without the incorporation of cardiac biomarkers?

Findings  In this secondary analysis of a randomized clinical trial population of 15 760 patients with type 2 diabetes and high cardiovascular risk, there was a stepwise increased risk of cardiovascular events according to baseline urinary albumin to creatinine ratio. The association with increased risk was present even at low-level elevations of urinary albumin to creatinine ratio, which are otherwise considered normal, although this relationship was attenuated when adjusted for cardiac biomarkers.

Meaning  Low levels of albuminuria improve risk stratification for future cardiovascular risk in patients with type 2 diabetes; urinary albumin to creatinine ratio provides minimal incremental prognostic utility beyond cardiac biomarkers.

Importance  An elevated level of urinary albumin to creatinine ratio (UACR) is a marker of renal dysfunction and predictor of kidney failure/death in patients with type 2 diabetes. The prognostic use of UACR in established cardiac biomarkers is not well described.

Objective  To evaluate whether UACR offers incremental prognostic benefit beyond risk factors and established plasma cardiovascular biomarkers.

Design, Setting, and Participants  The Saxagliptin Assessment of Vascular Outcomes Recorded in Patients With Diabetes Mellitus–Thrombolysis in Myocardial Infarction (SAVOR-TIMI) 53 study was performed from May 2010 to May 2013 and evaluated the safety of saxagliptin vs placebo in patients with type 2 diabetes with overt cardiovascular disease or multiple risk factors. Median follow-up was 2.1 years (interquartile range, 1.8-2.3 years).

Interventions  Patients were randomized to saxagliptin vs placebo plus standard care.

Main Outcomes and Measures  Baseline UACR was measured in 15 760 patients (95.6% of the trial population) and categorized into thresholds.

Results  Of 15 760 patients, 5205 were female (33.0%). The distribution of UARC categories were: 5805 patients (36.8%) less than 10 mg/g, 3891 patients (24.7%) at 10 to 30 mg/g, 4426 patients (28.1%) at 30 to 300 mg/g, and 1638 patients (10.4%) at more than 300 mg/g. When evaluated without cardiac biomarkers, there was a stepwise increase with each higher UACR category in the incidence of the primary composite end point (cardiovascular death, myocardial infarction, or ischemic stroke) (3.9%, 6.9%, 9.2%, and 14.3%); cardiovascular death (1.4%, 2.6%, 4.1%, and 6.9%); and hospitalization for heart failure (1.5%, 2.5%, 4.0%, and 8.3%) (adjusted P < .001 for trend). The net reclassification improvement at the event rate for each end point was 0.081 (95% CI, 0.025 to 0.161), 0.129 (95% CI, 0.029 to 0.202), and 0.056 (95% CI, −0.005 to 0.141), respectively. The stepwise increased cardiovascular risk associated with a UACR of more than 10 mg/g was also present within each chronic kidney disease category. The UACR was associated with outcomes after including cardiac biomarkers. However, the improvement in discrimination and reclassification was attenuated; net reclassification improvement at the event rate was 0.022 (95% CI, −0.022 to 0.067), −0.008 (−0.034 to 0.053), and 0.043 (−0.030 to 0.052) for the primary end point, cardiovascular death, and hospitalization for heart failure, respectively.

Conclusions and Relevance  In patients with type 2 diabetes, UACR was independently associated with increased risk for a spectrum of adverse cardiovascular outcomes. However, the incremental cardiovascular prognostic value of UACR was minimal when evaluated together with contemporary cardiac biomarkers.

