Cardiovascular Disease Risk Stratification in Wrist Wearable Devices and e-Health App Users: A Large-Scale Retrospective Study

Introduction: Wearable devices, including smart wristbands and watches, are often used with e-health applications (apps). The users' characteristics of wrist wearable devices currently lack description, and the cardiovascular disease (CVD) high-risk rate of users remains unknown. Purpose: This study aimed to (1) describe the basic characteristics and habits of users of the "Amazfit Health" app and Huami wrist wearable devices and (2) analyze the proportion and define the population characteristics of users with a high risk of developing CVD. Subjects and Methods: This study included users >18 years of age, residing in mainland China, using the "Amazfit Health" app and Huami wearable devices. Devices data and users' self-reported information were collected in the app. The risk stratification was based on WHO/ISH cardiovascular risk prediction charts for the Western Pacific Region. Subjects with CVD history, total cholesterol ≥8 mmol/L, or ≥10% predicted CVD risk and those with <10% predicted CVD risk were considered to be at high and low risk of developing CVD, respectively. Results: Data were obtained from 80,098 (total users) and 10,866 users (subjects) for risk stratification. The age of the total users and subjects were 45.6 ± 15.4 and 50.7 ± 14.0 years, respectively. The number of male and female users was 50,024, and 30,074 in total users, and 7,284, and 3,582 in subjects, respectively. The body mass index of total users and subjects was 24.0 ± 4.6 kg/m² and 24.6 ± 3.8 kg/m², respectively. By classifying users' residences into first-tier cities, municipalities and provincial capitals, and other areas, the numbers of total users were 20,179, 28,213, and 31,137, and subjects were 2,587, 3,966, and 4,269, respectively. The number of subjects with high CVD risk was 1,161, accounting for 10.7% of all subjects. Conclusions: Users with high CVD risk only accounted for a small proportion of the population of wearable devices users.

Trends in Bleeding Events Among Patients With Acute Coronary Syndrome in China, 2015 to 2019: Insights From the CCC-ACS Project

Objective: Major bleeding is a common complication following treatment for an acute coronary syndrome (ACS) and is associated with increased mortality. We aimed to explore the temporal trend of bleeding events in relation to changes of therapeutic strategies among patients hospitalized for ACS in China. Methods: The CCC-ACS project (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) is a collaborative initiative of the American Heart Association and the Chinese Society of Cardiology. We analyzed 113,567 ACS patients from 241 hospitals in China from 2015 to 2019. Major bleeding was defined as intracranial bleeding, retroperitoneal bleeding, a decline in hemoglobin levels ≥3 g/dL, transfusion with overt bleeding, bleeding requiring surgical intervention, and fatal bleeding. Kruskal-Wallis test was used to examine the trend of major bleeding over time. Results: The rate of in-hospital major bleeding decreased from 6.3% in 2015 to 4.7% in 2019 (unadjusted OR = 0.74, 95% CI: 0.68-0.80, and P < 0.001). The relative changes were consistent across almost all subgroups including patients with NSTE-ACS and STEMI, although the trend was more pronounced in NSTE-ACS patients. The decrease in bleeding was accompanied by a decrease in use of GP IIb/IIIa inhibitors and parenteral anticoagulation therapy during hospitalization. The annual reduced risk of bleeding (OR = 0.91, 95% CI: 0.89-0.93) was attenuated after stepwise adjusting for baseline characteristics and antithrombotic treatments (OR = 0.95, 95% CI: 0.93-0.97), but did not change after adjusting for invasive treatment (OR = 0.95, 95% CI: 0.93-0.97). Conclusions: There was a temporal reduction in in-hospital bleeding among Chinese ACS patients during the last 5 years, which was associated with more evidence-based use of antithrombotic therapies. Clinical Trial Registration: https://www.clinicaltrials.gov, identifier: NCT02306616.

The Effects on Adherence of a Mobile Application-based Self-management Digital Therapeutics among Coronary Heart Disease Patients: Pilot Randomized Controlled Trial

Background

The adherence to secondary prevention treatment in patients with coronary heart disease (CHD) is low. Digital therapeutics (DTx) refers to an emerging branch of medicine that delivers medical interventions directly to patients using evidence-based, clinically evaluated, technology-based software algorithms or apps to facilitate disease management, which may be an efficient tool to optimize adherence.

Objective

This paper aims to investigate the effect of mobile app–based self-management DTx on long-term use of secondary prevention medications in patients with CHD in China.

Methods

This pilot study was a parallel-designed, open-labeled, single-center, randomized controlled trial. Hospitalized patients with CHD admitted to Peking University First Hospital between April 2016 and June 2017 were randomized before discharge on a 1:1 ratio. The intervention group received regular follow-up combined with DTx, which is a self-management mobile app already installed on an Android 5 (Mi Pad 1, Xiaomi Corporation) tablet. Structured data from the hospital informatics system were integrated automatically, and medication, lifestyle intervention plan, follow-up protocol, and patient education materials were also provided according to the diagnosis. Participants could use DTx for self-management at home. The control group was under conventional hospital–based follow-up care. Patients were followed up for 1 year, and the primary end point was the percentage of all guideline-recommended medications at 12 months. The secondary end points included the percentage adhered to standard secondary prevention medications at 6 months, the control rate of lipid profile, and blood pressure at 6 months and 1 year.

Results

Among 300 randomized patients with CHD, 290 (96.7%) were included in the final analysis, including 49.3% (143/290) and 50.7% (147/290) of patients from the intervention and control groups, respectively. Baseline characteristics were similar between the 2 groups. There was a statistically significant improvement in the percentage of all guideline-recommended medications at 12 months in the intervention group compared with the control group (relative risk [RR] 1.34, 95% CI 1.12-1.61; P=.001), and there was no interaction with baseline characteristics. The intervention group had a significantly higher proportion of patients achieving blood pressure under control (systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg) and low-density lipoprotein cholesterol <1.8 mmol/L (RR 1.45, 95% CI 1.22-1.72; P<.001 and RR 1.40, 95% CI 1.11-1.75; P=.004, respectively) at 12 months. Furthermore, on logistic regression, the intervention group had a lower risk of withdrawing from guideline-recommended medications (odds ratio 0.46, 95% CI 0.27-0.78; P=.004).

Conclusions

Among patients with CHD, using a mobile app–based self-management DTx in addition to traditional care resulted in a significant improvement in guideline-recommended medication adherence at 12 months. The results of the trial will be applicable to primary care centers, especially in rural areas with less medical resources.

Trial Registration

ClinicalTrials.gov NCT03565978; https://clinicaltrials.gov/ct2/show/NCT03565978

A Potential Long-Acting LDL-Cholesterol–Lowering PCSK9 Monoclonal Antibody

The aim of the studies was to evaluate the safety, tolerability, and efficacy of tafolecimab, a novel proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody, in Chinese healthy volunteers and patients with hypercholesterolemia. Fifty-eight healthy volunteers (phase 1a) were randomized to receive a single dose of 25, 75, 150, 300, 450, or 600 mg tafolecimab subcutaneously, 75 or 450 mg intravenously, or placebo. Sixty patients with hypercholesterolemia (phase 1b) were randomized to receive 75 or 140 mg tafolecimab every 2 weeks, 300 or 420 mg every 4 weeks, or 450 or 600 mg every 6 weeks subcutaneously or placebo for 12 weeks. Tafolecimab was well tolerated. Adverse events in both studies were either mild or moderate. In the phase 1a study, a single dose of tafolecimab reduced low-density lipoprotein-cholesterol (LDL-C) levels up to 72% in healthy volunteers. In the phase 1b study, tafolecimab reduced LDL-C levels up to 71.6% and by more than 50% consistently to week 12 for all tafolecimab dose regimens. Tafolecimab is a safe PCSK9 monoclonal antibody with significant and potential long-acting LDL-C–lowering effect. (Single Ascending Dose Study of PCSK-9 Inhibitor [IBI306] in Healthy Subjects; NCT03366688) (Multiple Ascending Dose Study of PCSK-9 Inhibitor [IBI306] in Chinese Patients With Hypercholesterolemia; NCT03815812)

Active Versus Conventional Side Branch Protection Strategy for Coronary Bifurcation Lesions

The side branch (SB) provisional stenting strategy is currently the recommended approach for most coronary bifurcation lesions. However, this strategy may result in SB deterioration, which is associated with an increased incidence of periprocedural myocardial infarction (PMI) and may adversely affect the long-term prognosis. Various techniques for SB protection (SB-P) have been developed to reduce SB occlusion and improve the clinical prognosis. This meta-analysis was performed to compare the outcomes of an active SB-P strategy of jailed balloon technique, balloon-stent kissing technique, and jailed Corsair technique versus the conventional SB-P strategy based on jailed wire technique.This meta-analysis included 5 studies (4 randomized and 1 observational) involving a total of 1,174 patients in whom the active and conventional SB-P strategies were compared. Fixed- and random-effects models were used to calculate summary risk ratios (RRs).The risk of SB occlusion was significantly lower in active SB-P strategy [RR 0.47, 95% confidence interval (CI) 0.30-0.73 in fixed-effect model; RR 0.52, 95% CI 0.31-0.87 in random-effect model]. The risk of PMI was similar between the two strategies (RR 0.63, 95% CI 0.30-1.33 in fixed-effect model; RR 0.71, 95%CI 0.20-2.48 in random-effect model). The rate of long-term major adverse cardiovascular events was similar between the groups (RR 0.48, 95% CI 0.15-1.48 in fixed-effect model; RR 0.49, 95% CI 0.16-1.52 in random-effect model).The active SB-P strategy in coronary bifurcation lesions is associated with reduced SB deterioration, but it does not decrease PMI or improve the long-term prognosis.

