1. Acetylcysteine for the prevention of Contrast- induced nephropaThy (ACT) Trial: The ACT Trial Investigators Presenter: Otavio Berwanger (MD; PhD) Chair - Steering Committe A Pragmatic Multicenter Randomized Trial to Evaluate the Efficacy of Acetylcysteine for the Prevention of Renal Outcomes in Patients Undergoing Coronary and Vascular Angiography Sponsor: Ministry of Health-Brazil

2. Presenter Disclosure Information Presenter: Presenter: Otavio Berwanger Acetylcysteine for the Prevention of Contrast-Induced nephropaThy (ACT) Trial: a Pragmatic Multicenter Randomized Trial to Evaluate the Efficacy of Acetylcysteine for the Prevention of Renal Outcomes in Patients Undergoing Coronary and Vascular Angiography FINANCIAL DISCLOSURE: None to declare

3. Why do We Need a New Acetylcysteine Trial ? THE PROBLEM Contrast-induced nephropathy is associated with mortality and prolonged hospitalization. The incidence in patients with risk factors (such as renal failure, diabetes, age > 70 y) varies between 9% and 38%. ONE POTENTIAL SOLUTION Acetylcysteine (an antioxidant) represents a safe, non-expensive, easy to administer, and widely available drug THE EVIDENCE Low quality (few trials with allocation concealment, blinding, and ITT analysis) Low statistical power (median trial size = 80 patients) Uncertain effects on clinical endpoints Lack of standardization of acetylcysteine dose/scheme and co-interventions

4. Academic, Design: Academic, Pragmatic Randomized Multicenter Trial of Acetylcysteine versus Placebo for the Preventon of Renal Outcomes Prevention of Bias: Concealed allocation (central web-based randomization) and Intention-to-treat analysis Blinding of patients, investigators, caregivers, and outcome assessors Quality control: on-site monitoring + central statistical checking + e-CRF : Trial Size: 2,308* patients from 46 hospitals in Brazil recruited between September 2008 and July 2010 * Original Target Sample Size: 2300, considering incidence of CIN =15%, 30% relative risk reduction (RRR), with 90% statistical power, and two-tailed alpha of 5% The ACT Trial

5. Trial Organization Trial Steering Committe Otavio Berwanger Alexandre Biasi Cavalcanti Amanda Sousa Celso Amodeo J. Eduardo Sousa Leda D. Lotaif Project OfficeData Management/e-CRF Research Institute HCorCarlos Cardoso Alexandre Biasi CavalcantiAndre L.A. Firmino Anna Maria BuehlerDalmo Silva Mariana CarballoPaulo J. Soares Alessandra KodamaAdailton Mendes Eliana SantucciJose Lobato Centres Top Recruiting Sites: 46 Institutions in Brazil Hospital Bandeirantes (Sao Paulo ) Beneficiencia Portuguesa (Sao Paulo ) Hospital P.S. Mat. Santa Lucia (Minas Gerais) Instituto de Cardiologia (Sta Catarina)

6. 2,308 Patients undergoing an angiographic procedure with at least one of the following risk factors: Age > 70 years; Chronic Renal Failure; Diabetes Mellitus; Heart Failure or LVEF <0.45; Shock ITT Concealed Randomization Acetylcysteine 1200mg Orally Twice Daily for 2 Doses Before and 2 Doses After Procedure ITT Matching Placebo Primary Endpoint: Contrast-induced nephropathy (CIN) (≥ 25% elevation of serum creatinine above baseline 48h-96h after angiography) Secondary Endpoints: Secondary Endpoints: Total mortality, CV mortality, Need for dialysis, Doubling of serum creatinine, Side effects

7. Flow of patients 1,153 (98.4%) Had data included in the primary outcome analysis 1,171 (99.9%) Had data included in secondary outcome analyses 19 (1.6%) lost to 48-96 hour serum creatinine follow-up 4 (0.3%) died before 48-96 hours 15 (1.3%) did not return 1 (0.1%) lost 30 th day follow-up 1,172 Allocated to N-acetylcysteine 17 (1.5%) lost to 48-96 hour serum creatinine follow-up 3 (0.3%) died before 48-96 hours 14 (1.2%) did not return to 1 (0.1%) Was lost to 30 th day FU 7 (0.6%) did not receive study drug before angiography 2,308 Underwent randomization 12 (1.0%) did not receive study drug before angiography 1,136 Allocated to placebo 1,119 (98.5%) Had data included in the primary outcome analysis 1,135 (99.9%) Had data included in secondary outcome analyses

8. Baseline Characteristics 86.1% 72 (63 to 82) 72 (63 to 81) 86.5% Age > 70 years 52.9% 51.3% History of hypertension 0.2% 0.3% Shock 9.2% 9.9% Known heart failure 68.1  10.4 68.0  10.4 Age – yr Patients fulfilling inclusion criteria 59.7% 61.2% Diabetes mellitus 16.0% 15.4% Serum creatinine >1.5mg/dL 39.3% 38.0% Female sex Placebo (1136) Acetylcysteine (1172) Weight - Kg 35.1% 35.8% Acute coronary syndrome