Trial Registration  clinicaltrials.gov Identifier: NCT01107886

Chronic kidney disease is a well-recognized complication of type 2 diabetes (T2D) affecting 30% to 40% of patients.¹ Chronic kidney disease may be recognized by 2 distinct and complementary methods: estimated glomerular filtration rates (eGFR) and urinary albumin to creatinine ratio (UACR).^2-4 Elevated levels of urinary albumin, as assessed by UACR, reflect damage to the basement membrane and endothelium of glomerular capillaries and denote the presence of chronic kidney disease, even within different eGFR categories.^2,3 In patients with T2D, UACR often represents diabetic nephropathy, although other diseases, such as hypertension may also contribute. Urinary albumin to creatinine ratio levels between 30 mg/g to 300 mg/g, formerly termed microalbuminuria, represent moderately increased levels of albuminuria (Kidney Disease: Improving Global Outcomes category A2).^2,3,5 In healthy adults, UACR is typically less than 10 mg/g; however, even small elevations in urinary albumin between 10 mg/g and 29 mg/g have been associated with progression of renal disease and increased mortality.^6-10 The incremental value of UACR for the prediction of cardiovascular risk when combined with established cardiovascular biomarkers, such as high-sensitivity troponin T (hsTnT), natriuretic peptides, or high-sensitivity C-reactive protein (hsCRP), has not been well described, to our knowledge.

The Saxagliptin Assessment of Vascular Outcomes Recorded in Patients With Diabetes Mellitus–Thrombolysis in Myocardial Infarction (SAVOR-TIMI) 53 trial¹¹ evaluated the cardiovascular efficacy and safety of saxagliptin, a selective dipeptidyl peptidase-4 inhibitor, in 16 492 patients with T2D with overt atherosclerotic vascular disease or at risk for cardiovascular events. During a median follow-up of 2.1 years, saxagliptin did not alter the risk of the primary composite end point of cardiovascular death, myocardial infarction, or ischemic stroke, although there was a 27% increased relative risk of hospitalization for heart failure in patients assigned to receive saxagliptin.¹² In addition, saxagliptin improved UACR over time compared with placebo.^13,14As part of a prespecified analysis, we evaluated the cardiovascular risk associated with baseline UACR and eGFR together with cardiac biomarkers.

The SAVOR-TIMI 53 study¹¹ was a multicenter, randomized double-blind, placebo-controlled trial that randomized patients with T2D, hemoglobin A_1C level between 6.5% and 12.0% within 6 months of randomization, and either a history of established atherosclerotic vascular disease or multiple risk factors for vascular disease (ie, investigator-reported dyslipidemia, hypertension, or smoking) to receive either 5 mg of saxagliptin daily (or 2.5 mg daily in patients with an eGFR of ≤50 mL/min/1.73 m²) or matching placebo.¹¹ The protocol specified the inclusion of at least 800 patients with at least moderate to severe kidney impairment (eGFR, <50 mL/min/1.73 m²), of whom 300 patients were to have an eGFR less than 30 mL/min/1.73 m². Patients with a history of either end-stage renal disease receiving chronic dialysis, serum creatinine level of more than 6.0 mg/dL, or previous kidney transplant were excluded. The full eligibility criteria and analysis plan have been reported previously.^11,13 The trial protocol was reviewed and approved by all relevant ethics committees. Written informed consent was obtained from all patients.

The primary end point of the trial was a composite of the first occurrence of cardiovascular death, myocardial infarction, or ischemic stroke. The secondary composite end point included the elements of the primary end point and hospitalizations for heart failure, unstable angina, or coronary revascularization. A clinical events committee, unaware of the study group assignments, adjudicated all components of the primary and secondary composite efficacy end points^11,13 using definitions based on draft guidelines for the standardization of end points in cardiovascular trials proposed by the US Food and Drug Administration.¹⁵

The eGFR was determined according to the Modification of Diet in Renal Disease formula based on serum creatinine and categorized as more than 60, 30 to 60, and less than 30 mL/min/1.73 m². Urinary albumin to creatinine ratio was measured from a single voided urine sample by a central laboratory (albumin, lower detection limit of 3 mg/L; creatinine, Jaffe reaction, lower detection limit of 4.0 mg/dL). The lowest reportable level of UACR was 1.0 mg/g. Urinary albumin to creatinine ratio was prospectively categorized as less than 10mg/g, 10 mg/g to 29 mg/g, 30 mg/g to 300 mg/g, and more than 300 mg/g.

