1
|
HU SS. Epidemiology and current management of cardiovascular disease in China. J Geriatr Cardiol 2024; 21:387-406. [PMID: 38800543 PMCID: PMC11112149 DOI: 10.26599/1671-5411.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
The Annual Report on Cardiovascular Health and Diseases in China (2022) intricate landscape of cardiovascular health in China. This is the fourth section of the report with a specific focus on epidemiology and current management of cardiovascular disease (CVD) in China. This section of the report highlights the epidemiological trends of CVD in China. It reveal a concerning rise in prevalence, with approximately 330 million affected individuals, including significant numbers with stroke, coronary artery disease (CAD), heart failure, and other conditions. CVD stands as the primary cause of mortality among both urban and rural populations, accounting for nearly half of all deaths in 2020. Mortality rates are notably higher in rural areas compared to urban centers since 2009. While age-standardized mortality rates have decreased, the absolute number of CVD deaths has increased, primarily due to population aging. Ischemic heart disease, hemorrhagic and ischemic strokes are the leading causes of CVD-related deaths. Notably, the burden of atherosclerotic cardiovascular disease has risen substantially, with atherosclerotic cardiovascular disease-related deaths increasing from 1990 to 2016. The incidence of ischemic stroke and ischemic heart disease has shown similar increasing trends over the past three decades. CAD mortality, particularly acute myocardial infarction, has been on the rise, with higher mortality rates observed in rural areas since 2016. The prevalence of CAD has increased significantly, with over 11 million patients identified in 2013. Studies assessing hospital performance in managing acute coronary syndrome reveal gaps in adherence to guideline-recommended strategies, with disparities in care quality across hospitals. However, initiatives like the China Patient-centered Evaluative Assessment of Cardiac Events (PEACE)-Retrospective AMI Study and the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project aim to improve patient outcomes through enhanced care protocols. Moreover, advancements in medical technology, such as quantitative flow ratio-guided lesion selection during percutaneous coronary intervention, show promise in improving clinical outcomes for patients undergoing intervention.
Collapse
Affiliation(s)
- Sheng-Shou HU
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | |
Collapse
|
2
|
Jing J, Wanling L, Maofeng W. A Practical Nomogram for Predicting the Bleeding Risk in Patients with a History of Myocardial Infarction Treating with Aspirin. Clin Appl Thromb Hemost 2024; 30:10760296241262789. [PMID: 38870349 PMCID: PMC11179515 DOI: 10.1177/10760296241262789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/18/2024] [Accepted: 05/31/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Aspirin is a widely used antiplatelet medication to prevent blood clots, reducing the risk of cardiovascular event. Healthcare providers need to be mindful of the risk of aspirin-induced bleeding and carefully balancing its benefits against potential risks. The objective of this study was to create a practical nomogram for predicting bleeding risk in patients with a history of myocardial infarction treating with aspirin. METHODS A total of 2099 myocardial infarction patients with aspirin were enrolled. The patients were randomly divided into two groups, with a 7:3 ratio, for model development and internal validation. Boruta analysis was utilized to identify clinically significant features associated with bleeding. Logistic regression model based on independent bleeding risk factors was constructed and presented as a nomogram. Model performance was assessed from three aspects: identification, calibration, and clinical utility. RESULTS Boruta analysis identified eight clinical features from 25, and further multivariate logistic regression analysis selected four independent risk factors: hemoglobin, platelet count, previous bleeding, and sex. A visual nomogram was created based on these variables. The model achieved an area under the curve of 0.888 (95% CI: 0.845-0.931) in the training dataset and 0.888 (95% CI: 0.808-0.968) in the test dataset. Calibration curve analysis showed close approximation to the ideal curve. Decision curve analysis demonstrated favorable clinical net benefit for the model. CONCLUSIONS Our study focused on creating and validating a model to evaluate bleeding risk in patients with a history of myocardial infarction treated with aspirin, which demonstrated outstanding performance in discrimination, calibration, and net clinical benefit.
