The win ratio: a new approach to the analysis of composite endpoints in clinical trials based on clinical priorities

Eur Heart J. 2012 Jan;33(2):176-82. doi: 10.1093/eurheartj/ehr352. Epub 2011 Sep 6.


The conventional reporting of composite endpoints in clinical trials has an inherent limitation in that it emphasizes each patient's first event, which is often the outcome of lesser clinical importance. To overcome this problem, we introduce the concept of the win ratio for reporting composite endpoints. Patients in the new treatment and control groups are formed into matched pairs based on their risk profiles. Consider a primary composite endpoint, e.g. cardiovascular (CV) death and heart failure hospitalization (HF hosp) in heart failure trials. For each matched pair, the new treatment patient is labelled a 'winner' or a 'loser' depending on who had a CV death first. If that is not known, only then they are labelled a 'winner' or 'loser' depending on who had a HF hosp first. Otherwise they are considered tied. The win ratio is the total number of winners divided by the total numbers of losers. A 95% confidence interval and P-value for the win ratio are readily obtained. If formation of matched pairs is impractical then an alternative win ratio can be obtained by comparing all possible unmatched pairs. This method is illustrated by re-analyses of the EMPHASIS-HF, PARTNER B, and CHARM trials. The win ratio is a new method for reporting composite endpoints, which is easy to use and gives appropriate priority to the more clinically important event, e.g. mortality. We encourage its use in future trial reports.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Angiotensin II Type 1 Receptor Blockers / therapeutic use
  • Aortic Valve Stenosis / mortality
  • Aortic Valve Stenosis / therapy
  • Benzimidazoles / therapeutic use
  • Biphenyl Compounds
  • Cardiac Catheterization
  • Cardiovascular Diseases / mortality
  • Clinical Trials as Topic / statistics & numerical data*
  • Endpoint Determination / methods*
  • Eplerenone
  • Heart Failure / drug therapy
  • Heart Failure / mortality
  • Hospitalization / statistics & numerical data
  • Humans
  • Matched-Pair Analysis
  • Mineralocorticoid Receptor Antagonists / therapeutic use
  • Proportional Hazards Models
  • Risk Factors
  • Spironolactone / analogs & derivatives
  • Spironolactone / therapeutic use
  • Tetrazoles / therapeutic use


  • Angiotensin II Type 1 Receptor Blockers
  • Benzimidazoles
  • Biphenyl Compounds
  • Mineralocorticoid Receptor Antagonists
  • Tetrazoles
  • Spironolactone
  • Eplerenone
  • candesartan