Plasma Vitamin E and the Risk of First Stroke in Hypertensive Patients: A Nested Case-Control Study

Background: The association between plasma vitamin E levels and first stroke risk in men and women remains unclear. Objective: We aimed to examine the prospective association between plasma vitamin E and first stroke, and evaluate the effect modifiers for the association, among hypertensive patients. Design: The study sample was drawn from the China Stroke Primary Prevention Trial (CSPPT), which randomized a total of 20,702 hypertensive patients to a double-blind, daily treatment with either 10 mg enalapril and 0.8 mg folic acid or 10 mg enalapril alone. This nested case-control study, including 618 first stroke cases and 618 controls matched for age, sex, treatment group, and study site, was conducted after the completion of the CSPPT. Results: The median follow-up duration was 4.5 years. Among men, a significantly higher risk of first stroke (adjusted OR, 1.67; 95%CI: 1.01, 2.77) was found for those with plasma vitamin E ≥7.1 μg/mL (≥quartile 1) compared with those with plasma vitamin E < 7.1 μg/mL. Subgroup analyses further showed that the association between vitamin E (≥7.1 vs. <7.1 μg/mL) and first stroke in men was significantly stronger in non-drinkers (adjusted OR, 2.64; 95%CI: 1.41, 4.96), compared to current drinkers (adjusted OR, 0.84; 95% CI: 0.43, 1.66, P-interaction = 0.008). However, there was no significant association between plasma vitamin E and first stroke in women (P-interaction between sex and plasma vitamin E = 0.048). Conclusions: Among Chinese hypertensive patients, there was a statistically significant positive association between baseline plasma vitamin E and the risk of first stroke in men, but not in women. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT00794885, Identifier: NCT00794885.

Lipid goal attainment in post-acute coronary syndrome patients in China: Results from the 6-month real-world dyslipidemia international study II

BACKGROUND

Dyslipidemia International Study II (DYSIS II)-China was conducted to determine the low-density lipoprotein cholesterol (LDL-C) goal (<1.8 mmol/L) attainment rate in patients with post-acute coronary syndrome (ACS).

HYPOTHESIS

Compliance with treatment guideline recommendations improves the LDL-C goal attainment rate in post-ACS patients.

METHODS

This multicenter prospective observational study conducted at 28 tertiary hospitals determined the LDL-C goal attainment rates at admission and 6-month follow-up in patients on lipid-lowering treatment (LLT) for ≥3 months and those not on LLT (LLT-naive or off LLT for ≥3 months) at admission. Predictors of goal attainment at 6 months were identified using multivariate logistic regression.

RESULTS

The LDL-C goal attainment rate at admission in 1102/1103 enrolled patients was 17.1%; it was 41.2% among 752 patients with available lipid results at 6 months. The distance to goal was 0.7 mmol/L at 6 months. Statin monotherapy was the most prescribed LLT. Only 7.7% of patients were receiving statin + ezetimibe and 8.4% of patients were receiving an atorvastatin-equivalent dose of ≥40 mg/day at 6 months. Being male (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.6) and undergoing percutaneous coronary intervention during index hospitalization (OR 1.5, 95% CI 1.1 to 2.1) were the independent predictors for LDL-C goal attainment.

CONCLUSIONS

This real-world DYSIS II study in China reports a low LDL-C goal attainment rate in post-ACS patients even after 6 months of LLT. Lack of intensification of statin therapy and underutilization of combinations suggest gaps between real-world treatment practices and guideline recommendations.

Epidemiologic and Genetic Associations of Erythropoietin With Blood Pressure, Hypertension, and Coronary Artery Disease

[Figure: see text].

Exome-Wide Association Study Identifies East Asian-Specific Missense Variant MTHFR C136T Influencing Homocysteine Levels in Chinese Populations RH: ExWAS of tHCY in a Chinese Population

Plasma total homocysteine (tHCY) is a known risk factor of a wide range of complex diseases. No genome scans for tHCY have been conducted in East Asian populations. Here, we conducted an exome-wide association study (ExWAS) for tHCY in 5,175 individuals of Chinese Han origin, followed by a replication study in 668 Chinese individuals. The ExWAS identified two loci, 1p36.22 (lead single-nucleotide polymorphism (SNP) rs1801133, MTHFR C677T) and 16q24.3 (rs1126464, DPEP1), showing exome-wide significant association with tHCY (p < 5E-7); and both loci have been previously associated with tHCY in non-East Asian populations. Both SNPs were replicated in the replication study (p < 0.05). Conditioning on the genotype of C677T and rs1126464, we identified a novel East Asian-specific missense variant rs138189536 (C136T) of MTHFR (p = 6.53E-10), which was also significant in the replication study (p = 9.8E-3). The C136T and C677T variants affect tHCY in a compound heterozygote manner, where compound heterozygote and homozygote genotype carriers had on average 43.4% increased tHCY than had other genotypes. The frequency of the homozygote C677T genotype showed an inverse-U-shaped geospatial pattern globally with a pronounced frequency in northern China, which coincided with the high prevalence of hyperhomocysteinemia (HHCY) in northern China. A logistic regression model of HHCY status considering sex, age, and the genotypes of the three identified variants reached an area under the receiver operating characteristic curve (AUC) value of 0.74 in an independent validation cohort. These genetic observations provide new insights into the presence of multiple causal mutations at the MTHFR locus, highlight the role of genetics in HHCY epidemiology among different populations, and provide candidate loci for future functional studies.

Prognostic value of a novel index: computational pressure-flow dynamics derived fractional flow reserve in patients with stable coronary artery disease treated with optimal medical therapy alone

Background

The use of fractional flow reserve (FFR) is limited due to the need of invasive pressure wire and hyperaemic stimulus. Computational pressure-flow dynamics derived fractional flow reserve (caFFR) is a novel non-invasive index to determine the FFR in patients with stable coronary artery disease (CAD).

Purpose

The clinical value of caFFR remains uncertain. The aim of the study is to evaluate the prognostic role of caFFR in patients with stable CAD who were treated by optimal medical therapy alone.

Methods

A total of 558 stable CAD patients (mean age=64.5±11.2, 59.0% male) with ≥1 coronary lesion detected during conventional coronary angiogram were included. All of them did not undergo percutaneous coronary intervention and were treated with optimal medical therapy alone. Patients were then classified into 4 groups according to their caFFR value; caFFR ≤0.70 (n=40), caFFR = 0.71–0.80 (n=28), caFFR = 0.81–0.90 (n=292), caFFR = 0.91–1.00 (n=198), with a lower caFFR indicating a greater magnitude of myocardial ischemia. The primary endpoint was 3-year major adverse cardiac events (MACE), defined as a composite of all-cause mortality, myocardial infarction or any unplanned revascularization.

Results

During a median follow-up of 36 months, a total of 49 composite events occurred, including 27 all-cause mortality, 4 myocardial infarction and 18 unplanned revascularization.

After multivariate adjustment, caFFR was an independent predictor of MACE (adjusted hazard ratio [HR] = 0.97 per 0.01 increase in caFFR; 95% confidence interval [Cl], 0.95–0.99; P&lt;0.01), all-cause mortality (adjusted HR = 0.96 per 0.01 increase in caFFR; 95% Cl, 0.94–0.99; P&lt;0.01), and stroke (adjusted HR = 0.95 per 0.01 increase in caFFR; 95% Cl, 0.90–0.99; P=0.03).

The area under the curve (AUC) by receiver-operating characteristic curve analysis (ROC) is 0.70 (95% Cl, 0.62–0.78; P&lt;0.01). The optimal cut-off of caFFR defined by ROC analysis for predicting MACE is 0.80, concluding that patients with caFFR ≤0.80 have significantly higher adverse event rate, which is consistent with the cut-off from wire-based FFR.

Using caFFR = 0.91–1.00 as reference, the risk of MACE was highest in patients with caFFR ≤0.70 (adjusted HR = 4.65; 95% Cl, 1.81–11.94; P&lt;0.01), followed by caFFR = 0.71–0.80 (adjusted HR = 3.67; 95% Cl, 1.12–11.33; P=0.02). The risk of MACE was nonetheless similar among patients with caFFR &gt;0.8 (adjusted HR = 1.39; 95% Cl, 0.61–3.19, P=0.44).

Conclusion

In patients with stable CAD who were treated with optimal medical therapy alone, those with more significant myocardial ischemia, indicated by lower caFFR, had higher risks of adverse outcomes. The finding thus supports the use of this non invasive index to quantify the severity of myocardial ischemia, improve risk-stratification, and predict adverse outcomes in patients with stable CAD.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The University of Hong Kong, Queen Mary Hospital

Association between non-wire based computational angiography fractional flow reserve treatment threshold and major adverse cardiac events in patients with stable coronary artery disease

Introduction

Despite class IA guideline recommendations, the use of fractional flow reserve (FFR) in guiding percutaneous coronary intervention (PCI) in stable coronary artery disease (CAD) patients remains low due to limitations including the need of guidewire placement and hyperaemic stimulus. A novel non-invasive index, computational pressure-flow dynamics derived FFR (caFFR), was developed for measuring functional myocardial ischemia and overcoming the limitations of FFR. However, the clinical relevance of caFFR remains to be investigated. In the present study, we aim at evaluating the prognostic value of caFFR among stable CAD patients.

Methods

We retrospectively included patients with stable CAD who underwent coronary angiography during 2014–2016 at our center. Based on the caFFR value, patients were considered to be ischemic (caFFR ≤0.8) and non-ischemic (caFFR &gt;0.8). Further, we recombined the patients to form the adherence cohort, where patients were defined as adherent-to-caFFR if they were ischemic with PCI or non-ischemic without PCI, and nonadherent-to-caFFR if they were ischemic without PCI or non-ischemic with PCI. The primary endpoint was major adverse cardiac events (MACE), defined as a composite of all-cause mortality, non-fatal myocardial infarction, and any revascularization. Inverse probability of treatment weighting was used to account for treatment selection bias (PCI vs without PCI, or adherent vs non-adherent), and Cox proportional hazard model was used to evaluate the association with MACE.

Results

A total of 1322 patients, 782 patients in the ischemic cohort and 540 patients in the non-ischemic cohort respectively, were included in our analysis. PCI was associated with a lower risk of MACE in the ischemic cohort (hazard ratio [HR] 0.52; 95% confidence interval [CI], 0.34–0.80; P=0.002), but was not associated with MACE in the non-ischemic cohort. In the adherence cohort, adherent-to-caFFR group (n=803) had a lower risk of MACE compared with nonadherent-to-caFFR group (n=566) (HR, 0.61; 95% CI, 0.44–0.85; P=0.003).