Categorical variables were compared using χ² test and continuous variables with a Kruskal-Wallis test. Event rates are presented as 2-year Kaplan-Meier estimates. Estimated glomerular filtration rates and UACR were analyzed as continuous variables (as restricted cubic splines) and then based on the prespecified end points noted above. Multivariable models evaluating the association between UACR and clinical outcomes were adjusted for the following baseline variables: treatment arms (saxagliptin vs placebo), age (continuous), sex, race/ethnicity (white vs nonwhite), history of heart failure, duration of T2D (<5 years, 5-9 years, 10-14 years, 15-19 years, and ≥20 years), hemoglobin A_1C level (continuous), systolic blood pressure (continuous), prior myocardial infarction, history of hypertension, history of dyslipidemia, current smoker, and eGFR (continuous). The multivariable analyses were repeated with the inclusion of baseline N-terminal pro B-type natriuretic peptide (NT-proBNP), hsTnT, and hsCRP in the clinical model in analyses restricted to the 12 177 patients with data available on all 3 biomarkers. Biomarkers were examined as log-transformed as well as categorical variables using quartiles (NTproBNP and hsTnT) and categories for hsCRP (<1 mg/l, 1-3 mg/l, >3 mg/l) when comparing categories of UACR. All models were calibrated using slight variations of variables in the Cox proportional hazards model with and without biomarker data. Calibration was evaluated by deciles of predicted probabilities.¹⁶ Estimates of the C statistic for the clinical model created from previously listed variables were calculated based on the Harrell method¹⁷ and then compared with the models after the addition of the different biomarkers. The discriminative value of the biomarkers was further examined with the method described by Pencina and colleagues¹⁸ to determine the net reclassification improvement (NRI) at the event rate along with 95% CIs based on bootstrap resampling and integrated discrimination improvement.¹⁹

Of 16 492 patients in the SAVOR-TIMI 53 trial, baseline UACR was available in 15 760 patients (95.6%). In total, 5205 patients were female (33.0%). The median UACR was 17.0 mg/g (interquartile range, 6.0-68.0 mg/g). Overall, 5805 patients had a UACR less than 10 mg/g (36.8%); 3891 (24.7%), 10 mg/g to 29 mg/g; 4426 (28.1%), 30 mg/g to 300 mg/g; and 1638 (10.4%), more than 300 mg/g. Patients with higher UACR were more likely not to be white, have higher baseline systolic blood pressures, longer duration of diabetes, a higher prevalence of dyslipidemia, hypertension, and established atherosclerotic disease, more elevated hemoglobin A_1C levels, and lower eGFR. In addition, patients with higher UACR had higher concentrations of hsTnT, NT-proBNP, and hsCRP (eTable 1 in the Supplement).

When evaluated without cardiac biomarkers, there was a stepwise increase in the incidence of all cardiovascular events according to baseline UACR categories (Table 1 and Figure 1). When analyzed as a continuous variable in a multivariable model adjusted for baseline characteristics and eGFR, UACR was significantly associated with an increased risk of all-cause mortality, cardiovascular death, myocardial infarction, and hospitalization for heart failure (Table 2 and Figure 2). When examining the associated risk according to the prespecified UACR categories, there was a consistent, stepwise pattern of increased cardiovascular risk with each level of UACR. Notably, the risk associated with UACR began to increase significantly even in patients with UACR concentrations between 10 mg/g and 29 mg/g (Table 2). The addition of UACR to the clinical model (without biomarkers) significantly improved discrimination and reclassification of risk for all end points with the exception of ischemic stroke and hospitalization for coronary revascularization (Table 3). The NRI at the event rate after the addition of UACR was improved for the primary end point (NRI, 0.081; 95% CI, 0.025 to 0.161), cardiovascular death (NRI, 0.129; 95% CI, 0.029 to 0.202), myocardial infarction (NRI, 0.082; 95% CI, −0.018 to 0.154), and hospitalization for heart failure (NRI, 0.056; 95% CI, −0.005 to 0.141).

After adjusting for baseline levels of NT-proBNP, hsTnT, and hsCRP, levels of UACR remained significantly associated with cardiovascular outcomes; however, the relationship was attenuated (Table 2). With the inclusion of cardiac biomarkers, the improvements in C statistics, the NRI at the event rate, and integrated discrimination improvement, while present, were relatively small (Table 3).