Collapse
Affiliation(s)
- Jin Jing
- Department of Gynecology, Dongyang Women & Children Hospital, Dongyang, China
| | - Lei Wanling
- Department of Biomedical Sciences Laboratory, Affiliated Dongyang Hospital, Wenzhou Medical University, Dongyang, China
| | - Wang Maofeng
- Department of Biomedical Sciences Laboratory, Affiliated Dongyang Hospital, Wenzhou Medical University, Dongyang, China
| |
Collapse
|
3
|
Munafò AR, Montalto C, Franzino M, Pistelli L, Di Bella G, Ferlini M, Leonardi S, D'Ascenzo F, Gragnano F, Oreglia JA, Oliva F, Ortega-Paz L, Calabrò P, Angiolillo DJ, Valgimigli M, Micari A, Costa F. External validity of the PRECISE-DAPT score in patients undergoing PCI: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:709-721. [PMID: 37634083 DOI: 10.1093/ehjcvp/pvad063] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/11/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
AIMS To summarize the totality of evidence validating the Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) score, ascertaining its aggregate discrimination and validation power in multiple population subsets. METHODS AND RESULTS We searched electronic databases from 2017 (PRECISE-DAPT proposal) up to March 2023 for studies that reported the occurrence of out-of-hospital bleedings according to the PRECISE-DAPT score in patients receiving DAPT following percutaneous coronary intervention (PCI). Pooled odds ratios (OR) with 95% confidence interval (CI) were used as summary statistics and were calculated using a random-effects model. Primary and secondary endpoints were the occurrence of any and major bleeding, respectively. A total of 21 studies and 67 283 patients were included; 24.7% of patients (N = 16 603) were at high bleeding risk (PRECISE-DAPT score ≥25), and when compared to those at low bleeding risk, they experienced a significantly higher rate of any out-of-hospital bleeding (OR: 2.71; 95% CI: 2.24-3.29; P-value <0.001) and major bleedings (OR: 3.51; 95% CI: 2.71-4.55; P-value <0.001). Pooling data on c-stat whenever available, the PRECISE-DAPT score showed a moderate discriminative power in predicting major bleeding events at 1 year (pooled c-stat: 0.71; 95% CI: 0.64-0.77). CONCLUSION This systematic review and meta-analysis confirms the external validity of the PRECISE-DAPT score in predicting out-of-hospital bleeding outcomes in patients on DAPT following PCI. The moderate discriminative ability highlights the need for future improved risk prediction tools in the field.
Collapse
Affiliation(s)
- Andrea Raffaele Munafò
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Claudio Montalto
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Marco Franzino
- BIOMORF Department, University of Messina, 98125 Messina, Italy
| | | | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, Policlinic 'G. Martino', University of Messina, 98124 Messina, Italy
| | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Sergio Leonardi
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, 10126 Turin, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 81100 Caserta, Italy
| | - Jacopo A Oreglia
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 81100 Caserta, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Marco Valgimigli
- Cardiovascular Department, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Antonio Micari
- BIOMORF Department, University of Messina, 98125 Messina, Italy
| | - Francesco Costa
- BIOMORF Department, University of Messina, 98125 Messina, Italy
| |
Collapse
|
4
|
Tang KS, Banerjee S, Tang G, Patel PM, Frangieh AH. Shortened Duration of Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention: A Contemporary Clinical Review. Interv Cardiol 2023; 18:e31. [PMID: 38213748 PMCID: PMC10782423 DOI: 10.15420/icr.2023.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/08/2023] [Indexed: 01/13/2024] Open
Abstract
Percutaneous coronary intervention with stent implantation is an integral aspect of minimally interventional cardiac procedures. The technology and techniques behind stent design and implantation have evolved rapidly over several decades. However, continued discourse remains around optimal peri- and post-interventional management with dual antiplatelet therapy to minimise both major cardiovascular or cerebrovascular events and iatrogenic bleeding risk. Standard guidelines around dual antiplatelet therapy historically recommended long-term dual antiplatelet therapy for 12 months (with consideration for >12 months in certain patients); however, emerging data and generational improvements in the safety of drug-eluting stents have ushered in a new era of short-term therapy to reduce the incidence of major bleeding events. This case review will provide an overview of the current state of guidelines around duration of dual antiplatelet therapy and examine recent updates and continued gaps in existing research.