Conclusion

Our study is the first to demonstrate the prognostic value of caFFR, a non-wire based assessment of myocardial ischemia, in patients with stable CAD undergoing PCI. These findings support the use of caFFR that bears the potential of a wider adoption compared with wire-based FFR through a reduction in procedure time, risk and costs.

Funding Acknowledgement

Type of funding sources: None. Weighted Kaplan-Meier curvesWeighted Cox proportional hazards model

Prognostic value of per-vessel treatment adherence in stable coronary artery disease based on novel computational pressure-flow dynamics derived fractional flow reserve

Background

Computational pressure-flow dynamics derived fractional flow reserve (caFFR) is a novel index developed to evaluate the extent of myocardial ischemia in patients with coronary artery disease (CAD), which eliminates the need of invasive pressure guidewire and hyperaemic stimulus in conventional fractional flow reserve (FFR) measurement. Studies have shown improved clinical outcomes associated with adherence to functional myocardial ischemia assessment when deciding to perform percutaneous coronary intervention (PCI) at a per-patient level. However, the clinical significance of such treatment adherence at a per-vessel level remains uncertain.

Methods

A total of 928 patients (mean age 66.2±10.5, male 72.7%) with stable CAD were included in this study. The caFFR of all three major coronary vessels were obtained for every patient, and the FFR threshold of 0.8 was adopted as the threshold for caFFR to indicate functionally significant artery stenosis which warrants PCI, and vice versa. Based on the caFFR of each major coronary vessel and whether PCI was performed to the respective vessel, patients were stratified into 0–1 vessel with treatment adherence group (group 1) (n=105), 2 vessels with treatment adherence group (group 2) (n=338), and 3 vessels with treatment adherence group (group 3) (n=485). The primary endpoint was major adverse cardiac events (MACE), defined as a composite of all-cause mortality, non-fatal myocardial infarction and any subsequent revascularization.

Results

The severity of CAD based on SYNTAX score assessment was 18.6±10.2 in group 1, 14.6±8.9 in group 2, and 11.5±9.9 in group 3 (P&lt;0.001). The rates of MACE at 3 years were significantly different across groups 1, 2 and 3 (17.1% vs. 12.1% vs. 7.4%; P=0.004). With reference to group 3, the risk of MACE at 3 years was increased in group 2 (adjusted hazard ratio [HR]=1.597; 95% confidence interval [CI]=1.020–2.501; P=0.041), and further increased in group 1 (adjusted HR=1.933; 95% CI=1.081–3.457; P=0.026).

Conclusion

In stable CAD patients, the risk of MACE is incremental when fewer major coronary vessels are treated with adherence to caFFR threshold of 0.8. Per-vessel treatment adherence significantly affects clinical outcomes in terms of MACE.

Funding Acknowledgement

Type of funding sources: None.

Long-term prognostic implications of PCI in ACS patients without ischemia on the basis of computational pressure-flow dynamics derived fractional flow reserve

Background

A substantial proportion of patients with acute coronary syndrome (ACS) may have intermediate lesion that are non-ischemic during emergency coronary angiography. The prognosis of such patients, compared to those with stable ischemic heart disease (SIHD) without ischemic lesion is however uncertain. Recently, a novel index, computational pressure-flow dynamics derived fractional flow reserve (caFFR), has been developed to assess myocardial ischemia, without the need of invasive pressure wire and hyperaemic stimulus as required in conventional fractional flow reserve (FFR). By utilizing caFFR to assess for ischaemic status during coronary angiography, the aim of our study is first to assess the prognostic difference between ACS and SIHD with non-ischaemia intermediate lesions. Second, we ascertain whether PCI in patients with ACS with non-ischaemia intermediate lesions provides survival benefit in addition to medical therapy.

Methods

We retrospectively recruited 551 patients (mean age 64.4 years; male 59.9%) with absence of myocardial ischaemia, defined as caFFR ≥0.80 in all vessels, from our Hospital. Patients were stratified into those with index presentation of ACS (n=132) and those with SIHD (n=491). Among the ACS cohort, patients were further divided into those with PCI (n=83) and with medical therapy alone (n=49). The SIHD cohort (n=491), all of whom were treated with medical therapy alone, was considered as referent group. The primary end point was major adverse cardiovascular events (MACE) at 3 years, which was defined as a composite of all-cause mortality, non-fatal myocardial infarction (MI), and any unplanned revascularization.

Results

During a median follow-up of 36 months, 54 composite events occurred, including 38 all-cause mortality, 5 MI, and 14 unplanned revascularization. Compared to those with SIHD, patients with ACS was independently associated with MACE even in the absence of myocardial ischaemia (adjusted Hazard Ratios=2.531; 95% confidence interval=1.397–4.586; P=0.002). The 3-year incidence rate of MACE was the highest in ACS patients with medical therapy alone, followed by ACS patients with immediate PCI; the SIHD cohort had the lowest incidence rates (30.6% vs 12.0% vs 5.9%, P&lt;0.001). This was mainly driven by the rate of all-cause death (26.5% vs 12.0% vs 3.1%; P&lt;0.001). Similar findings were observed for hospitalisation due to heart failure (14.3% vs 6.0% vs 3.1%, P=0.031) and cardiac death (8.2% vs 4.8% vs 0.4%, P&lt;0.001) at 3 years.

Conclusion

In patients with intermediate lesion without myocardial ischaemia (defined as caFFR ≥0.8), those presented with ACS had a higher risk of MACE at 3 years compared to SIHD. Among ACS patients with intermediate lesion without myocardial ischaemia, PCI significantly reduces the rate of MACE. In patients with ACS, our finding suggests that PCI should be advocated to intermediate lesion even without myocardial ischaemia.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier curve for MACECumulative Events at 3 Years

Treatment of Chinese Patients with Hypertriglyceridemia with a Pharmaceutical-Grade Preparation of Highly Purified Omega-3 Polyunsaturated Fatty Acid Ethyl Esters: Main Results of a Randomized, Double-Blind, Controlled Trial

Introduction

The lipid-modifying potential of omega-3 polyunsaturated fatty acids in Chinese patients is under-researched. We conducted a multicenter, randomized, placebo-controlled, double-blind, parallel-group study of twice-daily treatment with OMACOR (OM3EE), a prescription-only formulation of highly purified ethyl esters of omega-3 polyunsaturated fatty acids in Chinese adult patients (≥18 years) who had elevated baseline fasting serum triglycerides (TG).

Methods

Patients were stratified according to the severity of their hypertriglyceridemia (severe HTG, with baseline TG ≥500 and <1000 mg/dL or moderate HTG, with baseline TG >200 and <500 mg/dL) or use of statins. Patients randomized to OM3EE therapy received 2 g/day for 4 weeks, then 4 g/day for 8 weeks. The primary efficacy endpoint was the percentage change in fasting serum TG between baseline and the end of treatment in patients with severe HTG. The study was concluded after a planned interim analysis demonstrated a significant TG-lowering effect of OM3EE in that contingent (p=0.0019).

Results

The mean TG end-of-treatment effect of OM3EE was -29.46% (standard deviation 40.60%) in the severe HTG contingent compared with +0.26% (standard deviation 54.68%) in the placebo group. Corresponding changes were -12.12% and -23.25% in the moderate HTG and combination cohorts (vs +55.45% and +6.24% in relevant placebo groups). A dose-dependent reduction in TG was evident in all patient contingents. Safety and tolerability of OM3EE were in line with previous experience.

Discussion

These data indicate that OMACOR therapy at a dose of 2-4 g/day is an effective treatment for Chinese patients with raised TG levels and is well tolerated.

Hydration for prevention of kidney injury after primary coronary intervention for acute myocardial infarction: a randomised clinical trial

OBJECTIVE

To evaluate the efficacy of aggressive hydration compared with general hydration for contrast-induced acute kidney injury (CI-AKI) prevention among patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).

METHODS

The Aggressive hydraTion in patients with STEMI undergoing pPCI to prevenT Contrast-Induced Acute Kidney Injury study is an open-label, randomised controlled study at 15 teaching hospitals in China. A total of 560 adult patients were randomly assigned (1:1) to receive aggressive hydration or general hydration treatment. Aggressive hydration group received preprocedural loading dose of 125/250 mL normal saline within 30 min, followed by postprocedural hydration performed for 4 hours under left ventricular end-diastolic pressure guidance and additional hydration until 24 hours after pPCI. General hydration group received ≤500 mL 0.9% saline at 1 mL/kg/hour for 6 hours after randomisation. The primary end point is CI-AKI, defined as a >25% or 0.5 mg/dL increased in serum creatinine from baseline during the first 48-72 hours after primary angioplasty. The safety end point is acute heart failure.

RESULTS

From July 2014 to May 2018, 469 patients were enrolled in the final analysis. CI-AKI occurred less frequently in aggressive hydration group than in general hydration group (21.8% vs 31.1%; risk ratio (RR) 0.70, 95% CI 0.52 to 0.96). Acute heart failure did not significantly differ between the aggressive hydration group and the general hydration group (8.1% vs 6.4%, RR 1.13, 95% CI 0.66 to 2.44). Several subgroup analysis showed the better effect of aggressive hydration in CI-AKI prevention in male, renal insufficient and non-anterior myocardial infarction participants.

CONCLUSIONS

Comparing with general hydration, the peri-operative aggressive hydration seems to be safe and effective in preventing CI-AKI among patients with STEMI undergoing pPCI.

Safety and efficacy of a platelet glycoprotein Ib inhibitor for patients with non-ST segment elevation myocardial infarction: A phase Ib/IIa study

STUDY OBJECTIVE

This study aimed to determine the safety and efficacy of a novel GP Ib receptor inhibitor in patients with non-ST segment elevation myocardial infarction (NSTEMI) undergoing percutaneous coronary intervention (PCI).

DESIGN AND SETTING

Multicenter, randomized, double-blind, placebo-controlled, dose-escalating, phase Ib-IIa clinical trial. Eligible patients were randomly assigned to the low-dose (n=20, 2 IU/60 kg), moderate-dose (n=20, 3 IU/60 kg), or high-dose anfibatide group (n=20, 5 IU/60 kg), or the placebo group (n=30). Anfibatide was administered for up to 48 hours along with standard aspirin and clopidogrel therapy.

