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Maimaitiming M, Ma J, Dong X, Zhou S, Li N, Zhang Z, Lu S, Chen L, Ma L, Yu B, Ma Y, Zhao X, Zheng Z, Shi H, Zheng Z, Jin Y, Huo Y. Factors associated with the delay in informed consent procedures of patients with ST-segment elevation myocardial infarction and its influence on door-to-balloon time: a nationwide retrospective cohort study. J Transl Int Med 2024; 12:86-95. [PMID: 38525440 PMCID: PMC10956723 DOI: 10.2478/jtim-2023-0127] [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] [Indexed: 03/26/2024] Open
Abstract
Background and Objectives ST-segment elevation myocardial infarction (STEMI) is the deadliest and most time-sensitive acute cardiac event. However, failure to achieve timely informed consent is an important contributor to in-hospital delay in STEMI care in China. We investigated the factors associated with informed consent delay in patients with STEMI undergoing percutaneous coronary intervention (PCI) and the association between the delay and door-to-balloon time. Methods We conducted a nationally representative retrospective cohort study using patient data reported by hospital-based chest pain centers from 1 January 2016 to 31 December 2020. We applied generalized linear mixed models and negative binomial regression to estimate factors independently predicting informed consent delay time. Logistic regressions were fitted to investigate the association of the informed consent delay time and door-to-balloon time, adjusting for patient characteristics. Results In total, 257, 510 patients were enrolled in the analysis. Mean informed consent delay time was 22.4 min (SD = 24.0), accounting for 39.3% in door-to-balloon time. Older age (≥65 years) was significantly correlated with informed consent delay time (RR: 1.034, P = 0.001). Compared with ethnic Han patients, the minority (RR: 1.146, P < 0.001) had more likelihood to extend consent giving; compared with patients who were single, longer informed consent time was found in married patients (RR: 1.054, P = 0.006). Patients with intermittent chest pain (RR: 1.034, P = 0.011), and chest pain relief (RR: 1.085, P = 0.005) were more likely to delay informed consent. As for transfer modes, EMS (RR: 1.063, P < 0.001), transfer-in (RR: 1.820, P < 0.001), and in-hospital onset (RR: 1.099, P = 0.002) all had positive correlations with informed consent delay time compared to walk-in. Informed consent delay was significantly associated with prolonged door-to-balloon time (OR: 1.002, P < 0.001). Conclusion Informed consent delay is significantly associated with the door-to-balloon time which plays a crucial role in achieving better outcomes for patients with STEMI. It is essential to shorten the delay time by identifying and intervening modifiable factors that are associated with shortening the informed consent procedure in China and other countries.
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Affiliation(s)
- Mailikezhati Maimaitiming
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Junxiong Ma
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Xuejie Dong
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Shuduo Zhou
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Na Li
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Zheng Zhang
- First People’s Hospital of Lanzhou University, Lanzhou, Gansu Province, China
| | - Shijuan Lu
- Haikou People’s Hospital, Haikou, Hainan Province, China
| | - Lianglong Chen
- Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Likun Ma
- Anhui Provincial Hospital, Hefei, Anhui Province, China
| | - Bo Yu
- Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Yitong Ma
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Xingsheng Zhao
- Inner Mongolia People’s Hospital, Huhhot, Inner Mongolia Autonomous Region, China
| | - Zhaofen Zheng
- Hunan Provincial People’s Hospital, Changsha, Hunan Province, China
| | - Hong Shi
- Chinese Medical Association, Beijing, China
| | - Zhijie Zheng
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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Zhang L, Zeng J, Huang H, Zhu Y, Peng K, Liu C, Luo F, Yang W, Wu M. Impact of chest pain center quality control indicators on mortality risk in ST-segment elevation myocardial infarction patients: a study based on Killip classification. Front Cardiovasc Med 2024; 10:1243436. [PMID: 38235291 PMCID: PMC10791892 DOI: 10.3389/fcvm.2023.1243436] [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: 06/27/2023] [Accepted: 11/29/2023] [Indexed: 01/19/2024] Open
Abstract
Background Despite the crucial role of Chest pain centers (CPCs) in acute myocardial infarction (AMI) management, China's mortality rate for ST-segment elevation myocardial infarction (STEMI) has remained stagnant. This study evaluates the influence of CPC quality control indicators on mortality risk in STEMI patients receiving primary percutaneous coronary intervention (PPCI) during the COVID-19 pandemic. Methods A cohort of 664 consecutive STEMI patients undergoing PPCI from 2020 to 2022 was analyzed using Cox proportional hazards regression models. The cohort was stratified by Killip classification at admission (Class 1: n = 402, Class ≥2: n = 262). Results At a median follow-up of 17 months, 35 deaths were recorded. In Class ≥2, longer door-to-balloon (D-to-B) time, PCI informed consent time, catheterization laboratory activation time, and diagnosis-to-loading dose dual antiplatelet therapy (DAPT) time were associated with increased mortality risk. In Class 1, consultation time (notice to arrival) under 10 min reduced death risk. In Class ≥2, PCI informed consent time under 20 min decreased mortality risk. Conclusion CPC quality control metrics affect STEMI mortality based on Killip class. Key factors include time indicators and standardization of CPC management. The study provides guidance for quality care during COVID-19.