The incidence of cardiovascular events increased with higher concentrations of UACR and lower eGFR, regardless of whether UACR was analyzed as a categorical or continuous variable. Even within each of the 3 different categories of eGFR, a higher UACR was associated with an increased risk of cardiovascular events and therefore identified differential risk within each eGFR category. For example, in patients with normal kidney function or mild kidney insufficiency (eGFR >60 mL/min/1.73 m²), the incidence of the primary end point increased progressively from 3.5% with a UACR of less than 10 mg/g to 12.3% in patients with a UACR of more than 300 mg/g (eTable 2 in the Supplement). This excess risk remained significant after adjusting for other baseline characteristics (eFigure and eTable 3 in the Supplement) and for cardiac biomarkers (eTable 4 in the Supplement).

The association between UACR and outcomes was consistent in patients treated with saxagliptin or placebo (P values for interactions were all >.05, except for ischemic stroke [P = .033]) (eTable 5 in the Supplement) and irrespective of baseline use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (eTable 6 in the Supplement).

In this study of 15 760 patients with T2D at high cardiovascular risk, we found that when evaluated together with standard clinical markers including eGFR, baseline UACR was independently associated with total mortality as well as cardiovascular events, such as cardiovascular death, myocardial infarction, ischemic stroke, and hospitalization for heart failure, thus expanding prior observations and supporting the hypothesis that UACR provides complementary insight into the association between diabetic kidney disease and cardiovascular risk. Currently, urinary albumin testing is already recommended for all patients with T2D to assess for chronic kidney disease. Urinary albumin to creatinine ratio could therefore readily be used as a more formal tool for cardiovascular risk prognostication without any additional testing or costs above standard therapy.

In contrast, when evaluated simultaneously with 3 frequently used cardiac plasma biomarkers (hsTnT, NT-proBNP, and hsCRP), the incremental prognostic value of UACR was minimal. This is not unexpected given the strong association between cardiac biomarkers and cardiovascular outcomes in patients with T2D.^20,21 To our knowledge, no practice guidelines, however, currently recommend their use in stable patients with diabetes. Consequently, hsTnT, NT-proBNP, and hsCRP are rarely used in this clinical setting, and UACR may therefore still offer additional incremental prognostic information. Eventual integration of cardiac biomarkers into risk stratification algorithms in T2D would provide additional clinical value, although at increased cost, through a more nuanced risk assessment.

In patients with T2D, increased levels of urinary albumin are likely an early signal of microvascular disease and indicate some degree of kidney damage.⁴ Historically, a cut point of 30 mg/g has been used in the diagnosis of albuminuria and thereby labeling a patient with kidney disease, which is diabetic nephropathy in most patients with T2D.^22,2 Our data indicate that from a prognostic stand point, even low-level elevations in UACR (10-30 mg/L), which would not be classified by contemporary clinical standards as elevated levels of albuminuria,⁵ are associated with increased all-cause mortality as well as cardiovascular risk when compared with patients with UACR of less than 10 mg/g and are therefore clinically relevant and successfully identify high-risk patients.

The association between UACR and heart failure has been reported previously in a general population of patients with prevalent heart failure^6,23-25 and in patients with T2D.^6,26,27 Without the inclusion of cardiac biomarkers, the risk of heart failure hospitalization in SAVOR-TIMI 53 began to rise with a UACR of more than 10 mg/g, even after adjusting for many baseline characteristics and regardless of baseline eGFR. We have previously demonstrated that in the SAVOR-TIMI 53 population, baseline eGFR is associated with an increased cardiovascular risk, including heart failure²⁸; however, that analysis did not include UACR. Levels of NT-proBNP and hsTnT are strongly associated with worsening heart failure in stable populations, so the attenuation of the association between UACR and hospitalization for heart failure when these cardiac biomarkers were added to the model is not surprising.