PATIENTS

Ninety patients with NSTEMI who underwent PCI at six academic hospitals in China.

MEASUREMENTS AND MAIN RESULTS

All three doses of anfibatide showed dose-dependent antiplatelet activity as measured by ex vivo platelet aggregation at 5 minutes, 24 hours, and 48 hours during infusion, and 4 hours post-infusion compared with placebo. Higher inhibition of platelet aggregation occurred in all anfibatide groups compared with the placebo group. The post-procedural TIMI grade flow, myocardial blush grade, and corrected TIMI frame count were not significantly different among the four groups. Thirty-day mortality, non-fatal myocardial infarction, and major bleeding were rare and comparable between patients who received anfibatide and placebo. There was no significant difference in the platelet count among the groups during follow-up.

CONCLUSIONS

This study shows that intravenous administration of the platelet receptor GP Ib antagonist anfibatide is feasible and safe to inhibit platelet aggregation without increasing the risk of bleeding and thrombocytopenia in patients with NSTEMI undergoing PCI.

Eutrophication increases deterministic processes and heterogeneity of co-occurrence networks of bacterioplankton metacommunity assembly at a regional scale in tropical coastal reservoirs

Understanding microbial metacommunity assembly and the underlying methanisms are fundamental objectives of aquatic ecology. However, little is known about how eutrophication, the primary water quality issue of aquatic ecosystems, regulates bacterioplankton metacommunity assembly at a regional scale in reservoirs. In this study, we applied a metacommunity framework to study bacterioplankton communities in 210 samples collected from 42 tropical coastal reservoirs in the wet summer season. We found that the spatial pattern of bacterioplankton community compositions (BCCs) at a regional scale was shaped mainly by species sorting. The reservoir trophic state index (TSI) was the key determinant of bacterioplankton metacommunity assembly. BCC turnover increased significantly with the TSI differences between sites (∆TSI) when ∆TSI was < 20, but remained at a level of about 80% when ∆TSI was > 20. Compared to oligo-mesotrophic and mesotrophic reservoirs, increased heterogeneity of co-occurrence bacterioplankton networks and bacterioplankton β-diversity were observed across eutrophic reservoirs. We propose that larger variation in phytoplankton community assembly may play directly or indirectly deterministic processes in controlling the bacterioplankton metacommunity assembly and became the potential mechanisms behind the observed higher BCC heterogeneity across the eutrophic reservoirs. Our research contributes to a broader understanding of the ecological effects of eutrophication on reservoir ecosystems and provides clues to the management of the tropical coastal reservoirs.

Treatment delay and reperfusion management of acute ST-segment elevation myocardial infarction: analysis of the China STEMI Care Project Phase 1

BACKGROUND

The China ST-segment elevation myocardial infarction (STEMI) Care Project (CSCAP) was launched in 2011 to address the problems of insufficient reperfusion and long treatment delay in STEMI care in China.

AIM

To describe the baseline status of STEMI emergency care in Tertiary PCI Hospitals using Phase 1 (CSCAP-1) data.

DESIGN

CSCAP-1 is a prospective multi-center STEMI registry.

METHODS AND RESULTS

A total of 4191 patients with symptom onset within 12 or 12-36 h requiring primary percutaneous coronary intervention (PCI), were enrolled from 53 tertiary PCI hospitals in 14 provinces, municipalities, and autonomous regions of China in CSCAP-1. Among them, 49.0% were self-transported to the hospital, 26.5% were transferred to the hospital by calling the emergency medical services directly, and 24.5% were transferred from other hospitals. In patients with symptom onset within 12 h, 83.2% received primary PCI, 5.9% received thrombolysis and 10.9% received conservative medications. The median door-to-balloon time was 115 (85-170) min and the median door-to-needle time for in-hospital thrombolysis was 80 (50-135) min. The overall in-hospital all-cause mortality was 2.4%, while it was 5.3% in the non-reperfusion group and 2.1% in the reperfusion group (P < 0.001).

CONCLUSION

Although a long treatment delay and a high proportion of patients transporting themselves to the hospital were observed, trends were positive with greater adoption of primary PCI and lower in-hospital mortality in tertiary hospitals in China. Our results provided important information for further integrated STEMI network construction in China.

Egg consumption associated with all-cause mortality in rural China: a 14-year follow-up study

BACKGROUND

Dietary recommendations regarding egg intake remain controversial topic for public health. We hypothesized that there was a positive association between egg consumption and all-cause mortality.

METHODS

To test this hypothesis, we enrolled 9885 adults from a community-based cohort in Anhui Province, China during 2003-05. Egg consumption was assessed by food questionnaire. Stratified analyses were performed for age, sex, body mass index (BMI), blood pressure, smoking, drinking and laboratory tests.

RESULTS

After an average follow-up of 14.1 years, 9444 participants were included for analysis. A total of 814 deaths were recorded. Participants' BMI and lipid profile had no significantly difference between three egg consumption groups. BMI was 21.6±2.7 of the whole population, especially BMI>24 was only 17.3%. A bivariate association of egg consumption >6/week with increased all-cause mortality was observed compared with ≤6/week (RR: 1.35, 95% CI: 1.05, 1.73, P = 0.018). A significant interaction was observed for BMI ≥ 21.2 kg/m2 vs. BMI<21.2 kg/m2 (P for interaction: 0.001). No other significant interactions were found.

CONCLUSIONS

In this study, consuming >6 eggs/week increased risk of all-cause mortality, even among lean participants, especially who with BMI ≥ 21.2 kg/m2. Eggs are an easily accessible and constitute an affordable food source in underdeveloped regions. Consuming <6 eggs/week may be the most suitable intake mode.

LDL cholesterol levels and in-hospital bleeding in patients on high-intensity antithrombotic therapy: findings from the CCC-ACS project

AIMS 

Emerging evidence has linked cholesterol metabolism with platelet responsiveness. We sought to examine the dose-response relationship between low-density lipoprotein cholesterol (LDL-C) and major in-hospital bleeds in acute coronary syndrome (ACS) patients.

METHODS AND RESULTS 

Among 42 378 ACS patients treated with percutaneous coronary intervention (PCI) enrolled in 240 hospitals in the Improving Care for Cardiovascular Disease in China-ACS project from 2014 to 2019, a total of 615 major bleeds, 218 ischaemic events, and 337 deaths were recorded. After controlling for baseline variables, a non-linear relationship was observed for major bleeds, with the higher risk at lower LDL-C levels. No dose-response relationship was identified for ischaemic events and mortality. A threshold value of LDL-C <70 mg/dL was associated with an increased risk for major bleeds (adjusted odds ratio: 1.49; 95% confidence interval: 1.21-1.84) in multivariable-adjusted logistic regression models and in propensity score-matched cohorts. The results were consistent in multiple sensitivity analyses. Among ticagrelor-treated patients, the LDL-C threshold for increased bleeding risk was observed at <88 mg/dL, whereas for clopidogrel-treated patients, the threshold was <54 mg/dL. Across a full spectrum of LDL-C levels, the treatment effect size associated with ticagrelor vs. clopidogrel on major bleeds favoured clopidogrel at lower LDL-C levels, but no difference at higher LDL-C levels.

CONCLUSIONS 

In a nationwide ACS registry, a non-linear association was identified between LDL-C levels and major in-hospital bleeds following PCI, with the higher risk at lower levels. As the potential for confounding may exist, further studies are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02306616.

Hypertensive Retinopathy and the Risk of Stroke Among Hypertensive Adults in China

Purpose

This study aimed to investigate the association between hypertensive retinopathy and the risk of first stroke, examine possible effect modifiers in hypertensive patients, and test the appropriateness of the Keith-Wagener-Barker (KWB) classification for predicting stroke risk.

Methods

In total, 9793 hypertensive participants (3727 males and 6066 females) without stroke history from the China Stroke Primary Prevention Trial were included in this study. The primary outcome was first stroke.

Results

Over a median follow-up of 4.4 years, 592 participants experienced their first stroke (509 ischemic, 77 hemorrhagic, and six unclassifiable strokes). In total, 5590 participants were diagnosed with grade 1 retinopathy (57.08%), 1466 with grade 2 retinopathy (14.97%), 231 with grade 3 retinopathy (2.36%), and three with grade 4 retinopathy (0.03%). Grades 1 and 2 were merged and classified as mild retinopathy, and grades 3 and 4 were merged and classified as severe retinopathy. There was a significant positive association between hypertensive retinopathy and the risk of first stroke and first ischemic stroke, and no effect modifiers were found. The hazard ratios (HRs) for first stroke were as follows: mild versus no retinopathy, 1.26 (95% confidence interval [CI], 1.01-1.58, P = 0.040), and severe versus no retinopathy, 2.40 (95% CI, 1.49-3.84, P < 0.001). The HRs for ischemic stroke were as follows: severe versus no retinopathy, 2.35 (95% CI, 1.41-3.90, P = 0.001), and nonsignificantly increased HRs for mild versus no retinopathy, 1.26 (95% CI, 0.99-1.60, P = 0.057).

Conclusions

There was a significant positive association between hypertensive retinopathy and the risk of first stroke in patients with hypertension, indicating that hypertensive retinopathy may be a predictor of the risk of stroke. A simplified two-grade classification system based on the KWB classification is recommended for predicting stroke risk.