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Affiliation(s)
- Lingling Zhang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
- Chest Pain Centre, Xiangtan Central Hospital, Xiangtan, China
- Medical Department, Xiangtan Central Hospital, Xiangtan, China
| | - Jianping Zeng
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
- Chest Pain Centre, Xiangtan Central Hospital, Xiangtan, China
- Department of Cardiology, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Haobo Huang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
- Chest Pain Centre, Xiangtan Central Hospital, Xiangtan, China
| | - Yunlong Zhu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
- Chest Pain Centre, Xiangtan Central Hospital, Xiangtan, China
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China
- Department of Cardiology, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ke Peng
- Department of Scientific Research, Xiangtan Central Hospital, Xiangtan, China
| | - Cai Liu
- Chest Pain Centre, Xiangtan Central Hospital, Xiangtan, China
| | - Fei Luo
- Chest Pain Centre, Xiangtan Central Hospital, Xiangtan, China
| | - Wenbin Yang
- Chest Pain Centre, Xiangtan Central Hospital, Xiangtan, China
- Medical Department, Xiangtan Central Hospital, Xiangtan, China
| | - Mingxin Wu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, China
- Chest Pain Centre, Xiangtan Central Hospital, Xiangtan, China
- Graduate Collaborative Training Base of Xiangtan Central Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China
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Zhang Y, Wang S, Qi D, Wang X, Li M, Zhu Z, Cheng Q, Hu D, Gao C. Changes in process and outcome for ST elevation myocardial infarction in central China from 2011 to 2018. Chin Med J (Engl) 2023; 136:2203-2209. [PMID: 37545028 PMCID: PMC10508564 DOI: 10.1097/cm9.0000000000002698] [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: 12/31/2022] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND Limited data are available on the changes in the quality of care for ST elevation myocardial infarction (STEMI) during China's health system reform from 2009 to 2020. This study aimed to assess the changes in care processes and outcome for STEMI patients in Henan province of central China between 2011 and 2018. METHODS We compared the data from the Henan STEMI survey conducted in 2011-2012 ( n = 1548, a cross-sectional study) and the Henan STEMI registry in 2016-2018 ( n = 4748, a multicenter, prospective observational study). Changes in care processes and in-hospital mortality were determined. Process of care measures included reperfusion therapies, aspirin, P2Y12 antagonists, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins. Therapy use was analyzed among patients who were considered ideal candidates for treatment. RESULTS STEMI patients in 2016-2018 were younger (median age: 63.1 vs . 63.8 years) with a lower proportion of women (24.4% [1156/4748] vs . 28.2% [437/1548]) than in 2011-2012. The composite use rate for guideline-recommended treatments increased significantly from 2011 to 2018 (60.9% [5424/8901] vs . 82.7% [22,439/27,129], P <0.001). The proportion of patients treated by reperfusion within 12 h increased from 44.1% (546/1237) to 78.4% (2698/3440) ( P <0.001) with a prolonged median onset-to-first medical contact time (from 144 min to 210 min, P <0.001). The use of antiplatelet agents, statins, and β-blockers increased significantly. The risk of in-hospital mortality significantly decreased over time (6.1% [95/1548] vs . 4.2% [198/4748], odds ratio [OR]: 0.67, 95% confidence interval [CI]: 0.50-0.88, P = 0.005) after adjustment. CONCLUSIONS Gradual implementation of the guideline-recommended treatments in STEMI patients from 2011 to 2018 has been associated with decreased in-hospital mortality. However, gaps persist between clinical practice and guideline recommendation. Public awareness, reperfusion strategies, and construction of chest pain centers need to be further underscored in central China.