Collapse
Affiliation(s)
- Kevin S Tang
- Division of Internal Medicine, Department of Medicine, University of California Irvine HealthOrange, CA, US
| | - Shoujit Banerjee
- Division of Internal Medicine, Department of Medicine, University of California Irvine HealthOrange, CA, US
| | - George Tang
- Division of Cardiology, Department of Medicine, University of California Irvine HealthOrange, CA, US
| | - Pranav M Patel
- Division of Cardiology, Department of Medicine, University of California Irvine HealthOrange, CA, US
| | - Antonio H Frangieh
- Division of Cardiology, Department of Medicine, University of California Irvine HealthOrange, CA, US
| |
Collapse
|
5
|
Celik A, Esin FK, Emren SV, Kiris T, Karaca M. The Clinical Value of the Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy Score in Predicting Long-Term Major Adverse Cardiovascular And Cerebrovascular Events and Major Bleeding in Acute Coronary Syndrome Patients Who Underwent Percutaneous Coronary Intervention. Angiology 2023; 74:958-969. [PMID: 36113050 DOI: 10.1177/00033197221127073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
The PRECISE-DAPT (predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy) score is recommended for predicting out-of-hospital bleeding after percutaneous coronary intervention (PCI). However, its long-term prediction remains unclear. We investigated the performance of this score in predicting long-term outcomes in patients with the acute coronary syndrome (ACS). We divided retrospectively enrolled patients (n = 1071) into two groups according to their PRECISE-DAPT scores: low < 25 and high ≥ 25. Bleeding was assessed using the Bleeding Academic Research Consortium criteria. The ischemic endpoints were all-cause death and major adverse cardiovascular and cerebrovascular events (MACCE). During follow-up (median 7.3 years), MACCE (55 vs 35%, P<.001) and major bleeding (9 vs 4%, P = .002) rates were greater in the high score group. The PRECISE-DAPT score was an independent predictor of MACCE in multivariate analysis (Hazard ratio [HR]: 1.028, 95% confidence interval [CI]: 1.016-1.039, P < .001). Also, the PRECISE-DAPT score predicted all-cause mortality (HR: 2.115, 95% CI: 1.508-2.965, P < .001) at long-term follow-up. The PRECISE-DAPT score may be useful for predicting MACCE at long-term follow-up in addition to the risk of bleeding.
Collapse
Affiliation(s)
- Aykan Celik
- Department of Cardiology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Fatma Kayaltı Esin
- Department of Cardiology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Sadık Volkan Emren
- Department of Cardiology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Tuncay Kiris
- Department of Cardiology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Mustafa Karaca
- Department of Cardiology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| |
Collapse
|
6
|
Ramazanoglu L, Kalyoncu Aslan I, Bugrul A, Onal Y, Velioglu M, Topcuoglu OM, Gozke E. Prediction of Bleeding by the PRECISE-DAPT Score in Patients with Carotid Artery Stenting. Cardiovasc Intervent Radiol 2023; 46:574-578. [PMID: 37012393 DOI: 10.1007/s00270-023-03419-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/11/2023] [Indexed: 04/05/2023]
Abstract
PURPOSE The predicting bleeding complications in patients undergoing stent implantation and the subsequent dual antiplatelet therapy (PRECISE-DAPT) score predicts the risk of bleeding in patients with dual antiplatelet therapy (DAPT) after percutaneous coronary interventions (PCIs). Patients with carotid artery stenting (CAS) are also treated with DAPT. In this study, we aimed to investigate the performance of the PRECISE-DAPT score in predicting bleeding in patients with CAS. METHODS Patients who had CAS between January 2018 and December 2020 were retrospectively enrolled. The PRECISE-DAPT score was calculated for each patient. The patients were divided into two groups based on their PRECISE-DAPT score: low < 25 and high ≥ 25. Bleeding and ischemia complications and laboratory data among the two groups were compared. RESULTS A total of 120 patients with a mean age of 67.3 ± 9.7 years were included. Forty-three patients had high PRECISE-DAPT scores, and 77 patients had low PRECISE-DAPT scores. Six patients developed bleeding events during the six-month follow-up, and five of them were in the PRECISE DAPT score ≥ 25 group. The difference between the two groups regarding bleeding events at six months was significant (P = 0.022). CONCLUSION The PRECISE-DAPT score might be used for predicting the bleeding risk in patients with CAS, and the bleeding rate was significantly higher in patients with a PRECISE-DAPT score ≥ 25.
