NEJM original articles

Background. Bronchiectasis guidelines are inconsistent with regard to the effectiveness of mucoactive agents, and their use varies geographically. Large trials are needed to assess safety and effectiveness.

Methods. For this open-label, randomized, two-by-two factorial trial at 20 sites in the United Kingdom, we enrolled participants with non-cystic fibrosis bronchiectasis who had frequent pulmonary exacerbations and daily sputum production. Current smokers and persons who had recently received mucoactive treatments were excluded. All participants received standard care and were also assigned either to one of three mucoactive-drug groups - hypertonic saline (the hypertonic-saline group), hypertonic saline and carbocisteine (the combination group), or carbocisteine (the carbocisteine group) - or to standard care alone. The comparisons were between hypertonic saline and no hypertonic saline and between carbocisteine and no carbocisteine, with each category consisting of two groups. The primary outcome was the number of pulmonary exacerbations over a 52-week period. Key secondary outcomes were scores on disease-specific health-related quality-of-life assessments, time to next pulmonary exacerbation, and safety.

Results. A total of 288 participants underwent randomization. No treatment interactions were found. The mean number of adjudicated fully qualifying pulmonary exacerbations over the 52-week period was 0.76 (95% confidence interval [CI], 0.58 to 0.95) with hypertonic saline as compared with 0.98 (95% CI, 0.78 to 1.19) with no hypertonic saline (adjusted between-group difference in the means, -0.25 [95% CI, -0.57 to 0.07; P = 0.12]) and 0.86 (95% CI, 0.66 to 1.06) with carbocisteine as compared with 0.90 (95% CI, 0.70 to 1.09) with no carbocisteine (adjusted between-group difference in the means, -0.04 [95% CI, -0.36 to 0.28; P = 0.81]). Secondary outcomes and the incidence of adverse events, including serious adverse events, were similar across the groups.

Conclusions. In participants with bronchiectasis, neither hypertonic saline nor carbocisteine significantly reduced the mean incidence of pulmonary exacerbations over a period of 52 weeks. (Funded by the National Institute for Health and Care Research Health Technology Assessment Programme and others; ISRCTN Registry number, ISRCTN89040295.).

Background. The appropriate antithrombotic regimen for patients with chronic coronary syndrome who are at high atherothrombotic risk and receiving long-term oral anticoagulation remains unknown.

Methods. We conducted a multicenter, double-blind, randomized, placebo-controlled trial in France involving patients with chronic coronary syndrome who had undergone a previous stent implantation (>6 months before enrollment) and were at high atherothrombotic risk and currently receiving long-term oral anticoagulation. The patients were randomly assigned in a 1:1 ratio to receive aspirin (100 mg once daily) or placebo; all the patients continued to receive their current oral anticoagulation therapy. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, stroke, systemic embolism, coronary revascularization, or acute limb ischemia. The key safety outcome was major bleeding.

Results. A total of 872 patients underwent randomization; 433 were assigned to the aspirin group, and 439 to the placebo group. The trial was stopped early at the advice of the independent data and safety monitoring board after a median follow-up of 2.2 years because of an excess of deaths from any cause in the aspirin group. A primary efficacy outcome event occurred in 73 patients (16.9%) in the aspirin group and in 53 patients (12.1%) in the placebo group (adjusted hazard ratio, 1.53; 95% confidence interval [CI], 1.07 to 2.18; P = 0.02). Death from any cause occurred in 58 patients (13.4%) in the aspirin group and in 37 (8.4%) in the placebo group (adjusted hazard ratio, 1.72; 95% CI, 1.14 to 2.58; P = 0.01). Major bleeding occurred in 44 patients (10.2%) in the aspirin group and in 15 patients (3.4%) in the placebo group (adjusted hazard ratio, 3.35; 95% CI, 1.87 to 6.00; P<0.001). A total of 467 and 395 serious adverse events were reported in the aspirin group and placebo group, respectively.

Conclusions. Among patients with chronic coronary syndrome at high atherothrombotic risk who were receiving an oral anticoagulant, the addition of aspirin led to a higher risk of cardiovascular death, myocardial infarction, stroke, systemic embolism, coronary revascularization, or acute limb ischemia than placebo, as well as higher risks of death from any cause and major bleeding. (Funded by the French Ministry of Health and Bayer Healthcare; ClinicalTrials.gov number, NCT04217447.).

Background. Misdiagnosis or underdiagnosis of rare diseases in patients with diagnoses of common diseases can lead to delayed or inappropriate treatments, thereby complicating the management of both rare and common conditions. Despite advances in molecular diagnostic techniques, the effect of rare diseases on the diagnosis of common diseases in research and clinical trials has not been comprehensively investigated.

Methods. We used exome- and genome-sequencing data from participants in the U.K. Biobank, a research study, and five clinical trials involving patients who had received a primary diagnosis of multiple sclerosis, inflammatory bowel disease, or atopic dermatitis to assess the incidence of monogenic rare diseases that often manifest with clinical symptoms overlapping with those of these common diseases.