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Affiliation(s)
- You Zhang
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan 451464, China
- Henan Institute of Cardiovascular Epidemiology, Zhengzhou, Henan 451464, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital, Zhengzhou, Henan 451464, China
| | - Shan Wang
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan 451464, China
- Henan Institute of Cardiovascular Epidemiology, Zhengzhou, Henan 451464, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital, Zhengzhou, Henan 451464, China
| | - Datun Qi
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan 451464, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital, Zhengzhou, Henan 451464, China
| | - Xianpei Wang
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan 451464, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital, Zhengzhou, Henan 451464, China
| | - Muwei Li
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan 451464, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital, Zhengzhou, Henan 451464, China
| | - Zhongyu Zhu
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan 451464, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital, Zhengzhou, Henan 451464, China
| | - Qianqian Cheng
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan 451464, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital, Zhengzhou, Henan 451464, China
| | - Dayi Hu
- Henan Institute of Cardiovascular Epidemiology, Zhengzhou, Henan 451464, China
- Institute of Cardiovascular Disease, Peking University People's Hospital, Beijing 100044, China
| | - Chuanyu Gao
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan 451464, China
- Henan Institute of Cardiovascular Epidemiology, Zhengzhou, Henan 451464, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital, Zhengzhou, Henan 451464, China
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Tern PJW, Vaswani A, Yeo KK. Identifying and Solving Gaps in Pre- and In-Hospital Acute Myocardial Infarction Care in Asia-Pacific Countries. Korean Circ J 2023; 53:594-605. [PMID: 37653695 PMCID: PMC10475691 DOI: 10.4070/kcj.2023.0169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/25/2023] [Indexed: 09/02/2023] Open
Abstract
Acute myocardial infarction (AMI) is a major cause of morbidity and mortality in the Asia-Pacific region, and mortality rates differ between countries in the region. Systems of care have been shown to play a major role in determining AMI outcomes, and this review aims to highlight pre-hospital and in-hospital system deficiencies and suggest possible improvements to enhance quality of care, focusing on Korea, Japan, Singapore and Malaysia as representative countries. Time to first medical contact can be shortened by improving patient awareness of AMI symptoms and the need to activate emergency medical services (EMS), as well as by developing robust, well-coordinated and centralized EMS systems. Additionally, performing and transmitting pre-hospital electrocardiograms, algorithmically identifying patients with high risk AMI and developing hospital networks that appropriately divert such patients to percutaneous coronary intervention-capable hospitals have been shown to be beneficial. Within the hospital environment, developing and following clinical practice guidelines ensures that treatment plans can be standardised, whilst integrated care pathways can aid in coordinating care within the healthcare institution and can guide care even after discharge. Prescription of guideline directed medical therapy for secondary prevention and patient compliance to medications can be further optimised. Finally, the authors advocate for the establishment of more regional, national and international AMI registries for the formal collection of data to facilitate audit and clinical improvement.
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Affiliation(s)
- Paul Jie Wen Tern
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Amar Vaswani
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore.
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Al-Kasasbeh A, Alghzawi AA, Ibrahim KS, Ababneh MJ, Ibdah R, Abusurrah O, Dweik K, Kheirallah KA. The Impact of COVID-19 National Lockdown on Myocardial Infarction (MI) Hospitalizations in Northern Jordan. Vasc Health Risk Manag 2023; 19:43-51. [PMID: 36713616 PMCID: PMC9880018 DOI: 10.2147/vhrm.s387074] [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: 08/31/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023] Open
Abstract
Background During COVID-19 lockdown periods, several studies reported decreased numbers of myocardial infarction (MI) admissions. The lockdown impact has not yet been determined in developing countries. The aim of this study was to investigate the impact that of the lockdown measures might have had on the mean number of MI hospital admissions in Northern Jordan. Methodology A single-center study examined consecutive admissions of MI patients during COVID-19 outbreak. Participants' data was abstracted from the medical records of King Abdullah University Hospital between 2018 and 2020. Mean and percentages of monthly admissions were compared by year and by lockdown status (pre-lockdown, lockdown, and post-lockdown time intervals). Results A total of 1380 participants were admitted with acute MI symptoms: 59.2% of which were STEMI. A decrease in number of MI admissions was observed in 2020, from 43.1 (SD: 8.017) cases per month in 2019 to 40.59 (SD: 10.763) in 2020 (P < 0.0001) while an increase in the numbers during the lockdown was observed. The mean number during the pre-lockdown period was 40.51 (SD: 8.883), the lockdown period was 44.74 (SD: 5.689) and the post-lockdown was 34.66 (SD: 6.026) (P < 0.0001 for all comparisons). Similar patterns were observed when percentages of admissions were used. Conclusion Upon comparing the lockdown period both to the pre- and post-lockdown periods separately, we found a significant increase in MI admissions during the lockdown period. This suggests that lockdown-related stress may have increased the risk of myocardial infarction.
