Prospective observational study of acute coronary syndromes in China: practice patterns and outcomes

A Machine Learning Model for Predicting In-Hospital Mortality in Chinese Patients With ST-Segment Elevation Myocardial Infarction: Findings From the China Myocardial Infarction Registry

BACKGROUND

Machine learning (ML) risk prediction models, although much more accurate than traditional statistical methods, are inconvenient to use in clinical practice due to their nontransparency and requirement of a large number of input variables.

OBJECTIVE

We aimed to develop a precise, explainable, and flexible ML model to predict the risk of in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

This study recruited 18,744 patients enrolled in the 2013 China Acute Myocardial Infarction (CAMI) registry and 12,018 patients from the China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE)-Retrospective Acute Myocardial Infarction Study. The Extreme Gradient Boosting (XGBoost) model was derived from 9616 patients in the CAMI registry (2014, 89 variables) with 5-fold cross-validation and validated on both the 9125 patients in the CAMI registry (89 variables) and the independent China PEACE cohort (10 variables). The Shapley Additive Explanations (SHAP) approach was employed to interpret the complex relationships embedded in the proposed model.

RESULTS

In the XGBoost model for predicting all-cause in-hospital mortality, the variables with the top 8 most important scores were age, left ventricular ejection fraction, Killip class, heart rate, creatinine, blood glucose, white blood cell count, and use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs). The area under the curve (AUC) on the CAMI validation set was 0.896 (95% CI 0.884-0.909), significantly higher than the previous models. The AUC for the Global Registry of Acute Coronary Events (GRACE) model was 0.809 (95% CI 0.790-0.828), and for the TIMI model, it was 0.782 (95% CI 0.763-0.800). Despite the China PEACE validation set only having 10 available variables, the AUC reached 0.840 (0.829-0.852), showing a substantial improvement to the GRACE (0.762, 95% CI 0.748-0.776) and TIMI (0.789, 95% CI 0.776-0.803) scores. Several novel and nonlinear relationships were discovered between patients' characteristics and in-hospital mortality, including a U-shape pattern of high-density lipoprotein cholesterol (HDL-C).

CONCLUSIONS

The proposed ML risk prediction model was highly accurate in predicting in-hospital mortality. Its flexible and explainable characteristics make the model convenient to use in clinical practice and could help guide patient management.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01874691; https://clinicaltrials.gov/study/NCT01874691.

Quantitative Detection of Multiple Cardiovascular Biomarkers by an Antibody Microarray-Based Metal-Enhanced Fluorescence Assay

Accurate detection of multiple cardiovascular biomarkers is crucial for the timely screening of acute coronary syndrome (ACS) and differential diagnosis from acute aortic syndrome (AAS). Herein, an antibody microarray-based metal-enhanced fluorescence assay (AMMEFA) has been developed to quantitatively detect 7 cardiovascular biomarkers through the formation of a sandwich immunoassay on the poly(glycidyl methacrylate-co-2-hydroxyethyl methacrylate)-decorated GNR-modified slide (GNR@P(GMA-HEMA) slide). The AMMEFA exhibits high specificity and sensitivity, the linear ranges span 5 orders of magnitude, and the limits of detection (LODs) of cardiac troponin I (cTnI), heart-type fatty acid binding protein (H-FABP), C-reactive protein (CRP), copeptin, myoglobin, D-Dimer, and N-terminal pro-brain natriuretic peptide (NT-proBNP) reach 0.07, 0.2, 65.7, 0.6, 0.2, 8.3, and 0.3 pg mL-1, respectively. To demonstrate its practicability, the AMMEFA has been applied to quantitatively analyze 7 cardiovascular biomarkers in 140 clinical plasma samples. In addition, the expression levels of cardiovascular biomarkers were analyzed by the least absolute shrinkage and selector operator (LASSO) regression, and the area under receiver operator characteristic curves (AUCs) of healthy donors (HDs), ACS patients, and AAS patients are 0.99, 0.98, and 0.97, respectively.

Prediction Model of New Onset Atrial Fibrillation in Patients with Acute Coronary Syndrome

OBJECTIVE

Atrial fibrillation (AF) is one of the most common complications of acute coronary syndrome (ACS) patients. Possible risk factors related to new-onset AF (NOAF) in ACS patients have been reported in some studies, and several prediction models have been established. However, the predictive power of these models was modest and lacked independent validation. The aim of this study is to define risk factors of NOAF in patients with ACS during hospitalization and to develop a prediction model and nomogram for individual risk prediction.

METHODS

Retrospective cohort studies were conducted. A total of 1535 eligible ACS patients from one hospital were recruited for model development. External validation was performed using an external cohort of 1635 ACS patients from another hospital. The prediction model was created using multivariable logistic regression and validated in an external cohort. The discrimination, calibration, and clinical utility of the model were evaluated, and a nomogram was constructed. A subgroup analysis was performed for unstable angina (UA) patients.