Genetic predisposition to coronary artery disease is predictive of recurrent events: a Chinese prospective cohort study

Evidence of the effects of genetic risk score (GRS) on secondary prevention is scarce and mixed. We investigated whether coronary artery disease (CAD) susceptible loci can be used to predict the risk of major adverse cardiovascular events (MACEs) in a cohort with acute coronary syndromes (ACSs). A total of 1667 patients hospitalized with ACS were enrolled and prospectively followed for a median of 2 years. We constructed a weighted GRS comprising 79 CAD risk variants and investigated the association between GRS and MACE using a multivariable cox proportional hazard regression model. The incremental value of adding GRS into the prediction model was assessed by integrated discrimination improvement (IDI) and decision curve analysis (DCA). In the age- and sex-adjusted model, each increase in standard deviation in the GRS was associated with a 33% increased risk of MACE (hazard ratio: 1.33; 95% confidence interval: 1.10-1.61; P = 0.003), with this association not attenuating after further adjustment for traditional cardiovascular risk factors. The addition of GRS to a prediction model of seven clinical risk factors and EPICOR prognostic model slightly improved risk stratification for MACE as calculated by IDI (+1.7%, P = 0.006; +0.3%, P = 0.024, respectively). DCA demonstrated positive net benefits by adding GRS to other models. GRS was associated with MACE after multivariable adjustment in a cohort comprising Chinese ACS patients. Future studies are needed to validate our results and further evaluate the predictive value of GRS in secondary prevention.

Long-Term Antithrombotic Therapy and Clinical Outcomes in Patients with Acute Coronary Syndrome and Renal Impairment: Insights from EPICOR and EPICOR Asia

BACKGROUND

Information is lacking on long-term management of patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m²).

OBJECTIVES

Our objectives were to describe antithrombotic management patterns and outcomes in patients with ACS with varying renal function from the EPICOR (long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients; NCT01171404) and EPICOR Asia (NCT01361386) studies.

METHODS

EPICOR and EPICOR Asia were prospective observational studies of patients who survived hospitalization for ACS and were enrolled at discharge in 28 countries across Europe, Latin America, and Asia. The studies were conducted from 2010 to 2013 and from 2011 to 2014, respectively. This analysis evaluated patient characteristics and oral antithrombotic management patterns and outcomes up to 2 years post-discharge according to admission eGFR: ≥ 90, 60-89, 30-59, or < 30 mL/min/1.73 m².

RESULTS

Among 22,380 patients with available data, eGFR < 60 mL/min/1.73 m² was observed in 16.7%. Patients with poorer renal function were older, were at greater cardiovascular risk, and had more prior cardiovascular disease and bleeding. Patients with CKD underwent fewer cardiovascular interventions and had more in-hospital cardiovascular and bleeding events. Dual antiplatelet therapy was less likely at discharge in patients with eGFR < 30 (82.3%) than in those with ≥ 90 (91.3%) mL/min/1.73 m² and declined more sharply during follow-up in patients with low eGFR (p < 0.0001). An adjusted proportional hazards model showed that patients with lower eGFR levels had a higher risk of cardiovascular events and bleeding.

CONCLUSIONS

The presence of CKD in patients with ACS was associated with less aggressive cardiovascular management and an increased risk of cardiovascular events.

Prospective association between baseline plasma zinc concentration and development of proteinuria in Chinese hypertensive patients

OBJECTIVE

We aimed to evaluate the association between baseline plasma zinc and the development of proteinuria as well as possible effect modifiers in hypertensive patients.

METHODS

This is a subset of the China Stroke Primary Prevention Trial (CSPPT) Renal Sub-Study. In the CSPPT, participants were randomized to receive a daily oral dose of 1 tablet containing 10 mg enalapril and 0.8 mg folic acid or 1 tablet containing 10 mg enalapril only. A total of 783 participants with plasma zinc measurements and without proteinuria at baseline were included in the current study. The study outcome was the development of proteinuria during the follow-up, defined as a urine dipstick reading of trace or ≥1+ at the exit visit.

RESULTS

During a median follow-up duration of 4.4 years, the development of proteinuria occurred in 93 (11.9 %) participants. There was an inverse relation of baseline plasma zinc with the development of proteinuria (per SD increment; OR, 0.74, 95 % CI: 0.55-0.99), p for trend of quartiles = 0.005.

CONCLUSIONS

In Chinese hypertensive patients, there was a significant inverse association between baseline plasma zinc and the development of proteinuria, although plasma zinc remained in the reference range.

Associations between remnant lipoprotein cholesterol and central systolic blood pressure in a Chinese community-based population: a cross-sectional study

Background

The lipid profile is reportedly related to peripheral blood pressure or pulse wave velocity. However, no studies have investigated the associations between lipid parameters, especially remnant lipoprotein cholesterol (RLP-C), and central systolic blood pressure (cSBP).

Methods

This study used baseline data of a community-based cohort in Beijing, China. Participants who had been treated with anti-hypertensive or lipid-lowering agents were excluded. RLP-C is equal to total cholesterol (TC) minus the sum of low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C). An Omron HEM-9000AI device was used to measure non-invasive cSBP. The associations between blood lipid profile and non-invasive cSBP were evaluated using multivariable regression models.

Results

The 5173 included participants were 55.0 ± 8.5 years old; 35.7% (1845) of participants were men. Increased cSBP was significantly associated with increased TC, LDL-C, non-high-density lipoprotein cholesterol (non-HDL-C), triglyceride (TG), and RLP-C but with decreased HDL-C, even after adjusting for possible covariates. When simultaneously entering individual pairs of RLP-C and other blood lipid parameters into the multivariable regression model, RLP-C remained significantly associated with cSBP, even after adjusting for other lipids. Compared with participants who had RLP-C levels in the first quartile (Q1), cSBP for those with RLP-C in Q4 was increased to 4.57 (95% confidence interval [CI]: 3.08–6.06) mmHg after adjusting for LDL-C, 4.50 (95%CI: 2.98–6.02) mmHg after adjusting for TC, 3.91 (95%CI: 1.92–5.89) mmHg after adjusting for TG, 5.15 (95%CI: 3.67–6.63) mmHg after adjusting for HDL-C, and 4.10 (95%CI: 2.36–5.84) mmHg after adjusting for non-HDL-C.

Conclusions

Increased blood RLP-C level was significantly associated with higher cSBP in a Chinese population, independently of other lipids, which indicates its importance in individual cardiovascular risk assessment.

Intra-aortic balloon pump on in-hospital outcomes of cardiogenic shock: findings from a nationwide registry, China

AIMS

The real-world usage of intra-aortic balloon pump (IABP) in various cardiogenic shocks (CS) and the association with outcomes are lacking. We aimed to investigate IABP adoption in CS in a nationwide registry in China.

METHODS AND RESULTS

We retrospectively retrieved data of 30 106 CS patients (age 67.1 ± 14.6 years, 37.6% female patients) in the Hospital Quality Monitoring System registry from 2013 to 2016. Ischaemic heart disease was the leading cause of CS (73.9%). Hypertension, cardiomyopathy, myocarditis, valvular, and congenital heart disease were seen in 36.0%, 7.5%, 2.6%, 7.3%, and 2.4% of the population. IABP was employed in 2320 (7.7%) subjects. The association between IABP usage and primary outcome of in-hospital mortality and secondary outcomes of expenses and lengths of stay were investigated. The patients with IABP support had similar in-hospital mortality to those without IABP (39.6% vs. 38.3%, P = 0.226), but longer hospital-stay [8.0 (2.0-16.0) vs. 6.0 (2.0-13.0) days, P < 0.001] and higher expenses [7.1(4.4-11.1) vs. 2.3 (0.8-5.5) 10 000RMB, P < 0.001]. IABP support was not associated with reduced mortality in the overall CS population in multivariate regression analysis [odds ratio (OR) 1.05, 95% confidence interval (CI) 0.95-1.17], except for subgroups with myocarditis (OR 0.61, 95% CI 0.39-0.95, P for interaction = 0.010) and those who did not receive the early percutaneous coronary intervention (PCI) (OR 0.86, 95% CI 0.75-0.97, P for interaction < 0.001). Similar results were further confirmed in the propensity-score-matched population.

CONCLUSIONS

In this nationwide registry of CS patients, IABP was not noted with improved survival but increased healthcare consumption. However, IABP appears protective in those with myocarditis or who failed to receive early PCI.

Sex difference in the association between plasma selenium and first stroke: a community-based nested case-control study

BACKGROUND

To date, there is no clearly defined association between plasma selenium levels and first stroke. We aimed to investigate the association between baseline plasma selenium and first stroke risk in a community-based Chinese population.

METHODS

Using a nested case-control study design, a total of 1255 first stroke cases and 1255 matched controls were analyzed. Participant plasma selenium concentrations were measured by inductively coupled plasma mass spectrometry (ICP-MS), and the association of plasma selenium with first stroke risk was estimated by conditional logistic regression models.

RESULTS

Overall, a non-linear negative association between plasma selenium and first total stroke and first ischemic stroke risks was found in males but not in females. Compared with participants with lower selenium levels (tertile 1-2, < 94.1 ng/mL), participants with higher selenium levels (tertile 3, ≥ 94.1 ng/mL) had significantly lower risks of first total stroke (OR 0.63; 95% CI 0.48, 0.83) and first ischemic stroke (OR 0.61; 95% CI 0.45, 0.83) in males but not in females with first total stroke (OR 0.92; 95% CI 0.69, 1.22) and first ischemic stroke (OR 0.89; 95% CI 0.65, 1.22). Furthermore, a stronger association between plasma selenium and first total stroke was found in males with higher vitamin E levels (≥ 13.5 μg/mL vs. < 13.5 μg/mL P-interaction = 0.007). No significant association was observed between plasma selenium and first hemorrhagic stroke risk in either males or females.

CONCLUSION

Our study indicated a significant, non-linear, negative association between plasma selenium and first stroke in males but not in females.

TRIAL REGISTRATION

ChiCTR1800017274 .