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Affiliation(s)
- Abdullah Al-Kasasbeh
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan,Correspondence: Abdullah Al-Kasasbeh, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan, Tel +962798339500, Email
| | - Ahmad Abdalmajeed Alghzawi
- Department of Public Health, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Khalid S Ibrahim
- Division of Cardiac Surgery, Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Muhannad J Ababneh
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Rasheed Ibdah
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Obada Abusurrah
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Khaled Dweik
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Khalid A Kheirallah
- Department of Public Health, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Hu D, Hao Y, Liu J, Yang N, Yang Y, Sun Z, Zhao D, Liu J. Inter-hospital transfer in patients with acute myocardial infarction in China: Findings from the improving care for cardiovascular disease in China-acute coronary syndrome project. Front Cardiovasc Med 2022; 9:1064690. [PMID: 36568538 PMCID: PMC9773877 DOI: 10.3389/fcvm.2022.1064690] [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: 10/08/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
Background Little is known about the current scenario of inter-hospital transfer for patients with acute myocardial infarction (AMI) in China. Methods From November 2014 to December 2019, 94,623 AMI patients were enrolled from 241 hospitals in 30 provinces in China. We analyzed the pattern of inter-hospital transfer, and compared in-hospital treatments and outcomes between transferred patients and directly admitted patients. Results Of these patients, 40,970 (43.3%) were transferred from hospitals that did not provide percutaneous coronary intervention (PCI). The proportion of patients who were transferred from non-PCI hospital was 46.3% and 11.9% (P < 0.001) in tertiary hospitals and secondary hospitals, respectively; 56.2% and 37.3% (P < 0.001) in hospitals locating in low-economic regions and affluent areas, respectively. Compared with directly admitted patients, transferred patients had lower rates of reperfusion for STEMI (57.8% vs. 65.2%, P < 0.001) and timely PCI for NSTEMI (34.7%vs. 41.1%, P < 0.001). The delay for STEMI patients were long, with 6.5h vs. 4.5h from symptom onset to PCI for transferred and directly admitted patients, respectively. The median time-point was 9 days for in-hospital outcomes. Compared with direct admission, the hazard ratios and 95% confidence intervals associated with inter-hospital transfer were 0.87 (0.75-1.01) and 0.87 (0.73-1.03) for major adverse cardiovascular events and total mortality, respectively, in inverse probability of treatment weighting models in patients with STEMI, and 1.02 (0.71-1.48) and 0.98 (0.70-1.35), respectively, in patients with NSTEMI. Conclusion More than 40% of the hospitalized AMI patients were transferred from non-PCI-capable hospitals in China. Further strategies are needed to enhance the capability of revascularization and reduce the inequality in management of AMI.
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Zhang Y, Tian Y, Dong P, Xu Y, Yu B, Li H, Li J, Ge J, Sun Y, Wang J, Wang L, Chen J, Yan H, Chen Y, Han Y, Huo Y. Treatment delay and reperfusion management of acute ST-segment elevation myocardial infarction: analysis of the China STEMI Care Project Phase 1. QJM 2021; 114:299-305. [PMID: 32569364 DOI: 10.1093/qjmed/hcaa186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 04/11/2020] [Accepted: 04/21/2020] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Y Zhang
- Department of Cardiology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing 100034, China
| | - Y Tian
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, 199 Dazhi Street, Nangang District, Harbin 150001, Heilongjiang Province, China
| | - P Dong
- Department of Cardiology, The First Affiliated Hospital of Henan University of Science and Technology, 24 Jinghua Road, Jianxi District, Luoyang 471003, Henan Province, China
| | - Y Xu
