We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
The Medical Literature |

Users' Guides to the Medical Literature:  XIX. Applying Clinical Trial Results
A. How to Use an Article Measuring the Effect of an Intervention on Surrogate End Points

Heiner C. Bucher, MD, MPH; Gordon H. Guyatt, MD, MSc; Deborah J. Cook, MD, MSc; Anne Holbrook, MD, MSc; Finlay A. McAlister, MD; for the Evidence-Based Medicine Working Group
JAMA. 1999;282(8):771-778. doi:10.1001/jama.282.8.771.
Text Size: A A A
Published online


Delmas PD, Bjarnason NH, Mitlak BH.  et al. Effects of raloxifene on bone mineral density, serum cholesterol concentrations, and uterine endometrium in postmenopausal women. N Engl J Med.1997;337:1641-1647.
Temple RJ.A regulatory authority's opinion about surrogate endpoints.In: Nimmo WS, Tucker GT, eds. Clinical Measurement in Drug Evaluation. New York, NY: John Wiley & Sons Inc; 1995:57.
Hammer SM, Katzenstein DA, Hughes MD.  et al. A trial comparing nucleoside monotherapy with combination therapy in HIV-infected adults with CD4 cell counts from 200 to 500 per cubic millimeter. N Engl J Med.1996;335:1081-1090.
Delta Coordinating Committee. Delta: a randomised double-blind controlled trial comparing combinations of zidovudine plus didanosine or zalcitabine with zidovudine alone in HIV-infected individuals. Lancet.1996;348:283-291.
Saravolatz LD, Winslow DL, Collins G.  et al. Zidovudine alone or in combination with didanosine or zalcitabine in HIV-infected patients with the acquired immunodeficiency syndrome or fewer than 200 CD4 cells per cubic millimeter. N Engl J Med.1996;335:1099-1106.
Hammer SM, Squires KE, Hughes MD.  et al. A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. N Engl J Med.1997;337:725-733.
Niebauer J, Coats AJ.Treating chronic heart failure: time to take stock. Lancet.1997;349:966-967.
Massie BM, Berk MR, Brozena SC.  et al. Can further benefit be achieved by adding flosequinan to patients with congestive heart failure who remain symptomatic on diuretic, digoxin, and an angiotensin converting enzyme inhibitor? results of the flosequinan-ACE inhibitor trial (FACET). Circulation.1993;88:492-501.
How to read clinical journals, IV: to determine etiology or causation. CMAJ.1981;124:985-990.
Oxman AD, Sackett DL, Guyatt GH.Users' guides to the medical literature, I: how to get started. JAMA.1993;270:2093-2095.
Guyatt G, Walter S, Shannon H, Cook D, Jaeschke R, Heddle N.Basic statistics for clinicians, IV: correlation and regression. CMAJ.1995;152:497-504.
Guyatt GH, Thompson PJ, Berman LB.  et al. How should we measure function in patients with chronic heart and lung disease? J Chronic Dis.1985;38:517-524.
Mahler DA, Weinberg DH, Wells CK, Feinstein AR.The measurement of dyspnea: contents, interobserver agreement, and physiologic correlates of two new clinical indexes. Chest.1984;85:751-758.
Verschuren WM, Jacobs DR, Bloemberg BP.  et al. Serum total cholesterol and long-term coronary heart disease mortality in different cultures. JAMA.1995;274:131-136.
Mellors JW, Rinaldo Jr CR, Gupta P.  et al. Prognosis in HIV-1 infection predicted by the quantity of virus in plasma. Science.1996;272:1167-1170.
Mellors JW, Kingsley LA, Rinaldo CR.  et al. Quantitation of HIV-1 RNA in plasma predicts outcome after seroconversion. Ann Intern Med.1995;122:573-579.
Ruiz L, Romeu J, Clotet B.  et al. Quantitative HIV-1 RNA as a marker of clinical stability and survival in a cohort of 302 patients with a mean CD4 cell count of 300 × 10(6)/1. AIDS.1996;10:F39-F44.
O'Brien TR, Blattner WA, Waters D.  et al. Serum HIV-1 RNA levels and time to development of AIDS in the Multicenter Hemophilia Cohort Study. JAMA.1996;276:105-110.
Yerly S, Perneger TV, Hirschel B.  et al. A critical assessment of the prognostic value of HIV-1 RNA levels and CD4+ cell counts in HIV-infected patients. Arch Intern Med.1998;158:247-252.