Relationship Between Different Risk Factor Patterns and Follow-Up Outcomes in Patients With ST-Segment Elevation Myocardial Infarction

Objective: Few studies have been concerned with the combined influences of the presence of multiple risk factors on follow-up outcomes in AMI patients. Our study aimed to identify risk factor patterns that may be associated with 1-year survival in male patients with ST-segment elevation myocardial infarction (STEMI). Methods: Data were from the China STEMI Care Project Phase 2 (CSCAP-2) collected between 2015 and 2018. A total of 15,675 male STEMI patients were enrolled in this study. Risk factor patterns were characterized using latent class analysis (LCA) according to seven risk factors. Associations between risk factor patterns and follow-up outcomes, including the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause death, were investigated by Cox proportional hazard regression analysis. Results: We obtained four risk factor patterns as "young and middle-aged with low levels of multimorbidity," "middle-aged with overweight," "middle-aged and elderly with normal weight," and "elderly with high multimorbidity." Four patterns had significant differences in event-free survival (P < 0.001). As compared with the patients of "young and middle-aged with low levels of multimorbidity" pattern, the risk of incidence of MACCE and all-cause death were increased in patients of "middle-aged with overweight" pattern (All-cause death: HR = 1.70, 95% CI:1.29~2.23; MACCE: HR = 1.49, 95% CI:1.29~1.72), "middle-aged and elderly with normal weight" pattern (All-cause death: HR = 3.04, 95% CI: 2.33~3.98; MACCE: HR = 1.82, 95% CI: 1.56~2.12), and "elderly with high multimorbidity" pattern (All-cause death: HR = 5.78, 95% CI: 4.49~7.42; MACCE: HR = 2.67, 95% CI: 2.31~3.10). Conclusions: By adopting a Latent Class Analysis Approach, STEMI patients can be characterized into four risk factor patterns with significantly different prognosis. The data is useful for the improvement of community health management in each specific subgroup of patients, which indicates a particular risk factor pattern.

High-Density Lipoprotein Cholesterol and the Risk of First Ischemic Stroke in a Chinese Hypertensive Population

BACKGROUND AND PURPOSE

Elevated high-density lipoprotein cholesterol (HDL-C) levels have displayed protection against cardiovascular disease. However, the association between specific lipoprotein classes and first ischemic stroke (IS) has not been well defined, particularly in higher-risk hypertensive populations. Our study evaluated the associations of HDL-C with first IS in a Chinese hypertensive population.

METHODS

The study population was obtained from a community-based cohort study of hypertension in Lianyungang and Rongcheng, China. A nested case-control design was used that included 2463 identified first IS cases and 2463 controls matched by age ± 1 year, sex, and region.

RESULTS

After adjusting for potential confounders, HDL-C was inversely associated with first IS (adjusted odds ratio [aOR]: 0.91; 95% confidence interval [CI]: 0.85-0.98). HDL-C levels of at least 65.4 mg/dL displayed a significant protective effect for first IS (aOR: 0.82; 95% CI: 0.69-0.98). Conversely, adverse effects of first IS were observed for low-density lipoprotein cholesterol (LDL-C) levels ≥138.1 mg/dL (aOR: 1.20; 95% CI: 1.02-1.42) and triglyceride (TG) levels ≥140.8 mg/dL (aOR: 1.27; 95% CI: 1.09-1.49). The risk associations of LDL-C and TG with first IS were attenuated in the presence of high HDL-C (≥53.0 mg/dL); an increased risk of first IS was only found in the presence of low HDL-C (<53.0 mg/dL) when LDL-C (aOR: 1.66; 95% CI: 1.19-2.31) and TG (aOR: 1.47; 95% CI: 1.17-1.84) were combined with HDL-C for analysis.

CONCLUSION

In this community-based Chinese hypertensive population, higher HDL-C was a significant protective factor of first IS. These data add to the evidence describing the relationship between lipids and IS and suggest that HDL-C maybe is a marker of IS risk in Chinses hypertensive population.

Heart Rate Predicts the Risk of New-Onset Peripheral Arterial Disease in a Community-Based Population in China

Introduction

Elevated heart rate is linked with poor prognosis and has been shown to accelerate the progress of atherosclerosis. However, the association between heart rate and new-onset PAD is unknown.

Methods

A total of 3463 participants without PAD at baseline from a community-based cohort in Beijing were included and followed up for 2.3 years. PAD was defined as ankle–brachial index (ABI) ≤0.9. We used multivariate logistic regression models to investigate the association of heart rate and the risk of new-onset PAD.

Results

Participants were 56.67 ± 8.54 years old, and 36.12% were men. The baseline ABI was 1.11 ± 0.08, and the incidence of new-onset PAD was 2.97%. Multivariate regression models, adjusted for sex, age, risk factor of atherosclerosis, medications, and baseline ABI, showed that heart rate was significantly associated with incidence of PAD (odds ratio [OR] = 1.22, 95% confidence interval [CI]: 1.03–1.43, P = 0.020); every increase of 10 heart beats per minute (bpm) was associated with a 22% increase in the odds of developing new-onset PAD. Respondents in the higher-heart rate group (≥80 bpm) had an increased risk of new-onset PAD, compared with those in the lower-heart rate group (<80 bpm) (OR = 1.73, 95% CI: 1.14–2.63, P = 0.010). Subgroup analyses revealed no significant heterogeneity among the analyzed subgroups.

Conclusion

Elevated heart rate was independently associated with the risk of new-onset PAD in a community-based population in Beijing. Heart rate management should be considered for the purpose of PAD prevention.

Lipid profiles and the risk of new-onset hypertension in a Chinese community-based cohort

BACKGROUND AND AIMS

Dyslipidemia and hypertension, key risk factors for cardiovascular disease, may share similar pathophysiological processes. A longitudinal association was reported between dyslipidemia and new-onset hypertension, but few data were published in Asian. We aimed to investigate the association of lipid profiles with new-onset hypertension in a Chinese community-based non-hypertensive cohort without lipid-lowering treatment (n = 1802).

METHODS AND RESULTS

New-onset hypertension was defined as any self-reported history of hypertension, systolic blood pressure ≥140 mmHg, or diastolic blood pressure ≥90 mmHg, or receiving antihypertensive medications at follow-up. Logistic regression models were used to evaluate the associations. Participants were aged 53.97 ± 7.49 years, 31.19% were men, and 64.54% with dyslipidemia. During a median of 2.30 years follow-up, the incidence of new-onset hypertension was 12.99%. Multivariate adjusted risks of new-onset hypertension increased with triglyceride increases (odds ratio [OR] = 1.14, 95% confidence interval [CI]: 1.03-1.27) and high-density lipoprotein cholesterol (HDL-C) decreases (OR = 0.47, 95% CI: 0.29-0.76) for one unit. However, threshold effects were observed for total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and non-HDL-C. Compared with subjects with hyperlipidemia, in those with normal concentrations of TC, LDL-C, and non-HDL-C increased risks of new-onset hypertension were observed with OR (95% CI) of 1.65 (1.10-2.46), 1.58 (1.07-2.33), and 1.57 (1.15-2.15) for one unit increasement, respectively, after adjusting for all covariates.

CONCLUSION

Higher TG and lower HDL-C increased the risk of new-onset hypertension, but for TC, LDL-C and non-HDLC, the risk of new-onset hypertension was increased only at normal concentrations in a Chinese community-based cohort.

An Asian-specific MPL genetic variant alters JAK-STAT signaling and influences platelet count in the population

Genomic discovery efforts for hematological traits have been successfully conducted through genome-wide association study on samples of predominantly European ancestry. We sought to conduct unbiased genetic discovery for coding variants that influence hematological traits in a Han Chinese population. A total of 5257 Han Chinese subjects from Beijing, China were included in the discovery cohort and analyzed by an Illumina ExomeChip array. Replication analyses were conducted in 3827 independent Chinese subjects. We analyzed 12 hematological traits and identified 22 exome-wide significant single-nucleotide polymorphisms (SNP)-trait associations with 15 independent SNPs. Our study provides replication for two associations previously reported but not replicated. Further, one association was identified and replicated in the current study, of a coding variant in the myeloproliferative leukemia (MPL) gene, c.793C > T, p.Leu265Phe (L265F) with increased platelet count (β = 20.6 109 cells/l, Pmeta-analysis = 2.6 × 10-13). This variant is observed at ~2% population frequency in East Asians, whereas it has not been reported in gnomAD European or African populations. Functional analysis demonstrated that expression of MPL L265F in Ba/F3 cells resulted in enhanced phosphorylation of Stat3 and ERK1/2 as compared with the reference MPL allele, supporting altered activation of the JAK-STAT signal transduction pathway as the mechanism underlying the novel association between MPL L265F and platelet count.

Coronary angiography-derived contrast fractional flow reserve

BACKGROUND

Based on coronary angiography and mean aortic pressure, a specially designed computational flow dynamics (CFD) method is proposed to determine contrast fractional flow reserve (cFFR) without using invasive pressure wire. This substudy assessed diagnostic performance of coronary angiography-derived cFFR in catheterization laboratory, based on a previous multicenter trial for online assessment of coronary angiography-derived FFR (caFFR).

METHODS

Patients with diagnosis of stable angina pectoris or unstable angina pectoris were enrolled in six centers. Wire-based FFR was measured in coronary arteries with 30-90% diameter stenosis. Offline angiography-derived cFFR was computed in blinded fashion against the wire-based FFR and caFFR at an independent core laboratory.

RESULTS

A total of 330 patients were enrolled to fulfill inclusion/exclusion criteria from June 26 to December 18, 2018. Offline angiography-derived cFFR and wire-based FFR results were compared in 328 interrogated vessels. The statistical analysis showed the highest diagnostic accuracy of 89.0 and 86.6% for angiography-derived cFFR with a cutoff value of 0.94 and 0.93 against the wire-based FFR with a cutoff value of 0.80 and 0.75, respectively. The corresponding sensitivity and specificity were 92.2 and 87.3% for the cutoff value of 0.94 and 80.0 and 88.4% for the cutoff value of 0.93, which are similar to those against the caFFR. The receiver-operating curve has area under the curve of 0.951 and 0.972 for the wire-based FFR with the cutoff value of 0.80 and 0.75, respectively.

CONCLUSIONS

Coronary angiography-derived cFFR showed higher accuracy, sensitivity, and specificity against wired-based FFR and caFFR. Hence, angiography-derived cFFR could enhance the hemodynamic assessment of coronary lesions.

Early results for iCMR in atrial flutter

Funding Acknowledgements

Type of funding sources: None.

Background

 As a standard of care, ablation of typical atrial flutter involves performing cardiac catheterization under x-ray fluoroscopy. The unique ability of magnetic resonance (MR) to provide real-time functional imaging in multiple views without ionizing radiation exposure has the potential to be a powerful tool for diagnostic and interventional procedures. Real-time MR imaging-guided radiofrequency (RF) ablation has been used as a part of clinical trials.