- Department of Cardiology, Tenth People's Hospital of Tongji University, 301 Yanchang Middle Road, Jingan District, Shanghai 200072, China
| | - B Yu
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, 246 Xuefu Road, Nangang District, Harbin 150086, Heilongjiang Province, China
| | - H Li
- Department of Cardiology, Daqing Oilfield General Hospital, 9 Zhongkang Street, Sartu District, Daqing 163001, Heilongjiang Province, China
| | - J Li
- Department of Cardiology, Qilu Hospital of Shandong University, 107 Wenhua West Road, Lixia District, Jinan 250012, Shandong Province, China
| | - J Ge
- Department of Cardiology, Zhongshan Hospital Fudan University, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Y Sun
- Department of Cardiology, Shanxi Datong Coal Group General Hospital, 5999 Herui Street, Hengan New District, Datong 037003, Shanxi Province, China
| | - J Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University, 88 Jiefang Road, Shangcheng District, Hangzhou 310009, Zhejiang Province, China
| | - L Wang
- Department of Cardiology, Beijing Chao-yang Hospital, 8 Gongti South Road, Chaoyang District, Beijing 100020, China
| | - J Chen
- Department of Cardiology, Guangdong General Hospital, 106 Zhongshan 2nd Road, Yuexiu District, Guangzhou 510080, Guangdong Province, China
| | - H Yan
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Y Chen
- Department of Cardiology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing 100036, China
| | - Y Han
- Department of Cardiology, General Hospital of Northern Theater Command of People's Liberation Army, 83 Wenhua Road, Shenhe District, Shenyang 110016, Liaoning Province, China
| | - Y Huo
- Department of Cardiology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing 100034, China
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Mao Q, Zhao J, Li Y, Xie L, Xiao H, Wang K, Qiu Y, Chen J, Xu Q, Xu Z, Yu Y, Zhang Y, Li Q, Pang X, Li Z, Ran B, Zhang Z, Li Z, Zeng C, Tong S, Jin J, Huang L, Zhao X. Impact of COVID-19 Pandemic on Mechanical Reperfusion in ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: A Multicenter Retrospective Study From a Non-epicenter Region. Front Cardiovasc Med 2021; 8:698923. [PMID: 34368255 PMCID: PMC8339207 DOI: 10.3389/fcvm.2021.698923] [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: 04/22/2021] [Accepted: 06/28/2021] [Indexed: 11/19/2022] Open
Abstract
Objective: The COVID-19 pandemic placed heavy burdens on emergency care and posed severe challenges to ST-segment-elevation myocardial infarction (STEMI) treatment. This study aimed to investigate the impact of COVID-19 pandemic on mechanical reperfusion characteristics in STEMI undergoing primary percutaneous coronary intervention (PPCI) in a non-epicenter region. Methods: STEMI cases undergoing PPCI from January 23 to March 29 between 2019 and 2020 were retrospectively compared. PPCI parameters mainly included total ischemic time (TIT), the period from symptom onset to first medical contact (S-to-FMC), the period from FMC to wire (FMC-to-W) and the period from door to wire (D-to-W). Furthermore, the association of COVID-19 pandemic with delayed PPCI risk was further analyzed. Results: A total of 14 PPCI centers were included, with 100 and 220 STEMI cases undergoing PPCI in 2020 and 2019, respectively. As compared to 2019, significant prolongations occurred in reperfusion procedures (P < 0.001) including TIT (420 vs. 264 min), S-to-FMC (5 vs. 3 h), FMC-to-W (113 vs. 95 min) and D-to-W (83 vs. 65 min). Consistently, delayed reperfusion surged including TIT ≥ 12 h (22.0 vs.3.6%), FMC-to-W ≥ 120 min (34.0 vs. 6.8%) and D-to-W ≥ 90 min (19.0 vs. 4.1%). During the pandemic, the patients with FMC-to-W ≥ 120 min had longer durations in FMC to ECG completed (6 vs. 5 min, P = 0.007), FMC to DAPT (24 vs. 21 min, P = 0.001), catheter arrival to wire (54 vs. 43 min, P < 0.001) and D-to-W (91 vs. 78 min, P < 0.001). The pandemic was significantly associated with high risk of delayed PPCI (OR = 7.040, 95% CI 3.610-13.729, P < 0.001). Conclusions: Even in a non-epicenter region, the risk of delayed STEMI reperfusion significantly increased due to cumulative impact of multiple procedures prolongation.