9. Acetylcysteine (1172) Placebo (1136) Previous Medication Use of NSAIDS > 7 days Use of ACE inhibitor Use of diuretics 5.4% Use of metformin 37.7% 30.9% 58.3% 29.6% 59.6% 35.4% 5.2% Glomerular filtration rate Serum creatinine – mg/dL 60.2 (45.4 to 84.5) 61.4 (45.2 to 83.3) 1.1 (0.9 to 1.4) Baseline Characteristics

10. Acetylcysteine (1172) Placebo (1136) Compliance with study protocol Adherence to study drug 1 st dose 2 nd dose 99.0% 4 th dose 3 rd dose 97.6% 96.4% 94.9% 96.1% 95.6% 97.3% 99.4%

11. Acetylcysteine (1172) Placebo (1136) NaCl 0.9% - any scheme NaCl or bicarbonate Hydration before procedure Hydration after procedure NaCl 0.9% - 1ml/Kg/h for 6 h 94.3% 47.5% 98.5% 71.2% 52.3% 54.8% 74.1% NaCl 0.9% - 1ml/Kg/h for 6 h NaCl 0.45% NaCl 0.9% - any scheme Bicarbonate 0.9% NaCl or bicarbonate NaCl 0.45% Bicarbonate 0.9% 4.6% 75.6% 0% 72.7% 0.1% 5.1% 47.1% 0.3% 97.9% 28.5% 28.8% 0% Compliance with study protocol

12. Acetylcysteine (1172) Placebo (1136) Characteristics of the angiography High osmolarity Contrast type 2.9% 22.0%22.9% 75.0% 3.0% 74.3% Iso- osmolar Low osmolarity Contrast volume* 100 (70 to 130) *Median (interquartile range) Procedure 67.1% 68.7% Percutaneous coronary intervention 30.1% 28.5% Peripheral vascular angiography Coronary diagnostic angiography 2.8% 2.9%

13. Results Primary Endpoint Acetylcysteine (N=1172) Placebo (N=1136)

14. Results Primary Endpoint Acetylcysteine (N=1172) Placebo (N=1136)

15. Clinical Outcomes at 30 days Mortality or need for dialysis Acetylcysteine (N=1172) Placebo (N=1136)

16. Clinical Outcomes at 30 days Mortality or need for dialysis Acetylcysteine (N=1172) Placebo (N=1136)

17. Acetylcysteine (n=1172) Placebo (n=1136) Relative Risk (95% CI) P Value Primary Outcome – 48h-96hNo. of events (% of patients) Elevation ≥ 0.5 mg/dL in serum creatinine 45 (3.9)42 (3.8)1.04 (0.69-1.57)0.85 Death7 (0.6)8 (0.7)0.85 (0.31-2.33)0.75 Need for dialysis2 (0.2)3 (0.3)0.65 (0.11-3.86)0.68 Death or CIN164 (14.2)163 (14.5)0.98 (0.80-1.19)0.81 Death or Need for dialysis or CIN152 (13.1)149 (13.3)0.99 (0.80- 1.22)0.92 Death or Need for dialysis or duplication of serum creatinine 21 (1.8)26 (2.3)0.78 (0.44- 1.38)0.40 Effects on Contrast-Induced Nephropathy

18. Acetylcysteine (n=1172) Placebo (n=1136) Relative Risk (95% CI) P Value Status in 30 daysNo. of events (% of patients) Death, need for dialysis or a doubling in serum creatinine in 30 days 45 (3.9)42 (3.8)0.90 (0.58 -1.39)0.63 Deaths or need for dialysis in 30 days 26 (2.2)26 (2.3)0.97 (0.57-1.66)0.91 Deaths in 30 days23 (2.0)24 (2.1)0.93 (0.53 -1.64)0.80 Need for dialysis in 30 days3 (0.3) 0.97 (0.20 -4.80)0.97 Doubling in serum creatinine13 (1.1)17 (1.5)0.74 (0.36 -1.52)0.41 Status after 30 daysNo. of events (% of patients) Cardiovascular deaths18 (1.5)18 (1.6)0.97 (0.51; 1.85)0.93 Other outcomes

19. Side Effects Acetylcysteine n (%) Placebo n (%) Nausea Vomiting 89 (7.6) 8 (0.7) 15 (1.3) 7 (0.6) 19 (1.6) 25 (2.1) 4 (0.3) 13 (1.1) 14 (1.2) 15 (1.2) 80 (7.0) Angina Fatigue Diarrhea Serious adverse events * 25 (2.2) 10 (0.9) Adverse events P value 0.43 0.33 0.09 0.01 0.12 0.61 0.09 Includes: stroke, pneumonia, sepsis, acute pulmonary edema - (Less then 10 events per endpoint)

20. Subgroups

22. Meta-analysis

23. Main Conclusions Largest acetylcysteine randomized trial conducted to date. Acetylcysteine does not reduce the short-term risk of CIN nor other clinically relevant outcomes (30 days) even among the higher risk subgroups. These results are consistent with meta-analysis of previous smaller high quality trials (zero heterogeneity). These results may help to inform clinical practice and to update current guidelines.

24. Future Directions Cystatin C substudy Complete Updtated Systematic Review and Meta- Analysis and Meta-regression analysis Complete Updtated Systematic Review and Meta- Analysis and Meta-regression analysis Registries can document impact of ACT Trial Results in Clinical Practice