Objective

 To implement the MR imaging-guided RF ablation of typical atrial flutter in the clinical routine.

Methods

 From January to July 2020, 15 consecutive patients with typical atrial flutter have been referred for ablation. Patient preparation, conscious sedation and groin puncture took place inside the 1.5 Tesla MR scanner as a part of an MR-only workflow. The catheter advancement as well as the RF ablation procedure have been performed under direct visualisation of catheters with integrated micro-coils using an interactive sequence with active tip tracking and automatic slice positioning in the plane where the catheter tip has been detected. During catheter advancement a single frontal plane has been used to visualize the passage of the catheter through femoral veins and inferior vena cava. With both diagnostic and ablation catheters in the right atrium, an axial stack of balanced steady-state free precession acquisitions has been acquired and used to reconstruct planes in the short- and long cardiac axis. These have been used to provide a "left- and right anterior oblique" view familiar to an interventional electrophysiologist. The subsequent catheter placement and ablation have been performed under direct visualisation in these two planes (see figure).

Results

 The ablation was successful in 14 patients, one patient had to undergo a conventional procedure on the following day. The mean time to reach right atrium and coronary sinus was 4 [3,5] and 7 [6,10] minutes, respectively. The mean total ablation duration and procedure time was 18 [12,26] and 43 [33,58] minutes, respectively. There were no adverse events.

Conclusion

 The implementation of the MR imaging-guided RF ablation of typical atrial flutter in the clinical routine is feasible and leads to similar success rates and procedure times as the conventional fluoroscopy-based ablation.

Abstract Figure.

Relationship of Weight Change Patterns From Young to Middle Adulthood With Incident Cardiovascular Diseases

CONTEXT

The effect of weight change patterns on cardiovascular diseases (CVD) remains uncertain.

OBJECTIVE

We aim to examine the relation of weight change patterns and absolute weight change from young adulthood to midlife with incident CVD.

DESIGN

Retrospective cohort study.

SETTING

National Health and Nutrition Examination Survey 1999-2016.

PARTICIPANTS

A total of 20 715 US adults aged 40 through 79 with recalled weight at young adulthood (25 years) and midlife (10 years before baseline).

MAIN OUTCOME MEASURE

CVD status was determined by self-report of a prior diagnosis, and age at diagnosis was used to establish time of CVD onset. CVD events was defined as the first occurrence of a congestive heart failure, coronary heart disease, angina pectoris, heart attack, or stroke.

RESULTS

After 9.76 years of follow-up, compared with participants who remained at normal weight, those in maximum overweight, changing from nonobese to obese, changing from obese to nonobese, maintaining obesity between young and middle adulthood had a 39% (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.19-1.62), 93% (HR, 1.93; 95% CI, 1.64-2.28), 125% (HR, 2.25; 95% CI, 1.29-3.94), and 132% (HR, 2.32; 95% CI, 1.68-3.20) higher risk of CVD, respectively. In addition, compared with weight change within 2.5 kg, weight gain ≥ 10.0 kg was associated with higher risk of CVD.

CONCLUSIONS

Both nonobese to obese, obese to nonobese, and stable obese from young to middle adulthood were associated with increased risks of CVD. The findings emphasize the importance of maintaining normal weight throughout the adulthood for preventing CVD in later life.

Visit-to-visit variability in blood pressure and the development of chronic kidney disease in treated general hypertensive patients

BACKGROUND

Data on the association between visit-to-visit variability (VVV) in blood pressure (BP) and the risk of chronic kidney disease (CKD) in general treated hypertensive patients were limited. We aimed to evaluate the relation of VVV in BP with the development of CKD, and examine any possible effect modifiers in hypertensive patients without prior cardiovascular diseases (CVDs) or CKD.

METHODS

This is a post hoc analysis of the Renal Sub-study of the China Stroke Primary Prevention Trial (CSPPT). A total of 10 051 hypertensives without CVD and CKD and with at least six visits of BP measurements from randomization to the 24-month visit were included. The main VVV in BP was expressed as standard deviation (SD). The primary outcome was the development of CKD, defined as a decrease in estimated glomerular filtration rate ≥30% and to a level of <60 mL/min/1.73 m2, or end-stage renal disease.

RESULTS

The median treatment duration was 4.4 years. After multivariable adjustment, including baseline systolic blood pressure (SBP) and mean SBP during the first 2-year treatment period, there was a significantly positive relationship of SD of SBP with the risk of CKD development (per SD increment; odds ratio, 1.27; 95% confidence interval: 1.10-1.46). The results were similar for coefficient of variation (CV) of SBP. Results across various subgroups, including age, sex, SBP at baseline, treatment compliance, concomitant antihypertensive medications and mean SBP during the first 24-month treatment period, were consistent.

CONCLUSIONS

SBP variability, irrespective of mean BP level, was significantly associated with the development of CKD in general treated hypertensive patients.

Survey on uric acid in Chinese subjects with essential hypertension (SUCCESS): a nationwide cross-sectional study

Background

Hyperuricemia (HUA) is associated with hypertension and increased cardiovascular risk. Current data regarding the prevalence of HUA in Chinese hypertensive patients are lacking. Our study aims to explore the prevalence and determinants of HUA in Chinese hypertensive adults.

Methods

Treatment-naive hypertensive adults or those taking single antihypertensive agent were included in a nationwide cross-sectional study. Basic demographics, antihypertensive medications, serum uric acid (UA), and other parameters were documented.

Results

The overall prevalence rate of HUA was 38.7% among 33,785 valid cases, 35.1% for males (UA >420 µmol/L), and 45.2% for females (UA >360 µmol/L). A multiple logistic regression analysis, adjusted for demographic and clinical factors (model 1), revealed that female sex [odds ratio (OR), 95% CI, 1.43, 1.36–1.51], age of ≥65 years (1.12, 1.05–1.19), low evaluated glomerular filtration rate [eGFR; 2.06, 1.91–2.23, the lowest [Q1] vs. the highest quartile (Q4)], unmarried (1.58, 1.10–2.27), Western China residency (3.21, 3.33–3.91), longer hypertension duration (1.97, 1.78–2.12, Q4 vs. Q1) and aspirin use (1.21, 1.14–1.29) were associated with HUA. In a multiple logistic regression analysis adjusted for clinical and metabolic parameters (model 2), female sex (OR, 95% CI, 1.34, 1.27–1.41), age of ≥65 years (1.09, 1.03–1.16), low eGFR (2.35, 2.19–2.52, Q1 vs. Q4), new–onset hypertension (2.01, 1.73–2.33), higher quartile of fasting blood glucose (FBG), triglyceride (TG), low density lipoprotein cholesterol (LDL-C) levels, and body mass index (BMI) were associated with higher risk of HUA (1.89, 1.76–2.03; 2.15, 1.99–2.31; 2.86, 2.67–3.06; 1.27, 1.27–1.36, respectively, Q4 vs. Q1). Losartan, valsartan, and nifedipine were associated with lower risk of HUA (OR, 95% CI, 0.77, 0.67–0.88, 0.68, 0.60–0.77; 0.87, 0.77–0.99, 0.79, 0.70–0.89 and 0.80, 0.70–0.91, 0.82, 0.72–0.92), respectively, in models 1 and 2.

Conclusions

The prevalence rate of HUA in Chinese hypertensive patients was 38.7%. Female sex, aging (≥65 years), and low eGFR were independent predictors of HUA. HUA was lower among the patients who were taking losartan, valsartan, and nifedipine. Western region residents, new-onset hypertension, longer hypertension duration, aspirin use, higher FBG, TG, LDL-C levels and BMI were potential risk factors for HUA.

Effectiveness of chest pain centre accreditation on the management of acute coronary syndrome: a retrospective study using a national database

BACKGROUND

Large-scale real-world data to evaluate the impact of chest pain centre (CPC) accreditation on acute coronary syndrome (ACS) emergency care in heavy-burden developing countries like China are rare.

METHODS

This study is a retrospective study based on data from the Hospital Quality Monitoring System (HQMS) database. This study included emergency patients admitted with ACS to hospitals that uploaded clinical data continuously to the database from 2013 to 2016. Propensity score matching was used to compare hospitals with and without CPC accreditation during this period. A longitudinal self-contrast comparison design with mixed-effects models was used to compare management of ACS before and after accreditation.

RESULTS

A total of 798 008 patients with ACS from 746 hospitals were included in the analysis. After matching admission date, hospital levels and types and adjusting for possible covariates, patients with ACS admitted to accredited CPCs had lower in-hospital mortality (OR=0.70, 95% CI 0.53 to 0.93), shorter length of stay (LOS; adjusted multiplicative effect=0.89, 95% CI 0.84 to 0.94) and more percutaneous coronary intervention (PCI) procedures (OR=3.53, 95% CI 2.20 to 5.66) than patients admitted in hospitals without applying for CPC accreditation. Furthermore, when compared with the 'before accreditation' group only in accredited CPCs, the in-hospital mortality and LOS decreased and the usage of PCI were increased in both 'accreditation' (for in-hospital mortality: OR=0.86, 95% CI 0.79 to 0.93; for LOS: 0.94, 95% CI 0.93 to 0.95; for PCI: OR=1.22, 95% CI 1.18 to 1.26) and 'after accreditation' groups (for in-hospital mortality: OR=0.90, 95% CI 0.84 to 0.97; for LOS: 0.89, 95% CI 0.89 to 0.90; for PCI: OR=1.36, 95% CI 1.33 to 1.39). The significant benefits of decreased in-hospital mortality, reduced LOS and increased PCI usage were also observed for patients with acute myocardial infarction.

CONCLUSIONS

CPC accreditation is associated with better management and in-hospital clinical outcomes of patients with ACS. CPC establishment and accreditation should be promoted and implemented in countries with high levels of ACS.