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Affiliation(s)
- Qi Mao
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Jianhua Zhao
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Youmei Li
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Li Xie
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Han Xiao
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Ke Wang
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Youzhu Qiu
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Jianfei Chen
- Department of Cardiology, People's Hospital of Banan District, Chongqing, China
| | - Qiang Xu
- Department of Cardiology, The Fifth People's Hospital, Chongqing, China
| | - Zhonglin Xu
- Department of Cardiology, The Ninth People's Hospital, Chongqing, China
| | - Yang Yu
- Department of Cardiology, People's Hospital of Dianjiang District, Chongqing, China
| | - Ying Zhang
- Department of Cardiology, Emergency Medical Center, Chongqing, China
| | - Qiang Li
- Department of Cardiovascular Medicine, People's Hospital of Nanchuan District, Chongqing, China
| | - Xiaohua Pang
- Department of Cardiovascular Medicine, The Three Gorges Central Hospital, Chongqing, China
| | - Zhenggong Li
- Department of Cardiac Intervention Therapy, Zhongshan Hospital District, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Boli Ran
- Department of Cardiology, The Third Hospital District, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Zhihui Zhang
- Department of Cardiology, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhifeng Li
- Department of Cardiology, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
| | - Chunyu Zeng
- Department of Cardiology, Daping Hospital, Army Medical University, Chongqing, China
| | - Shifei Tong
- Department of Cardiology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Jin
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Lan Huang
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xiaohui Zhao
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing, China
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9
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Salwan R, Seth A. Development of ST-elevation Myocardial Infarction Programs in Developing Countries: Global Challenges and Solutions. Interv Cardiol Clin 2021; 10:401-411. [PMID: 34053626 DOI: 10.1016/j.iccl.2021.03.010] [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: 11/30/2022]
Abstract
Cardiovascular disease (CVD) is the leading cause of death worldwide; approximately 80% of CVD deaths occur in low-income and middle-income countries (LMICs). The epidemiologic transition to a high burden of ischemic heart disease (IHD) has happened with greater rapidity in LMICs than in high-income countries. The absolute number of individuals with premature IHD has increased substantially. Higher event rates are observed compared with high-income countries. The technological capability to do extraordinary things for patients has increased, as has patient demand, in a setting of constrained resources and expensive health care of variable quality.
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Affiliation(s)
- Roopa Salwan
- Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Ashok Seth
- Fortis Escorts Heart Institute, Okhla Road, New Delhi 110025, India.
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10
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Chen S, Che Q, Zheng Q, Zhang Y, Jia J, Wu Y, Huo Y, Chen D. Relationship Between Different Risk Factor Patterns and Follow-Up Outcomes in Patients With ST-Segment Elevation Myocardial Infarction. Front Cardiovasc Med 2021; 8:633992. [PMID: 34113659 PMCID: PMC8185218 DOI: 10.3389/fcvm.2021.633992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Si Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Qianzi Che
- Department of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Qiwen Zheng
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jia Jia
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yiqun Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Dafang Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
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11
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Che Q, Zhang Y, Wang J, Wan Z, Fu X, Chen J, Yan H, Chen Y, Ge J, Chen D, Huo Y. General glycosylated hemoglobin goals potentially increase myocardial infarction severity in diabetes patients with comorbidities: Insights from a nationwide multicenter study. J Diabetes Investig 2020; 11:1498-1506. [PMID: 32383543 PMCID: PMC7610123 DOI: 10.1111/jdi.13287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/24/2020] [Accepted: 04/29/2020] [Indexed: 01/21/2023] Open
Abstract
AIMS/INTRODUCTION We aimed to investigate the relationship between glycemic status and coronary artery disease (CAD) extent and severity in ST-elevation myocardial infarction (STEMI) patients, and further examine whether diabetes patients could benefit from glycosylated hemoglobin (HbA1c) below the recommended level. MATERIALS AND METHODS Consecutive STEMI patients admitted in 2015-2017 across 244 hospitals were included in the China STEMI Care Project-2. We carried out a cross-sectional study comprising 8,370 participants with a record of HbA1c testing after admission. CAD extent and severity were assessed by admission heart rate, Killip classification and the number of stenosed vessels based on the coronary angiogram. RESULTS Diabetes patients showed a greater risk for higher Killip class, admission tachycardia (admission heart rate ≥100 b.p.m.) and multivessel CAD (presence of left main and/or triple vessel disease). Likewise, HbA1c level was significantly associated with CAD extent and severity. While dividing diabetes patients according to general HbA1c targets (HbA1c ≤6.5, 6.5-7.0 and ≥7.0%), diabetes patients with HbA1c ≤6.5% showed a 1.30-fold higher risk for multivessel CAD (adjusted odds ratio 1.30, 95% confidence interval 1.05-1.62). In stratified analysis, the association was even stronger in patients with hypertension (adjusted odds ratio 1.41, 95% confidence interval 1.08-1.86) or hyperlipidemia (adjusted odds ratio 1.57, 95% confidence interval 1.17-2.12). CONCLUSIONS HbA1c level is independently correlated with CAD extent and severity in STEMI patients. HbA1c below generally recommended levels might still increase the risk of CAD progression, especially for diabetes patients with hypertension or hyperlipidemia.