Collapse
Affiliation(s)
- Leyla Ramazanoglu
- Department of Neurology, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey.
| | - Isil Kalyoncu Aslan
- Department of Neurology, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Bugrul
- Meram Faculty of Medicine, Department of Neurology, Necmettin Erbakan University, Konya, Turkey
| | - Yilmaz Onal
- Department of Radiology, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Murat Velioglu
- Department of Radiology, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | | | - Eren Gozke
- Department of Neurology, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
7
|
Tam CC, Tse HF. Antiplatelet Therapy Aims and Strategies in Asian Patients with Acute Coronary Syndrome or Stable Coronary Artery Disease. J Clin Med 2022; 11:jcm11247440. [PMID: 36556067 PMCID: PMC9784545 DOI: 10.3390/jcm11247440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) has been the mainstay treatment to reduce ischemic events, such as myocardial infarction or stroke, in patients with coronary artery disease (CAD). The development of potent P2Y12 inhibitors (ticagrelor and prasugrel) has helped to further reduce ischemic events, particularly among high-risk patients. Meanwhile, the evolution of newer generations of drug-eluting stents are also improving outcomes of percutaneous coronary intervention. Research studies on antiplatelet therapy in recent years have focused on balancing ischemic and bleeding risks through different strategies, which include P2Y12 inhibitor monotherapy, escalation and de-escalation, and extended DAPT. Because results from the large number of clinical studies may sometimes appear conflicting, this review aims to summarize recent advances, and demonstrate that they are aligned by a general principle, namely, strategies may be adopted based on treatment aims for specific patients at several time points. Another aim of this review is to outline the important considerations for using antiplatelet therapy in Asian patients, in whom there is a greater prevalence of CYP2C19 loss-of-function mutations, and a common increased risk of bleeding, despite high platelet reactivity (the so-called "East Asian Paradox").
Collapse
Affiliation(s)
- Chor-Cheung Tam
- Division of Cardiology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
- Correspondence:
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| |
Collapse
|
8
|
Abstract
The majority of cardiovascular randomized controlled trials (RCTs) test interventions in selected patient populations under explicitly protocol-defined settings. Although these ‘explanatory’ trial designs optimize conditions to test the efficacy and safety of an intervention, they limit the generalizability of trial findings in broader clinical settings. The concept of ‘pragmatism’ in RCTs addresses this concern by providing counterbalance to the more idealized situation underpinning explanatory RCTs and optimizing effectiveness over efficacy. The central tenets of pragmatism in RCTs are to test interventions in routine clinical settings, with patients who are representative of broad clinical practice, and to reduce the burden on investigators and participants by minimizing the number of trial visits and the intensity of trial-based testing. Pragmatic evaluation of interventions is particularly important in cardiovascular diseases, where the risk of death among patients has remained fairly stable over the past few decades despite the development of new therapeutic interventions. Pragmatic RCTs can help to reveal the ‘real-world’ effectiveness of therapeutic interventions and elucidate barriers to their implementation. In this Review, we discuss the attributes of pragmatism in RCT design, conduct and interpretation as well as the general need for increased pragmatism in cardiovascular RCTs. We also summarize current challenges and potential solutions to the implementation of pragmatism in RCTs and highlight selected ongoing and completed cardiovascular RCTs with pragmatic trial designs. In this Review, Khan and colleagues discuss the benefits and challenges of including pragmatism in the design, conduct and interpretation of randomized controlled trials (RCTs) for cardiovascular disease and highlight selected ongoing and completed cardiovascular RCTs that incorporate a pragmatic design. Most cardiovascular randomized controlled trials (RCTs) conducted to date have been ‘explanatory’, that is, designed to study the intervention in optimized conditions with selected patient populations and frequent protocolized assessments. Although explanatory RCT designs increase validity, they limit the generalizability of trial findings, whereas a ‘pragmatic’ approach to RCTs yields findings more relevant to real-world practice. In pragmatic RCTs, interventions are tested in patients who are broadly representative of the condition being studied, and the study is aligned with routine clinical care to reduce costs and organizational burden. Although pragmatic RCTs tend to attenuate estimates of treatment effects, they do provide a more realistic understanding of population-level effectiveness and costs than explanatory trials. Pragmatic trials can highlight barriers to the implementation of therapies and are better suited than explanatory RCTs to assessing the effects of implementation strategies and health-care policies at the population level. Widespread implementation of pragmatic trials would require the development of technological infrastructure to collect and share data as well as regulatory guidelines amenable to findings derived from routinely collected data.
Collapse
|