Abstract
BackgroundMajor adverse cardiovascular events (MACE) are increasingly used as composite outcomes in randomized controlled trials (RCTs) and observational studies. However, it is unclear how observational studies most commonly define MACE in the literature when using administrative data.MethodsWe identified peer-reviewed articles published in MEDLINE and EMBASE between January 1, 2010 to October 9, 2020. Studies utilizing administrative data to assess the MACE composite outcome using International Classification of Diseases 9th or 10th Revision diagnosis codes were included. Reviews, abstracts, and studies not providing outcome code definitions were excluded. Data extracted included data source, timeframe, MACE components, code definitions, code positions, and outcome validation.ResultsA total of 920 articles were screened, 412 were retained for full-text review, and 58 were included. Only 8.6% (n = 5/58) matched the traditional three-point MACE RCT definition of acute myocardial infarction (AMI), stroke, or cardiovascular death. None matched four-point (+unstable angina) or five-point MACE (+unstable angina and heart failure). The most common MACE components were: AMI and stroke, 15.5% (n = 9/58); AMI, stroke, and all-cause death, 13.8% (n = 8/58); and AMI, stroke and cardiovascular death 8.6% (n = 5/58). Further, 67% (n = 39/58) did not validate outcomes or cite validation studies. Additionally, 70.7% (n = 41/58) did not report code positions of endpoints, 20.7% (n = 12/58) used the primary position, and 8.6% (n = 5/58) used any position.ConclusionsComponents of MACE endpoints and diagnostic codes used varied widely across observational studies. Variability in the MACE definitions used and information reported across observational studies prohibit the comparison, replication, and aggregation of findings. Studies should transparently report the administrative codes used and code positions, as well as utilize validated outcome definitions when possible.
Highlights
Major adverse cardiovascular events (MACE) are increasingly used as composite outcomes in randomized controlled trials (RCTs) and observational studies
Bosco et al BMC Med Res Methodol (2021) 21:241 (EMA) in 2012, provided guidance on utilizing a threepoint MACE outcome, which includes acute myocardial infarction (AMI), stroke, and cardiovascular mortality in all trials evaluating the cardiovascular safety of diabetic agents [3]
Our objectives were: i) assess each study’s definition of MACE components (e.g., AMI, stroke), ii) assess the diagnostic criteria used for outcome ascertainment such as codes used and position of codes, and iii) assess whether outcomes had been validated
Summary
Major adverse cardiovascular events (MACE) are increasingly used as composite outcomes in randomized controlled trials (RCTs) and observational studies. It is unclear how observational studies most commonly define MACE in the literature when using administrative data. The composite endpoint of “major adverse cardiovascular events” (MACE) is an increasingly common primary outcome of interest. Some trials have utilized a four-point MACE as well, by including hospitalization for unstable angina or revascularization procedures [3, 4]. While MACE is a better-defined and more ubiquitous outcome among RCTs, its use in observational studies to assess the safety and real-world effectiveness of therapies remains less clear
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