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Affiliation(s)
- Qianzi Che
- Department of Epidemiology and BiostatisticsSchool of Public HealthPeking UniversityBeijingChina
| | - Yan Zhang
- Department of CardiologyPeking University First HospitalBeijingChina
| | - Jianan Wang
- Department of CardiologyThe Second Affiliated HospitalZhejiang UniversityHangzhouChina
| | - Zheng Wan
- Department of CardiologyTianjin Medical University General HospitalTianjinChina
| | - Xianghua Fu
- Department of CardiologySecond Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Jiyan Chen
- Department of CardiologyGuangdong General HospitalGuangzhouChina
| | - Hongbing Yan
- Department of CardiologyChinese Academy of Medical Sciences & Peking Union Medical College Fuwai HospitalBeijingChina
| | - Yundai Chen
- Department of CardiologyChinese PLA General HospitalBeijingChina
| | - Junbo Ge
- Department of CardiologyZhongshan Hospital Fudan UniversityShanghaiChina
| | - Dafang Chen
- Department of Epidemiology and BiostatisticsSchool of Public HealthPeking UniversityBeijingChina
| | - Yong Huo
- Department of CardiologyPeking University First HospitalBeijingChina
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12
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Dharma S. Comparison of Real-Life Systems of Care for ST-Segment Elevation Myocardial Infarction. Glob Heart 2020; 15:66. [PMID: 33150131 PMCID: PMC7528675 DOI: 10.5334/gh.343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 09/14/2020] [Indexed: 01/30/2023] Open
Abstract
The success of ST-segment elevation myocardial infarction (STEMI) networks application in Europe and the United States in delivering rapid reperfusion therapy in the community have become an inspiration to other developing countries to develop regional STEMI network in order to improve the STEMI care. Although barriers are found in the beginning phase of constructing the network, recent analysis from national or regional registries worldwide have shown improvement of the STEMI care in many countries over the years. To improve the overall care of patients with STEMI particularly in developing countries, improvements should be focusing on how to minimize the total ischemia time, and this includes care improvement at each step of care after the patient shows signs and symptoms of chest pain. Innovation in health technology to develop the electrocardiogram transmission and communication system, along with routine performance measures of the STEMI network may help bridging the disparities of STEMI system of care between guideline recommended therapy and the real world clinical practice.
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Affiliation(s)
- Surya Dharma
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, Indonesian Cardiovascular Research Center, National Cardiovascular Center Harapan Kita, Jakarta, ID
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13
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Fu XY, Shen XF, Cheng YR, Zhou MY, Ye L, Feng ZH, Xu Z, Chen J, Wang MW, Zhang XW. Effect of COVID-19 outbreak on the treatment time of patients with acute ST-segment elevation myocardial infarction. Am J Emerg Med 2020; 44:192-197. [PMID: 33039221 PMCID: PMC7494496 DOI: 10.1016/j.ajem.2020.09.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/27/2020] [Accepted: 09/12/2020] [Indexed: 01/30/2023] Open
Abstract
Objective To explore the effect of COVID-19 outbreak on the treatment time of patients with ST-segment elevation myocardial infarction (STEMI) in Hangzhou, China. Methods We retrospectively reviewed the data of STEMI patients admitted to the Hangzhou Chest Pain Center (CPC) during a COVID-19 epidemic period in 2020 (24 cases) and the same period in 2019 (29 cases). General characteristics of the patients were recorded, analyzed, and compared. Moreover, we compared the groups for the time from symptom onset to the first medical contact (SO-to-FMC), time from first medical contact to balloon expansion (FMC-to-B), time from hospital door entry to first balloon expansion (D-to-B), and catheter room activation time. The groups were also compared for postoperative cardiac color Doppler ultrasonographic left ventricular ejection fraction (LVEF),the incidence of major adverse cardiovascular and cerebrovascular events (MACCE),Kaplan-Meier survival curves during the 28 days after the operation. Results The times of SO-to-FMC, D-to-B, and catheter room activation in the 2020 group were significantly longer than those in the 2019 group (P < 0.05). The cumulative mortality after the surgery in the 2020 group was significantly higher than the 2019 group (P < 0.05). Conclusion The pre-hospital and in-hospital treatment times of STEMI patients during the COVID-19 epidemic were longer than those before the epidemic. Cumulative mortality was showed in Kaplan-Meier survival curves after the surgery in the 2020 group was significantly different higher than the 2019 group during the 28 days.The diagnosis and treatment process of STEMI patients during an epidemic should be optimized to improve their prognosis.