Ho DD.Viral counts in HIV infection. Science.1996;272:1124-1125.
Cummings SR, Nevitt MC, Browner WS.  et al. Risk factors for hip fracture in white women. N Engl J Med.1995;332:767-773.
Marshall D, Johnell O, Wedel H.Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ.1996;312:1254-1259.
Huang C, Ross PD, Wasnich RD.Short-term and long-term fracture prediction by bone mass measurements. J Bone Miner Res.1998;13:107-113.
Bigger Jr JT, Fleiss JL, Kleiger R.  et al. The relationships among ventricular arrhythmias, left ventricular dysfunction, and mortality in the 2 years after myocardial infarction. Circulation.1984;69:250-258.
McAlister FA, Teo KK.Antiarrhythmic therapies for the prevention of sudden cardiac death. Drugs.1997;54:235-252.
Echt DS, Liebson PR, Mitchell LB.  et al. and the Cardiac Arrhythmia Suppression Trial. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. N Engl J Med.1991;324:781-788.
Moore TJ.Deadly Medicine.New York, NY: Simon & Schuster; 1995.
Drexler H, Banhardt U, Meinertz T.  et al. Contrasting peripheral short-term and long-term effects of converting enzyme inhibition in patients with congestive heart failure: a double-blind, placebo-controlled trial. Circulation.1989;79:491-502.
Lewis GR.Comparison of lisinopril versus placebo for congestive heart failure. Am J Cardiol.1989;63:12D-16D.
Giles TD, Fisher MB, Rush JE.Lisinopril and captopril in the treatment of heart failure in older patients. Am J Med.1988;85:44-47.
Riegger GA.Effects of quinapril on exercise tolerance in patients with mild to moderate heart failure. Eur Heart J.1991;12:705-711.
Garg R, Yusuf S.Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. JAMA.1995;273:1450-1456.
Di Bianco R, Shabetai R, Kostuk W.  et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med.1989;320:677-683.
Sueta CA, Gheorghiade M, Adams KF.  et al. and the Epoprostenol Multicenter Research Group. Safety and efficacy of epoprostenol in patients with severe congestive heart failure. Am J Cardiol.1995;75:34A-43A.
Packer M, Carver JR, Rodeheffer RJ.  et al. for the Promise Study Research Group. Effect of oral milrinone on mortality in severe chronic heart failure. N Engl J Med.1991;325:1468-1475.
Califf RM, Adams KF, McKenna WJ.  et al. A randomized controlled trial of epoprostenol therapy for severe congestive heart failure. Am Heart J.1997;134:44-54.
Yee KM, Struthers AD.Can drug effects on mortality in heart failure be predicted by any surrogate measure? Eur Heart J.1997;18:1860-1864.
Hampton JR, van Veldhuisen DJ, Kleber FX.  et al. Randomised study of effect of ibopamine on survival in patients with advanced severe heart failure. Lancet.1997;349:971-977.
Cameron DW, Heath-Chiozzi M, Danner S.  et al. and the Advanced HIV Disease Ritonavir Study Group. Randomised placebo-controlled trial of ritonavir in advanced HIV-1 disease. Lancet.1997;351:543-549.
Watts NB, Harris ST, Genant HK.  et al. Intermittent cyclical etidronate treatment of postmenopausal osteoporosis. N Engl J Med.1990;323:73-79.
Storm T, Thamsborg G, Steiniche T, Genant HK, Sorensen OH.Effect of intermittent cyclical etidronate therapy on bone mass and fracture rate in women with postmenopausal osteoporosis. N Engl J Med.1990;322:1265-1271.
Liberman UA, Weiss SR, Broll J.  et al. and the Alendronate Phase III Osteoporosis Treatment Study Group. Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. N Engl J Med.1995;333:1437-1443.
Riggs BL, Hodgson SF, O'Fallon WM.  et al. Effect of fluoride treatment on the fracture rate in postmenopausal women with osteoporosis. N Engl J Med.1990;322:802-809.
Meunier PJ, Sebert J-L, Reginster J-Y.  et al. Fluoride salts are no better at preventing new vertebral fractures than calcium-vitamin D in postmenopausal osteoporosis. Osteoporos Int.1998;8:4-12.