RESULTS

During hospitalization, the incidence of NOAF was 8.21% and 6.12% in the training and validation cohorts, respectively. Age, admission heart rate, left atrial diameter, right atrial diameter, heart failure, brain natriuretic peptide (BNP) level, less statin use, and no percutaneous coronary intervention (PCI) were independent predictors of NOAF. The AUC was 0.891 (95% CI: 0.863-0.920) and 0.839 (95% CI: 0.796-0.883) for the training and validation cohort, respectively, and the model passed the calibration test (P > 0.05). The clinical utility evaluation shows that the model has a clinical net benefit within a certain range of the threshold probability.

CONCLUSION

A model with strong predictive power was constructed for predicting the risk of NOAF in patients with ACS during hospitalization. It might help with the identification of ACS patients at risk and early intervention of NOAF during hospitalization.

Practice of reperfusion in patients with ST-segment elevation myocardial infarction in China: findings from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome project

BACKGROUND

Reperfusion therapy is fundamental for ST-segment elevation myocardial infarction (STEMI). However, the details of contemporary practice and factors associated with reperfusion therapy in China are largely unknown. Therefore, this study aimed to explore reperfusion practice and its associated factors among hospitalized patients with STEMI in China.

METHODS

Patients with STEMI who were admitted to 159 tertiary hospitals from 30 provinces in China were included in the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome project from November 2014 to December 2019. The associations of the characteristics of patients and hospitals with reperfusion were examined using hierarchical logistic regression. The associations between therapies and in-hospital major adverse cardiovascular events were examined with a mixed effects Cox regression model.

RESULTS

Among the 59,447 patients, 37,485 (63.1%) underwent reperfusion, including 4556 (7.7%) receiving fibrinolysis and 32,929 (55.4%) receiving primary percutaneous coronary intervention (PCI). The reperfusion rate varied across geographical regions (48.0%-73.5%). The overall rate increased from 60.0% to 69.7% from 2014 to 2019, mainly due to an increase in primary PCI within 12 h of symptom onset. Timely PCI, but not fibrinolysis alone, was associated with a decreased risk of in-hospital major adverse cardiovascular events compared with no reperfusion, with an adjusted hazard ratio (95% confidence interval) of 0.64 (0.54,0.76) for primary PCI at <12 h, 0.53 (0.37,0.74) for primary PCI at 12 to 24 h, 0.46 (0.25,0.82) for the pharmaco-invasive strategy, and 0.79 (0.54,1.15) for fibrinolysis alone.

CONCLUSIONS

Nationwide quality improvement initiatives should be strengthened to increase the reperfusion rate and reduce inequality in China.

TRIAL REGISTRATION

www.ClinicalTrials.gov , NCT02306616.

Regional Differences in the Ratio of Observed and Expected In-hospital Mortality for Acute Coronary Syndrome Patients in China: The Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project Analysis

Previous studies reported regional variations in in-hospital acute coronary syndrome (ACS) mortality, but the reasons for that were not clearly defined. We explored whether differences in patient characteristics could explain regional variation. The Improving Care for Cardiovascular Disease in China (CCC)-ACS project is an ongoing national registry and quality improvement project, involving 150 tertiary hospitals from 30 provinces across China. We applied a prediction model that included patient-specific variables to calculate the expected in-hospital mortality. For each province, we reported the observed, expected in-hospital mortality and the risk-adjusted ratio which is based on the observed divided by the expected mortality. From 2014 to 2018, 79 585 ACS patients were enrolled. The average in-hospital mortality was 1.8%. There was a wide variation in the in-hospital mortality among different provinces (0.2-3.9%). Patient characteristics explained part of this variation because of differences in the expected in-hospital mortality (0.7-2.8%). There was a substantial variation in the risk-adjusted ratio among provinces (0.2-3.5), which suggests that the variations in the mortality cannot be completely explained by the differences in patient characteristics. In conclusion, we observed a wide regional variation in mortality for ACS, part of which could be explained by the difference in patient characteristics.

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.