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Affiliation(s)
- Xin-Yan Fu
- Affiliated Hospital of Hangzhou Normal University, Hangzhou 310015, China
| | - Xiang-Feng Shen
- Affiliated Hospital of Hangzhou Normal University, Hangzhou 310015, China
| | - Yong-Ran Cheng
- Zhejiang Academy of Medical Sciences, Hangzhou 310012, China; Hangzhou Medical college, Hangzhou 311300, China
| | | | - Lan Ye
- Basic medical college, Guizhou Medical University, Guizhou 550004, China
| | - Zhan-Hui Feng
- Department of Neurology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Zhao Xu
- Affiliated Hospital of Hangzhou Normal University, Hangzhou 310015, China.
| | - Juan Chen
- Affiliated Hospital of Hangzhou Normal University, Hangzhou 310015, China
| | - Ming-Wei Wang
- Affiliated Hospital of Hangzhou Normal University, Hangzhou 310015, China.
| | - Xing-Wei Zhang
- Affiliated Hospital of Hangzhou Normal University, Hangzhou 310015, China.
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14
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Xiang D, Xiang X, Zhang W, Yi S, Zhang J, Gu X, Xu Y, Huang K, Su X, Yu B, Wang Y, Fang W, Huo Y, Ge J. Management and Outcomes of Patients With STEMI During the COVID-19 Pandemic in China. J Am Coll Cardiol 2020; 76:1318-1324. [PMID: 32828614 PMCID: PMC7438071 DOI: 10.1016/j.jacc.2020.06.039] [Citation(s) in RCA: 152] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND ST-segment elevation myocardial infarction (STEMI) is a fatal cardiovascular emergency requiring rapid reperfusion treatment. During the coronavirus disease-2019 (COVID-19) pandemic, medical professionals need to strike a balance between providing timely treatment for STEMI patients and implementing infection control procedures to prevent nosocomial spread of COVID-19 among health care workers and other vulnerable cardiovascular patients. OBJECTIVES This study evaluates the impact of the COVID-19 outbreak and China Chest Pain Center's modified STEMI protocol on the treatment and prognosis of STEMI patients in China. METHODS Based on the data of 28,189 STEMI patients admitted to 1,372 Chest Pain Centers in China between December 27, 2019 and February 20, 2020, the study analyzed how the COVID-19 outbreak and China Chest Pain Center's modified STEMI protocol influenced the number of admitted STEMI cases, reperfusion strategy, key treatment time points, and in-hospital mortality and heart failure for STEMI patients. RESULTS The COVID-19 outbreak reduced the number of STEMI cases reported to China Chest Pain Centers. Consistent with China Chest Pain Center's modified STEMI protocol, the percentage of patients undergoing primary percutaneous coronary intervention declined while the percentage of patients undergoing thrombolysis increased. With an average delay of approximately 20 min for reperfusion therapy, the rate of in-hospital mortality and in-hospital heart failure increased during the outbreak, but the rate of in-hospital hemorrhage remained stable. CONCLUSIONS There were reductions in STEMI patients' access to care, delays in treatment timelines, changes in reperfusion strategies, and an increase of in-hospital mortality and heart failure during the COVID-19 pandemic in China.
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Affiliation(s)
- Dingcheng Xiang
- Department of Cardiology, General Hospital of Southern Theatre Command of PLA, Guangzhou, China.
| | - Xin Xiang
- Graduate School of Arts and Sciences, Harvard University, Cambridge, Massachusetts
| | - Wei Zhang
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China
| | - Shaodong Yi
- Department of Cardiology, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Jinxia Zhang
- Department of Cardiology, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Xiaolong Gu
- Department of Cardiology, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Yawei Xu
- Department of Cardiology, 10th Hospital of Tongji University, Shanghai, China
| | - Kai Huang
- Department of Cardiology, Union Hospital of Huazhong University of Science and Technology, Wuhan, China
| | - Xi Su
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, China
| | - Bo Yu
- Department of Cardiology, Key Laboratories of Education Ministry for Myocardial Ischemia Mechanism and Treatment, 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yan Wang
- Department of Cardiology, Xiamen Heart Center, Xiamen, China
| | - Weiyi Fang
- Department of Cardiology, Shanghai Dongfang Hospital, Shanghai, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China.
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
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