The association between albuminuria and cardiovascular mortality and end-stage kidney disease are well described in patients with T2D and in the general population.^6,7,9,29-31 Other studies, many including patients without T2D, found an association between UACR and heart failure,^25,32 coronary heart disease³² and incident hypertension. None of these studies included cardiac biomarkers, which have been described as some of the most robust predictors of risk in primary and secondary prevention populations of patients with T2D.^20,21 Other studies in patients with and without diabetes that also found an association between UACR and cardiovascular events lacked a sufficient number of patients to evaluate the different cardiac events individually³³ or did not simultaneously assess both natriuretic peptides and high-sensitivity troponin.^34-36

In addition to inhibitors of the renin-angiotensin-aldosterone system, several glucose-lowering drugs, including dipeptidyl peptidase 4 inhibitors,³⁷ sodium-glucose cotransporter 2 inhibitors,³⁸ and glucagon-like peptide 1 agonist,³⁹ improve UACR. In SAVOR-TIMI 53, saxagliptin improved UACR compared with placebo, regardless of baseline eGFR and UACR.^13,14 The apparent discordance between the minor reductions in UACR with saxagliptin without any corresponding benefit in major adverse cardiovascular events with saxagliptin may be because of a median follow-up of 2 years that may have been sufficient to improve UACR but not sufficient to observe any cardiovascular benefit. Moreover, it is not known whether UACR is a causal vs bystander marker of cardiovascular risk such that lower UACR per se would result in improved outcomes.

Urinary albumin to creatinine ratio was only measured once at baseline in this study; thus, we cannot exclude intrapatient sampling variability. However, this imprecision would likely bias toward a weaker association between UACR and outcomes. We did not measure cystatin C in this population and therefore cannot correlate outcomes with this kidney biomarker. Changes after baseline in medications and subsequent changes in glycemic indices or blood pressure were not evaluated in this analysis and therefore cannot account for any differences that might influence the association between UACR and outcomes.

Elevated levels of UACR, even within what has been considered to be in the normal range, are independently associated with increased risk of all-cause mortality as well as across a spectrum of cardiovascular end points, even after adjusting for known cardiovascular risk factors and eGFR. In contrast, the prognostic value of UACR when evaluated in the context of cardiac biomarkers such as natriuretic peptides and high-sensitivity troponin was minimal. Thus the utility of using UACR as a tool for cardiovascular risk assessment in patients with T2D is dependent on whether established cardiac biomarkers are also being assessed simultaneously.

Accepted for Publication: September 21, 2017.

Published Online: December 6, 2017. doi:10.1001/jamacardio.2017.4228

Corresponding Author: Benjamin M. Scirica, MD, MPH, Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 (bscirica@partners.org).

Author Contributions: Dr Scirica had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Scirica and Mosenzon served as co-first authors and contributed equally to the work.

Study concept and design: Scirica, Mosenzon, Bhatt, Udell, Steg, McGuire, Bruanwald.

Acquisition, analysis, or interpretation of data: Scirica, Mosenzon, Bhatt, Udell, Steg, McGuire, Im, Kanevsky, Stahre, Sjostrand, Raz.

Drafting of the manuscript: Scirica.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Im, Kanevsky.

Obtained funding: Bhatt, Bruanwald.

Administrative, technical, or material support: Scirica, Stahre, Sjostrand, Bruanwald.