Health Care Quality Improvement for ST-Segment Elevation Myocardial Infarction: A Retrospective Study Based on Propensity-Score Matching Analysis

Reducing the treatment delay by organizing delivery of care on a regional basis is a priority for improving the quality of ST-segment elevated myocardial infarction (STEMI) care. This study aimed to evaluate the impact of the combined measures on quality metrics of healthcare delivery in Suzhou. The data were collected from the National Chest Pain Center (CPC) Data Reporting Database. 4775 patients were recruited, and after propensity-score matching, 1078 pairs were finally included for analysis. We examined the changes in quality metrics of care including prehospital and in-hospital processes, and clinic outcomes. Quality improvement (QI) implementation improved most process indicators. However, these improvements did not yield decreased in-hospital mortality. The door-to-balloon and the FMC-to-device time decreased from 85.0 and 98.0 min to 78 and 88 min, respectively (p < 0.001). Cases transferred directly via EMS had a greater improvement in most of process indicators. The proportion of patients transferred directly via EMS was 10.3%, much lower than that of self-transported patients at 58.3%. Tertiary hospitals showed greater performance improvement in process indicators than secondary hospitals. The percentage of cases using EMS remained low for suburban areas. The establishment of coordinated STEMI care needs to be accompanied with solving the fragmented situation of the prehospital and hospital care, and patient delay should be addressed, especially in suburban areas and on transferred-in inpatients.

Protocol for the Acute Myocardial Infarction Study in Northeastern China (AMINoC): a real-world prospective cohort study

INTRODUCTION

Acute myocardial infarction (AMI) has become one of the major causes of mortality and morbidity in China. However, little is known about the characteristics, medical care and outcomes of patients with AMI in Northeastern China. The Acute Myocardial Infarction Study in Northeastern China (AMINoC) is aimed at obtaining timely real-world knowledge in terms of characteristics, clinical care and outcomes of patients with AMI and at providing care-quality improvement efforts in Northeastern China.

METHODS AND ANALYSIS

The AMINoC is a real-world, prospective, multicentre cohort study. The study selected 20 hospitals using stratified cluster sampling from different levels of hospitals among nine districts throughout Jilin Province. Hospitalised patients with a primary diagnosis of AMI in each site are consecutively enrolled for 1 year. Demographic characteristics, clinical data, treatments, outcomes and cost are collected by local investigators. Patient follow-up after discharge is planned for up to 2 years.

ETHICS AND DISSEMINATION

The protocol has been approved by the ethics committee at the Second Hospital of Jilin University. The findings of this study will be published in peer-reviewed journals and medical conferences.

TRIAL REGISTRATION

NCT04451967.

Detection of circRNA Biomarker for Acute Myocardial Infarction Based on System Biological Analysis of RNA Expression

Acute myocardial infarction (AMI) is myocardial necrosis caused by the persistent interruption of myocardial blood supply, which has high incidence rate and high mortality in middle-aged and elderly people in the worldwide. Biomarkers play an important role in the early diagnosis and treatment of AMI. Recently, more and more researches confirmed that circRNA may be a potential diagnostic biomarker and therapeutic target for cardiovascular diseases. In this paper, a series of biological analyses were performed to find new effective circRNA biomarkers for AMI. Firstly, the expression levels of circRNAs in blood samples of patients with AMI and those with mild coronary stenosis were compared to reveal circRNAs which were involved in AMI. Then, circRNAs which were significant expressed abnormally in the blood samples of patients with AMI were selected from those circRNAs. Next, a ceRNA network was constructed based on interactions of circRNA, miRNA and mRNA through biological analyses to detect crucial circRNA associated with AMI. Finally, one circRNA was selected as candidate biomarker for AMI. To validate effectivity and efficiency of the candidate biomarker, fluorescence in situ hybridization, hypoxia model of human cardiomyocytes, and knockdown and overexpression analyses were performed on candidate circRNA biomarker. In conclusion, experimental results demonstrated that the candidate circRNA was an effective biomarker for diagnosis and therapy of AMI.

Weekly variation in quality of care for acute ST-segment elevation myocardial infarction by day and time of admission: a retrospective observational study

BACKGROUND

The admission time of patients with ST-segment elevation myocardial infarction (STEMI) may affect the quality of care they receive. This study aimed to explore the pattern and magnitude of variation in quality of care for patients with STEMI in both the process and outcome domains.

METHODS

We performed a retrospective study based on STEMI data from China. We estimated the adjusted ORs of six process indicators and one outcome indicator of STEMI care quality by fitting multilevel multivariable regression models across 42 4hour time periods per week.

RESULTS

The study cohort comprised 98 628 patients with STEMI. Care quality varied by time of arrival to the emergency department. We identified three main patterns of variation, which were consistent across days of the week. In the first pattern, which applied to electrocardiographic examination within 10 min of arrival and to aspirin or clopidogrel use within 10 min of arrival, quality was lowest for arrivals between 08:00 and 12:00, rose through the day and peaked for arrivals between 24:00 and 04:00. Percutaneous transluminal coronary intervention treatment within 90 min showed the same pattern but with maximal performance for those arriving 20:00-24:00. In the third pattern, applying to lipid function evaluation within 24 hours and beta blocker use within 24 hours, quality was best for arrivals between 04:00-08:00 and 16:00-19:00 and worst for arrivals between 24:00-04:00 and 12:00-16:00.