Coronary Angiography-Derived Index of Microvascular Resistance

A coronary angiography-derived index of microvascular resistance (caIMR) is proposed for physiological assessment of microvasular diseases in coronary circulation. The aim of the study is to assess diagnostic performance of caIMR, using wire-derived index of microvascular resistance (IMR) as the reference standard. IMR was demonstrated in 56 patients (57 vessels) with stable/unstable angina pectoris and no obstructive coronary arteries in three centers using the Certus pressure wire. Based on the aortic pressure wave and coronary angiograms from two projections, the caIMR was computed and assessed in blinded fashion against the IMR at an independent core laboratory. Diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of the caIMR with a cutoff value of 25 were 84.2% (95% CI: 72.1% to 92.5%), 86.1% (95% CI: 70.5% to 95.3%), 81.0% (95% CI: 58.1% to 94.6%), 88.6% (95% CI: 76.1% to 95.0%), and 77.3% (95% CI: 59.5% to 88.7%) against the IMR with a cutoff value of 25. The receiver-operating curve had area under the curve of 0.919 and the correlation coefficient equaled to 0.746 between caIMR and wire-derived IMR. Hence, caIMR could eliminate the need of a pressure wire, reduce technical error, and potentially increase adoption of physiological assessment of microvascular diseases in patients with ischemic heart disease.

Degree of blood pressure control and the risk of new-onset hyperuricemia in treated hypertensive patients

Background

The relationship between blood pressure (BP) control and the risk of new-onset hyperuricemia remains uncertain. We aimed to examine the association between degree of time-averaged on-treatment BP control and new-onset hyperuricemia in general hypertensive patients.

Methods

A total of 10,617 hypertensive patients with normal uric acid (UA) concentrations (<357 µmol/L) at baseline were included from the UA Sub-study of the China Stroke Primary Prevention Trial (CSPPT). Participants were randomized to receive a double-blind daily treatment of enalapril 10 mg and folic acid 0.8 mg or enalapril 10 mg alone. BP measurements were taken every three months after randomization. The primary outcome was new-onset hyperuricemia, defined as a UA concentration ≥417 µmol/L in men or ≥357 µmol/L in women at the exit visit.

Results

Over a median of 4.4 years, 1,664 (15.7%) participants developed new-onset hyperuricemia. Overall, there was a significantly positive association between time-averaged on-treatment diastolic BP (DBP) and new-onset hyperuricemia (per 10 mmHg increment; OR 1.13; 95% CI: 1.02–1.26). Consistently, a significantly higher risk of new-onset hyperuricemia was found in participants with time-averaged on-treatment DBP ≥82.9 mmHg (median) (vs. <82.9 mmHg; 17.3% vs. 14.1%; OR 1.25; 95% CI: 1.10–1.44). Furthermore, the lowest new-onset hyperuricemia risk (12.1%) was found in those with both time-averaged on-treatment SBP (median: 138.3 mmHg) and DBP below the median (P-interaction=0.023). The results were similar for time-averaged DBP during the first 12- or 24-month treatment period, or in the analysis using propensity scores. Furthermore, a non-significant higher risk of new-onset hyperuricemia was observed in participants with time-averaged on-treatment SBP ≥120 mmHg (vs. <120 mmHg; OR 1.61; 95% CI: 0.88–2.97).

Conclusions

A tight DBP control of <82.9 mmHg was associated with lower risk of new-onset hyperuricemia among hypertensive patients without hyperuricemia.

Plasma 25-Hydroxyvitamin D3 Concentrations and Risk of New-Onset Proteinuria in Patients With Hypertension

OBJECTIVE

We aimed to evaluate the relationship of plasma 25-hydroxyvitamin D3 (25[OH]D3) with the risk of new-onset proteinuria and examine the possible effect modifiers in patients with hypertension and without chronic kidney disease at baseline.

METHODS

This is a post hoc analysis of the renal substudy of the China Stroke Primary Prevention Trial. A total of 1655 patients with hypertension, who had plasma 25(OH)D3 measurements, as well as without proteinuria and with an estimated glomerular filtration rate of ≥60 mL/min/1.73 m² at baseline, were included in the present study. The main outcome was new-onset proteinuria, defined as a urine dipstick reading of ≥1+ at the exit visit.

RESULTS

The mean (standard deviation) 25(OH)D3 level at baseline was 18.6 (7.5) ng/mL. The median follow-up duration was 4.4 years. Overall, there was a significant inverse association between plasma 25(OH)D3 and the risk of new-onset proteinuria (per standard deviation increment; [odds ratio] OR: 0.70; 95% confidence interval [CI]: 0.50, 0.97). Accordingly, when 25(OH)D3 was assessed as quartiles, a significantly lower risk of new-onset proteinuria was found in participants in quartiles 3-4 (≥17.8 ng/mL; OR: 0.45; 95% CI: 0.23, 0.87), compared with those in quartile 1 (<13.1 ng/mL). Furthermore, a stronger inverse relationship of plasma 25(OH)D3 and new-onset proteinuria was observed in nondiabetic participants (per standard deviation increment; OR: 0.57; 95% CI: 0.39, 0.83; vs. diabetics: OR: 1.48; 95% CI: 0.67, 3.28; P for interaction = 0.028).

CONCLUSION

There was a significant inverse association between plasma 25(OH)D3 and the risk of proteinuria in patients with hypertension, especially in those without diabetes.

Plasma Magnesium Concentrations and Risk of Incident Cancer in Adults with Hypertension: A Nested Case-Control Study

OBJECTIVE

The association between plasma magnesium and risk of incident cancer remains inconclusive in previous studies. We aimed to investigate the prospective relationship of baseline plasma magnesium concentrations with the risk of incident cancer and to examine possible effect modifiers.

METHODS

A nested case-control study with 228 incident cancer cases and 228 matched controls was conducted using data from the China Stroke Primary Prevention Trial (CSPPT), a randomized, double-blind, controlled trial, conducted from May 2008 to August 2013. Study outcomes included incident cancer and its subtypes.

RESULTS

When plasma magnesium concentrations were assessed as quartiles, a significantly higher incident risk of total cancer was found in participants in quartile 1 (<0.76 mmol/L; odds ratio [OR] = 2.70; 95% CI: 1.33-5.49) and quartile 4 (≥0.89 mmol/L; OR = 2.05; 95% CI: 1.12-3.76), compared with those in quartile 3 (0.83 to <0.89 mmol/L). In cancer site-specific analyses, similar trends were found for gastrointestinal cancer, esophageal cancer, gastric cancer, breast cancer, lung cancer, and other cancers. Furthermore, none of the variables, including age, sex, current smoking status, current alcohol intake, BMI, systolic blood pressure, and total cholesterol levels at baseline significantly modified the association between plasma magnesium and cancer risk.

CONCLUSIONS

Both low and high plasma magnesium concentrations were significantly associated with an increased incident risk of cancer, compared with the reference concentrations of 0.83 to <0.89 mmol/L among hypertensive adults.

Ultrasonic evaluation of systemic and renal perfusion in sepsis patients before and after fluid resuscitation

OBJECTIVE

This study aimed to explore the significance of renal Doppler ultrasound in evaluating systemic and renal perfusion in sepsis patients before and after fluid resuscitation.

PATIENTS AND METHODS

Forty sepsis patients admitted to the Department of Intensive Medicine and intensive care unit (ICU) of the Fourth Hospital of Hebei Medical University from June 2014 to December 2014 were enrolled in this study, and 35 patients were included in the final analysis. These patients were divided into positive and negative fluid responsiveness groups. They were also divided into an acute kidney injury (AKI) group and a non-AKI group according to changes in creatinine and urine volume. The correlations of the changes in hemodynamics before and after fluid resuscitation in each group with the changes in renal resistance index (RRI) and renal blood flow (RBF) grades were evaluated.

RESULTS

Before and after fluid resuscitation, the heart rate (HR), blood creatinine (Cre), and lactate (Lac) levels of all patients, including the patients in the positive fluid responsiveness group decreased, and the stroke volume (SV) and central venous pressure (CVP) increased. Only HR decreased in the negative fluid responsiveness group. In the AKI group, HR, Cre, and Lac decreased, while in the non-AKI group, HR decreased, but CVP and SV increased. There were differences between HR, Lac, and change rate of Lac (Lac%) after fluid resuscitation for the positive and negative fluid responsiveness groups. There was no statistical difference between the RRI values of each group before and after fluid resuscitation. The RRI values of the AKI group were higher than those of the non-AKI group, while the AKI group's RBF grades were lower than those of the non-AKI group. The change rate of RRI (RRI%) was higher in the AKI group than in the non-AKI group. Except for the negative fluid responsiveness group, the RBF grade of each group increased.

CONCLUSIONS

The approach of RBF classification based on Doppler ultrasound can be used to evaluate the systemic and renal perfusion of patients with severe sepsis before and after fluid resuscitation, while the RRI value cannot be used for evaluation. However, the RRI value can be used as a dynamic index for the evaluation of renal perfusion in patients with AKI.

Assessment of quality indicators for acute myocardial infarction management in 28 countries and use of composite quality indicators for benchmarking

Background:

The European Society of Cardiology established a set of quality indicators for the management of acute myocardial infarction. Our aim was to evaluate their degree of attainment, prognostic value and potential use for centre benchmarking in a large international cohort.

Methods:

Quality indicators were extracted from the long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients (EPICOR) (555 hospitals, 20 countries in Europe and Latin America, 2010–2011) and EPICOR Asia (218 hospitals, eight countries, 2011–2012) registries, including non-ST-segment elevation acute myocardial infarction (n=6558) and ST-segment elevation acute myocardial infarction (n=11,559) hospital survivors. The association between implementation rates for each quality indicator and two-year adjusted mortality was evaluated using adjusted Cox models. Composite quality indicators were categorized for benchmarking assessment at different levels.

Results:

The degree of attainment of the 17 evaluated quality indicators ranged from 13% to 100%. Attainment of most individual quality indicators was associated with two-year survival. A higher compliance with composite quality indicators was associated with lower mortality at centre-, country- and region-level. Moreover, the higher the risk for two-year mortality, the lower the compliance with composite quality indicators.

Conclusions:

When EPICOR and EPICOR Asia were conducted, the European Society of Cardiology quality indicators would have been attained to a limited extent, suggesting wide room for improvement in the management of acute myocardial infarction patients. After adjustment for confounding, most quality indicators were associated with reduced two-year mortality and their prognostic value should receive further attention. The two composite quality indicators can be used as a tool for benchmarking either at centre-, country- or world region-level.