Study supervision: Scirica, Bhatt, Im, Sjostrand, Raz, Bruanwald.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Scirica reports research grants from AstraZeneca, Eisai, Merck, and Poxel; consulting fees from AstraZeneca, Biogen Idec, Boehringer Ingelheim, Covance, Dr Reddy’s Laboratory, Elsevier Practice Update Cardiology, GlaxoSmithKline, Lexicon, Merck, NovoNordisk, Sanofi, St. Jude's Medical; and equity in Health[at]Scale. Dr Mosenzon is on the advisory board of Novo Nordisk, Eli Lilly, Sanofi, Merck Sharp & Dohme, Boehringer Ingelheim, Jansen and Jansen, Novartis, and AstraZeneca; receives grants paid to institution as study physician by AstraZeneca and Bristol-Myers Squibb; receives research grant support through Hadassah Hebrew University Hospital and Novo Nordisk; and is on the speaker’s bureau for AstraZeneca, Bristol-Myers Squibb, Novo Nordisk, Eli Lilly, Sanofi, Novartis, Merck, Sharp & Dohme, and Boehringer Ingelheim. Dr Bhatt is on the advisory board for Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; is on the board of directors for Boston VA Research Institute and the Society of Cardiovascular Patient Care; is a chair for the American Heart Association Quality Oversight Committee; is on the data monitoring committees for Cleveland Clinic, Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, and Population Health Research Institute; receives honoraria from the American College of Cardiology (senior associate editor), Clinical Trials and News, ACC.org, Belvoir Publications (editor, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (editor, Journal of Invasive Cardiology), Journal of the American College of Cardiology (guest editor; associate editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (chief medical editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (secretary/treasurer), and WebMD (continuing medical education steering committees); is deputy editor of Clinical Cardiology; chair of National Cardiovascular Data Registry-ACTION Registry Steering Committee and VA CART Research and Publications Committee (Chair); has received research funding from Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Ironwood, Ischemix, Lilly, Medtronic, Pfizer, Roche, Sanofi Aventis, and The Medicines Company; receives royalties from Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); is a site co-investigator at Biotronik, Boston Scientific, and St. Jude Medical (now Abbott); is a trustee at American College of Cardiology; and has unfunded research with FlowCo, Merck, PLx Pharma, and Takeda. Dr Udell reports grants from AstraZeneca and Bristol-Myers Squibb; personal fees/honoraria for advisory board participation from Janssen, Merck, Sanofi Pasteur, and Novartis outside the submitted work; and grants from Novartis for participation as a site investigator in a clinical trial. Dr Steg reports grants from Merck, Sanofi, and Servier; personal fees from Amarin, AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers-Squibb, CSL-Behring, Daiichi-Sankyo, GlaxoSmithKline, Janssen, Lilly, Novartis, Pfizer, Regeneron, Roche, Sanofi, Servier, and the Medicines Company, outside the submitted work. Dr McGuire reports receiving personal fees for clinical trial leadership from Boehringer-Ingelheim, Janssen Research and Development LLC, Merck Sharp and Dohme, Lilly USA, Novo Nordisk, GlaxoSmithKline, Takeda Pharmaceuticals North America, AstraZeneca, Lexicon, Eisai, and Akebia Pharmaceuticals; and personal consulting fees from Sanofi-Aventis Group, Merck Sharp and Dohme, Novo Nordisk, Lilly USA, and Regeneron. Dr Im and Ms Kanevsky report research funding via the TIMI Study and Brigham and Women’s Hospital from AstraZeneca. Drs Stahre and Sjöstrand are employees of AstraZeneca. Dr Raz reports being on the advisory board of AstraZeneca/Bristol-Meyers Squibb, Eli Lilly and Company, Merck Sharp and Dohme Limited, Novo Nordisk, Inc, Sanofi, Orgenesis, SmartZyme Innovation Ltd, Labstyle Innovations Ltd, and Boehringer Ingelheim; consulting for AstraZeneca/Bristol-Meyers Squibb, Insuline Medical, Gili Medical, Kamada Ltd, FuturRx Ltd, Nephrogenex Inc, and Diabetes Medical Center (Tel Aviv, Israel); being on the speaker’s bureau for AstraZeneca/Bristol-Meyers Squibb, Eli Lilly and Company, Johnson & Johnson, Merck Sharp and Dohme Limited, Novartis Pharma AG, Novo Nordisk, Inc, Sanofi, Teva, and Boehringer Ingelheim; being a stock shareholder of Insuline Medical, Labstyle Innovations, SmartZyme Innovation Ltd, Orgenesis, and Glucome Ltd. Dr Braunwald reports grants from AstraZeneca, Daiichi-Sankyo, GlaxoSmithKline, Merck, and Novartis; personal fees from the Medicines Company, Theravance, Daiichi Sankyo, Menarini International, and Medscape; and uncompensated consultancies and lectures from Merck and Novartis.

Funding/Support: This study was supported by AstraZeneca and Bristol-Myers Squibb.

Role of the Funder/Sponsor: The Thrombolysis in Myocardial Infarction Study Group, Hadassah Medical Organization, and the sponsors were responsible for the design and conduct of the study. The Thrombolysis in Myocardial Infarction Study Group and Hadassah Medical Organization are responsible for the current analysis, collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.