Results. We identified 153 U.K. Biobank participants who carried a rare variant that contributes to a molecular diagnosis of a monogenic disorder - 53 of 1850 (2.86%) with a diagnosis of multiple sclerosis, 75 of 6681 (1.12%) with a diagnosis of inflammatory bowel disease, and 25 of 998 (2.50%) with a diagnosis of atopic dermatitis. We replicated the findings regarding such rare disease-causing variants in two independent cohorts - one including patients with a diagnosis of multiple sclerosis, and the other patients with a diagnosis of inflammatory bowel disease - who had undergone genome sequencing for research and for clinical trials, respectively. By combining genome and transcriptome analyses, we showed that molecular diagnosis can potentially elucidate mechanisms of inadequate response to therapeutic intervention.

Conclusions. Our study shows the value of systematic genome sequencing in understanding the phenotypic heterogeneity of common diseases and identifying failure to diagnose rare diseases and highlights the benefits of deep molecular phenotyping in clinical trials and patient care. (Funded by AbbVie and NIHR Cambridge Biomedical Research Centre.).

Background. Sotatercept, an activin-signaling inhibitor, reduces morbidity and mortality among patients with long-standing pulmonary arterial hypertension. Its effects in patients with pulmonary arterial hypertension within the first year after diagnosis are unclear.

Methods. In this phase 3 trial, we enrolled adult patients with World Health Organization functional class II or III pulmonary arterial hypertension who had received the diagnosis less than 1 year earlier, had an intermediate or high risk of death, and were receiving double or triple background therapy. Patients were randomly assigned to receive add-on therapy with subcutaneous sotatercept (starting dose, 0.3 mg per kilogram of body weight; escalated to target dose, 0.7 mg per kilogram) or placebo every 21 days. The primary end point was clinical worsening, a composite of death from any cause, unplanned hospitalization lasting at least 24 hours for worsening of pulmonary arterial hypertension, atrial septostomy, lung transplantation, or deterioration in performance in exercise testing due to pulmonary arterial hypertension, assessed in a time-to-first-event analysis.

Results. The trial was stopped early owing to loss of clinical equipoise after the reporting of positive results from previous sotatercept trials. A total of 320 patients were included (160 each in the sotatercept and placebo groups). The median duration of follow-up was 13.2 months. At least one primary end-point event occurred in 17 patients (10.6%) in the sotatercept group and in 59 patients (36.9%) in the placebo group (hazard ratio, 0.24; 95% confidence interval, 0.14 to 0.41; P<0.001). Deterioration in performance in exercise testing due to pulmonary arterial hypertension occurred in 8 patients (5.0%) in the sotatercept group and in 46 patients (28.8%) in the placebo group; unplanned hospitalization for worsening of pulmonary arterial hypertension occurred in 3 patients (1.9%) and 14 patients (8.8%), respectively; and death from any cause occurred in 7 patients (4.4%) and 6 patients (3.8%). No cases of atrial septostomy or lung transplantation occurred. The most common adverse events with sotatercept were epistaxis (31.9%) and telangiectasia (26.2%).

Conclusions. Among adults with pulmonary arterial hypertension who had received the diagnosis less than 1 year earlier, the addition of sotatercept to background therapy resulted in a lower risk of clinical worsening than placebo. (Funded by Merck Sharp and Dohme, a subsidiary of Merck [Rahway, NJ]; HYPERION ClinicalTrials.gov number, NCT04811092.).

Background. Amid the declining clinical severity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and diminishing public uptake of annual coronavirus disease 2019 (Covid-19) vaccines, contemporary evidence on vaccine effectiveness against clinically relevant outcomes is needed.

Methods. We conducted an observational study that used the electronic health records of the Department of Veterans Affairs to evaluate the effectiveness of the 2024-2025 Covid-19 vaccine among veterans who received the Covid-19 and influenza vaccines on the same day (164,132 participants) and in an active-comparator group of veterans who received the influenza vaccine only (131,839 participants), between September 3 and December 31, 2024. Participants were followed for 180 days or until the occurrence of an outcome, whichever came first. We used inverse-probability-weighted models to estimate vaccine effectiveness (calculated as 1 minus the risk ratio) against Covid-19-associated emergency department visits, hospitalizations, and deaths at 6 months.

Results. At 6 months of follow-up, the estimated vaccine effectiveness was 29.3% (95% confidence interval [CI], 19.1 to 39.2) against Covid-19-associated emergency department visits (risk difference per 10,000 persons, 18.3; 95% CI, 10.8 to 27.6), 39.2% (95% CI, 21.6 to 54.5) against Covid-19-associated hospitalizations (risk difference per 10,000 persons, 7.5; 95% CI, 3.4 to 13.0), and 64.0% (95% CI, 23.0 to 85.8) against Covid-19-associated deaths (risk difference per 10,000 persons, 2.2; 95% CI, 0.5 to 6.9). Vaccine effectiveness against a composite of these outcomes was 28.3% (95% CI, 18.2 to 38.2), with a risk difference per 10,000 persons of 18.2 (95% CI, 10.7 to 27.5). The Covid-19 vaccine was associated with decreased risks of these outcomes across prespecified subgroups defined according to age (<65 years, 65 to 75 years, and >75 years), the presence or absence of major coexisting conditions, and immunocompetence status.

Conclusions. In this national cohort of U.S. veterans, the receipt of the 2024-2025 Covid-19 vaccine was associated with decreased risks of severe clinical outcomes. (Funded by the Department of Veterans Affairs.).