Dawson-Hughes B, Harris SS, Krall EA, Dallal GE.Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age and older. N Engl J Med.1977;337:670-676.
McAlister FA, Straus S, Sackett DL.Randomized clinical trials of antihypertensive drugs: all that glitters is not gold. CMAJ.1998;159:488-490.
Staessen JA, Fagard R, Thijs L.  et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet.1997;350:757-764.
Psaty BM, Siscovick DS, Weiss NS.  et al. Hypertension and outcomes research: from clinical trials to clinical epidemiology. Am J Hypertens.1996;9:178-183.
Borhani NO, Mercuri M, Borhani PA.  et al. Final outcome results of the multicenter isradipine diuretic atherosclerosis study (MIDAS): a randomized controlled trial. JAMA.1996;276:785-791.
Tatti P, Pahor M, Byington RP.  et al. Outcome results of the fosinopril versus amlodipine cardiovascular events randomized trial (FACET) in patients with hypertension and NIDDM. Diabetes Care.1998;21:597-603.
Estacio RO, Jeffers BW, Hiatt WR, Biggerstaff SL, Gifford N, Schrier RW.The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin-dependent diabetes and hypertension. N Engl J Med.1998;338:645-652.
McAlister FA, Laupacis A, Wells GA, Sackett DL.for the Evidence-Based Medicine Working Group. Users' guide to the medical literature, XIX: applying clinical trial results part B: guidelines for determining whether a drug is exerting (more than) a class effect. JAMA.In press.
Bucher HC, Griffith LE, Guyatt GH.Systematic review on risk and benefit of different cholesterol lowering interventions. Arterioscler Thromb Vasc Biol.1999;19:187-195.
Muldoon MF, Manuck SB, Matthews KA.Lowering cholesterol concentration and mortality. BMJ.1990;301:309-314.
Smith GD, Song F, Sheldon TA.Cholesterol lowering and mortality. BMJ.1993;306:1367-1373.
Prentice RL.Surrogate endpoints in clinical trials. Stat Med.1989;8:431-440.
Fleming TR.Surrogate markers in AIDS and cancer trials. Stat Med.1994;13:1423-1435.
Cooper DA, Gatell JM, Kroon S.  et al. and the European-Australian Collaborative Group. Zidovudine in persons with asymptomatic HIV infection and CD4+ cell counts greater than 400 per cubic millimeter. N Engl J Med.1993;329:297-303.
Concorde Coordinating Committee. Concorde: MRC/ANRS randomised double-blind controlled trial of immediate and deferred zidovudine in symptom-free HIV infection. Lancet.1994;343:871-881.
Guyatt GH, Sackett DL, Cook DJ.for the Evidence-Based Medicine Working Group. Users' guides to the medical literature, II: how to use an article about therapy or prevention A: are the results of the study valid? JAMA.1993;270:2598-2601.
Dans AL, Dans LF, Guyatt GH, Richardson S.for the Evidence-Based Medicine Working Group. Users' guides to the medical literature, XIV: how to decide on the applicability of clinical trial results to your patient. JAMA.1998;279:545-549.
Ettinger B, Black D, Cummings S.  et al. Raloxifene reduces the risk of incident vertebral fractures: 24 month interim analyses. Osteoporos Int.1998;8(suppl 3):11.
Clendeneninn N, Quart B, Anderson R, Knowles M, Chang Y.Analysis of long-term virologic data from the viracept (nelfinavir) 511 protocol using 3 HIV-RNA assays.In: Abstracts from the 5th Conference on Retroviruses and Opportunistic Infections; Chicago, Ill; 1998.
Brun-Vezinet F, Boucher C, Loveday C.  et al. and the Delta Virology Working Group and Coordinating Committee. HIV-1 viral load, phenotype, and resistance in a subset of drug-naive participants from the Delta trial: the national virology groups. Lancet.1997;350:983-990.
Montaner JS, Reiss P, Cooper D.  et al. A randomized, double-blind trial comparing combinations of nevirapine, didanosine, and zidovudine for HIV-infected patients: the Netherlands, Canada, and Australia (INCAS) study. JAMA.1998;279:930-937.
