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Why we ask the important questions in clinical research
September 28, 2016
As the RCSI celebrates the 10th anniversary of its School of Postgraduate Studies,June Shannonspoke with one of the College’s renowned alumni, prolific researcher in cardiovascular diseaseProf Koon Teo, who was in Dublin this month
Graduates of Irish medical schools are renowned the world over as being highly qualified, well respected clinicians and researchers. One such highly distinguished graduate is cardiologistProf Koon Teo, Professor of the Departments of Medicine and Clinical Epidemiology and Biostatistics at the McMaster University in Canada.
Prof Teo graduated from the RCSI in 1978 and spent his formative years in cardiology under the tutelage of renowned Irish cardiologistProf John Horganin the Richmond Hospital in Dublin. He then moved to Canada and has since become one of world’s foremost researchers in cardiovascular disease.
On moving to Canada, Prof Teo underwent further training in cardiology and research at the University of Alberta, Edmonton, obtaining his PhD in 1988. He also carried out further advanced training in clinical trials and epidemiology at the US National Institutes of Health in Bethesda, Maryland, from 1988 to 1990.
On his return to Canada, he joined the Faculty of Medicine at the University of Alberta, where he set up the Cardiology Clinical Trials Centre and the Epidemiology and Coordinating Centre (EPICORE Centre).
Currently, Prof Teo is an Associate Director of the Population Health Research Institute (PHRI) providing senior leadership to the Institute’s direction and research studies. He is a Professor of Medicine in the Division of Cardiology at McMaster University and an Associate member of the Department of Clinical Epidemiology and Biostatistics. Previously, he served as the acting director of the Division of Cardiology at McMaster University and Hamilton Health Sciences and Chief of Cardiology, McMaster University Medical Centre.
Prof Koon Teo speaking at the meeting at the RCSI
CVD risk factors
Prof Teo’s recent work has focused on major clinical trials in the prevention of cardiovascular diseases (CVD) and large epidemiology studies on the societal and environmental causes of CVD risk factors. He has been lead investigator in a number of major high impact studies such as the ONTARGET/TRANSCEND trials on 31,000 patients and the PURE epidemiology cohort study in 155,000 individuals from 17 countries.
He is also the Canadian Principal Investigator for the COURAGE trial — the results of which impacted on the practice of cardiology worldwide — and for the Canadian Institute for Health Research-funded ongoing FAMILY study, which is examining the origins of obesity and cardiometabolic risk factors in early childhood.
Prof Teo is also co-principal investigator of The International Polycap Studies (TIPS) evaluating the effects of a polypill on CVD risk factors and in primary and secondary prevention. His wide range of published work includes 16 book chapters, 410 peer-reviewed articles and 280 abstracts, which have featured in more than 15 medical journals worldwide. In recognition of his research publications, Prof Teo has been named by Thomson Reuters in 2014 and 2015 as ranking among the top 1 per cent of researchers for most cited publications in clinical medicine.
IMTcaught up with Prof Teo recently when he returned to his alma mater to address a special event marking the 10th anniversary of the RCSI School of Postgraduate Studies. As a guest presenter at the event, Prof Teo addressed the conference on ‘Asking important questions in clinical research’, stressing that his initial and guiding question when undertaking any clinical research was always “does this work?”
Speaking toIMT, Prof Teo said: “We need to keep asking does this work? What is the evidence that tells me that this treatment works? I think that is an important question and we are only able to do this when we demonstrate in people, not in the lab.”
While laboratory-based research was important in telling us how a medication should work, Prof Teo said the only way to prove something worked or not in humans was with properly designed studies. In his view, real-life studies were important as humans were free living individuals who could decide whether or not to take a certain medication and as individuals, processed or absorbed different medications differently.
The RCSI graduate said he believed that clinical researchers were currently asking the right questions, however his advice to the next generation of young researchers was to “keep asking”.
Indeed, his determination to ask the right questions had resulted in several high-profile trials in CVD, a number of which have subsequently changed clinical practice.
From left to right: RCSI’s Dr Tom Farrell; Prof Anne Hickey; and Prof Celine Marmion, pictured at the 10 Year Anniversary of the RCSI School of Postgraduate Studies
HOPE Trial
One such study was the Heart Outcomes Prevention Evaluation, or HOPE, trial. This was the first study in the world to find a beneficial effect of the ace inhibitor ramipril in patients with a history of stroke, MI, peripheral vascular disease or diabetes.
The study, which was published in the New England Journal of Medicine in January 2000, concluded that its findings clearly demonstrated that ramipril, which is a long-acting angiotensin-converting-enzyme inhibitor, reduced the rates of death, myocardial infarction, stroke, revascularisation, cardiac arrest, heart failure, complications related to diabetes, and new cases of diabetes in a broad spectrum of high-risk patients. “Treating 1,000 patients with ramipril for four years prevents about 150 events in approximately 70 patients,” the trial found.
COURAGE Trial
Another study that Prof Teo was involved in was The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation, or COURAGE, trial, which, he explained, was a follow-on from HOPE. In the COURAGE trial, researchers compared the use of optimal medical therapy alone with optimal medical therapy plus percutaneous cardiac intervention (PCI), stents, balloons, in patients with stable ischaemic heart disease and found no significant difference between the treatment groups.
Prof Teo explained that at the time of the COURAGE Trial (1998) approximately 1 million PCI procedures were being carried out every year in the US alone and the results of the trial, which took 10 years to complete, had led to a reduction in the number of people undergoing PCI.
From left to right: Dr Frank Doyle; Prof Ronan Conroy; Prof Hannah McGee, Dean of the Faculty of Medicine and Health Sciences; and Dr Barbara Bates-Jensen
FAMILY Trial
The McMaster University professor is currently working with a team of researchers on the innovative FAMILY study, which as mentioned above is examining the origins of obesity and cardiometabolic risk factors in early childhood.
According to Prof Teo, the idea for the FAMILY trial came about from the rising childhood obesity rates that were first noticed almost 20 years ago.
The Family Atherosclerosis Monitoring In earLY life (FAMILY) study is examining the early determinants of atherosclerosis by following children from utero to 10 years of age. For the trial, some 850 children and their families (mother, father, eldest sibling) were recruited during pregnancy. Researchers are aiming to investigate the effect of (a) prenatal and postnatal determinants and (b) individual and family (maternal/paternal) determinants for the development of adiposity and CVD risk factors at ages 3, 5, and 10 years.
Celebrating Research
Prof Teo was in Dublin to address a special event marking the 10th anniversary of the RCSI School of Postgraduate Studies. The one-day conference, entitled ‘Celebrating Research — Past, Present and Future’, took place on September 9. Commenting on this milestone event, Prof Cathal Kelly, RCSI Chief Executive, said: “Over the past decade the postgraduate researchers that have come through the RCSI School of Postgraduate Studies programmes have made an outstanding contribution to research that will make a real difference to the patient experience, which will ultimately benefit both society and the economy.
“I am delighted to welcome back our Alumni who, along with our next generation of graduates, will continue to create new knowledge and innovations and inform new policies that will make a real difference to human health,” added Prof Kelly.
The number of postgraduate research students enrolled at the RCSI School of Postgraduate Studies has almost doubled in the past decade, with an increase from 125 in 2005/2006 to 235 presently enrolled. Since 2006, the School has facilitated 520 graduates to achieve MSc, MCh, MD or PhD degrees.