mist i & iii studies andrew j. dowson director headache services king’s college hospital...
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MIST I & III StudiesMIST I & III Studies
Andrew J. DowsonDirector Headache Services
King’s College Hospital
London, UK
For the MIST investigators
Within the past 12 months, I or my spouse/partner Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or have had a financial interest/arrangement or affiliation with the organization listed below.affiliation with the organization listed below.
Affiliation/Financial RelationshipAffiliation/Financial Relationship CompanyCompany
Grant/Research Support NMT MedicalGrant/Research Support NMT Medical
Disclosure Statement of Disclosure Statement of Financial InterestFinancial Interest
MIST I InvestigatorsMIST I InvestigatorsCardiologists
J De-Giovanni
D Hildick-Smith
WS Hillis
A Khan
I Malik
L Morrison
M Mullen
P Wilmshurst
Neurologists
A Dowson*
G Elrington
SL Lipscombe
K Muir
S Nightingale
R Peatfield
T Rees
C Wells
DSAEMB
H Sievert**
E Eeckhout**
L Doyal
R Kern
F Baudet
R Taylor
L Missault***
*Study chief Investigator** Chairman of DSAEMB*** Medical monitor
Eligible Migraine PatientsEligible Migraine Patients
Contrast Transthoracic Echocardiogram (cTTE)Contrast Transthoracic Echocardiogram (cTTE)
3 Month Healing Phase3 Month Healing Phase
PFO Closure with STARFlex®PFO Closure with STARFlex® Sham ProcedureSham Procedure
MIST I Trial Design
3 Month Analysis Phase3 Month Analysis Phase
aspirin &clopidogrelaspirin &
clopidogrel
TEE and Randomization Under GATEE and Randomization Under GA
MIST - OutliersMIST - OutliersHistogram of Total Number of Migraine Headache Days per Month
for Each Patient in Analysis Period per Protocol Population
Total Number of Migraine Headache Days per Month
Nu
mb
er o
f P
atie
nts
MIST Study Exploratory AnalysesMIST Study Exploratory Analyses
05
101520253035404550
% R
ed
uct
ion Implant
Shampp<0.027*<0.027*
Total Migraine Headache DaysTotal Migraine Headache Days
*=2 outliers removed
Closure Rate 94%Closure Rate 94%
As reported per protocol by As reported per protocol by implanting cardiologistimplanting cardiologist
Active ArmActive Arm
Additional 18 month f/uAdditional 18 month f/u
MIST III Trial DesignMIST III Trial Design
Followed for 6 months Followed for 6 months
Sham ArmSham Arm
Offered PFO Closure with STARFlex® when unblindedOffered PFO Closure with
STARFlex® when unblinded
Additional 18 month f/uAdditional 18 month f/u
MIST III DemographicsMIST III Demographics
Implant Sham
# enrolled# enrolled 5454 3535
Age (mean)Age (mean) 46.246.2 46.146.1
Sex (% female)Sex (% female) 89%89% 89%89%
Race (% Caucasian)Race (% Caucasian) 98%98% 100%100%
Atrial septal aneurysmAtrial septal aneurysm 31%31% Not knownNot known
MIST III – Headache DaysMIST III – Headache Days
0
1
2
3
4
5
6
7
Baseline 6m 9m 12m 15m 18m
Mean
Median
Time (months)
Hea
dac
he
Day
s
N 52 52 36 36 40 33
MIDAS Total Score MIDAS Total Score
0
10
20
30
40
50
60
Baseline 3m 6m 12m 15m 18m
Mean Median
Time (months)
MID
AS
To
tal
Sco
re
N 48 46 47 30 27 21
Severe 21+Moderate 11-20
Mild or infrequent 6-10Minimal or infrequent 0-5
HIT- 6 Total ScoreHIT- 6 Total Score
45
47
49
51
53
55
57
59
61
63
65
67
69
Baseline Day 90 Day 180 9m 12m 15m 18m
Mean Median
Time (months)
HIT
- 6
To
tal
Sco
re
N 48 46 47 45 29 27 21
≥ 60 – Severe56-59 Substantial
50-55 Some impact< 50 – Little or no impact
MIST III Interim FindingsMIST III Interim Findings
• MIST headache-day reductions hold MIST headache-day reductions hold and improve over time.and improve over time.
• Disability measures improve over time.Disability measures improve over time.
• Encouraging results need to be Encouraging results need to be replicated in current randomized replicated in current randomized controlled trials.controlled trials.