CEASAR Coordinating Committee. Randomised trial of addition of lamivudine or lamivudine plus loviride to zidovudine-containing regimens for patients with HIV-1 infection: the CAESAR trial. Lancet.1997;349:1413-1421.
Fischl M, Greenberg S, Clumeck N.  et al. Safety and activity of abacavir (1592, ABC) with 3TC/ZDV in antiretroviral naive subjects.In: Abstracts from the 12th World AIDS Conference: Geneva, Switzerland; June 28-July 3, 1998.
Katzenstein DA, Hammer SM, Hughes MD.  et al. and the AIDS Clinical Trials Group Study 175 Virology Study Team. The relation of virologic and immunologic markers to clinical outcomes after nucleoside therapy in HIV-infected adults with 200 to 500 CD4 cells per cubic millimeter. N Engl J Med.1996;335:1091-1098.
Collins R, Peto R, MacMahon S.  et al. Blood pressure, stroke, and coronary heart disease, part 2: short-term reductions in blood pressure; overview of randomised drug trials in their epidemiological context. Lancet.1990;335:827-838.
MacMahon S, Peto R, Cutler J.  et al. Blood pressure, stroke, and coronary heart disease, part 1: prolonged differences in blood pressure; prospective observational studies corrected for the regression dilution bias. Lancet.1990;335:765-774.
Psaty BM, Smith NL, Siscovick DS.  et al. Health outcomes associated with antihypertensive therapies used as first-line agents: a systematic review and meta-analysis. JAMA.1997;277:739-745.
Heinonen TM, Stein E, Weiss SR.  et al. The lipid-lowering effects of atorvastatin, a new HMG-coA reductase inhibitor: results of a randomized, double-masked study. Clin Ther.1996;18:853-863.
Bakker-Arkema RG, Davidson MH, Goldstein RJ.  et al. Efficacy and safety of a new HMG-coA reductase inhibitor, atorvastatin, in patients with hypertriglyceridemia. JAMA.1996;275:128-133.
Law MR, Wald NJ, Thompson SG.By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ.1994;308:367-372.
Winocour PH, Durrington PN, Bhatagnar D.  et al. The effect of bezafibrate on very low density lipoprotein (VLDL), intermediate density lipoprotein (IDL), and low density lipoprotein (LDL) composition in type 1 diabetes associated with hypercholesterolaemia or combined hyperlipidaemia. Atherosclerosis.1992;93:83-94.
Jones IR, Swai A, Taylor R, Miller M, Laker MF, Alberti KG.Lowering of plasma glucose concentrations with bezafibrate in patients with moderately controlled NIDDM. Diabetes Care.1990;13:855-863.
Jones P, Kafonek S, Laurora I, Hunninghake D.Comparative dose efficacy study of atorvastatin versus simvastatin, pravastatin, lovastatin, and fluvastatin in patients with hypercholesterolemia (the CURVES study). Am J Cardiol.1998;81:582-587.
Downs JR, Clearfield M, Weis S.  et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels. JAMA.1998;279:1615-1622.
Shepherd J, Cobbe SM, Ford I.  et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med.1995;333:1301-1307.
Karpf DB, Shapiro DR, Seeman E.  et al. Prevention of nonvertebral fractures by alendronate: a meta-analysis. JAMA.1997;277:1159-1164.
Black DM, Cummings SR, Karpf DB.  et al. and the Fracture Intervention Trial Research Group. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet.1996;348:1535-1541.
Cummings SR, Eckert S, Krueger KA.  et al. The effect of raloxifene on risk of breast cancer in postmenopausal women. JAMA.1999;281:2189-2197.
Ettinger B, Black DM, Mitlak BH.  et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized trial. JAMA.1999;282:637-645.

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal

First Page Preview

View Large
First page PDF preview




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles

Users' Guides to the Medical Literature
Surprising Results of Randomized Trials

Users' Guides to the Medical Literature
Composite End Points