CONCLUSIONS

The quality of care for STEMI shows three patterns of diurnal variation. Detecting the times at which quality is relatively low may lead to quality improvement in healthcare. Quality improvement should focus on reducing the weekend effect and off-hour effect and the diurnal temporal variation.

Effect of a Quality of Care Improvement Initiative in Patients With Acute Coronary Syndrome in Resource-Constrained Hospitals in China: A Randomized Clinical Trial

Importance

Prior observational studies suggest that quality of care improvement (QCI) initiatives can improve the clinical outcomes of acute coronary syndrome (ACS). To our knowledge, this has never been demonstrated in a well-powered randomized clinical trial.

Objective

To determine whether a clinical pathway-based, multifaceted QCI intervention could improve clinical outcomes among patients with ACS in resource-constrained hospitals in China.

Design, Setting, Participants

This large, stepped-wedge cluster randomized clinical trial was conducted in nonpercutaneous coronary intervention hospitals across China and included all patients older than 18 years and with a final diagnosis of ACS who were recruited consecutively between October 2011 and December 2014. We excluded patients who died before or within 10 minutes of hospital arrival. We recruited 5768 and 0 eligible patients for the control and intervention groups, respectively, in step 1, 4326 and 1365 in step 2, 3278 and 3059 in step 3, 1419 and 4468 in step 4, and 0 and 5645 in step 5.

Interventions

The intervention included establishing a QCI team, training clinical staff, implementing ACS clinical pathways, sequential site performance assessment and feedback, online technical support, and patient education. The usual care was the control that was compared.

Main Outcomes and Measures

The primary outcome was the incidence of in-hospital major adverse cardiovascular events (MACE), comprising all-cause mortality, reinfarction/myocardial infarction, and nonfatal stroke. Secondary outcomes included 16 key performance indicators (KPIs) and the composite score developed from these KPIs.

Results

Of 29 346 patients (17 639 men [61%]; mean [SD] age for control, 64.1 [11.6] years; mean [SD] age for intervention, 63.9 [11.7] years) who were recruited from 101 hospitals, 14 809 (50.5%) were in the control period and 14 537 (49.5%) were in the intervention period. There was no significant difference in the incidence of in-hospital MACE between the intervention and control periods after adjusting for cluster and time effects (3.9% vs 4.4%; odds ratio, 0.93; 95% CI, 0.75-1.15; P = .52). The intervention showed a significant improvement in the composite KPI score (mean [SD], 0.69 [0.22] vs 0.61 [0.23]; P < .01) and in 7 individual KPIs, including the early use of antiplatelet therapy and the use of appropriate secondary prevention medicines at discharge. No unexpected adverse events were reported.

Conclusions and Relevance

Among resource-constrained Chinese hospitals, introducing a multifaceted QCI intervention had no significant effect on in-hospital MACE, although it improved a few of the care process indicators of evidence-based ACS management.

Trial Registration

ClinicalTrials.gov identifier: NCT01398228.

Prospective randomized controlled trial study of Luofengning granule in the treatment of unstable angina

INTRODUCTION

Although the current western treatment plans for unstable angina (UA) has been optimized in past decades, UA still is a common phenotype of acute coronary syndrome and significantly influence the quality of life and endanger lives. In China, the clinical application of Chinese herb medicine is considered as an effective approach to treating UA and widely recognized by patients. In clinical practices, we found Luofengning granule (LFN-G) could improve clinical manifestations of patients with UA, but there is lack of rigorous proof of evidence-based medicine. This trial aims to further evaluate the efficacy of LFN-G in the treatment of UA.

METHODS

A prospective, open-label, randomized, placebo-controlled clinical will be performed. A total of 60 patients diagnosed with UA will be randomly allocated to either the treatment group or the control group with a 1:1 ratio. The participants in the treatment group will receive LFN-G treatment and the participants in the control group will receive placebo. Meanwhile, both groups continue to undergo standard western medicine treatments. The duration of interventions is 4 weeks. The primary endpoint is the incidence of major cardiac adverse events, defined as a composite of recurrent angina, acute myocardial infarction (AMI), severe arrhythmia, heart failure, and cardiac death. Secondary outcomes include Seattle angina scale score, Chinese medicine syndromes and electrocardiograph (at weeks 0, 1, 2, 4), myocardial nuclides perfusion, measurement of wall motion score index and left ventricular ejection fraction, serum inflammation factors such as C-reactive protein, high sensitive-C-reactive protein, interleukin-6, matrix metalloproteinase-9, and so on (at weeks 0, 4). In addition, some biochemical indexes of blood and hematological indexes will be used to assess the safety of treatments. Any adverse effects of the treatment will be recorded.

DISCUSSION

The results of this trial will provide compelling evidence of the efficacy and safety of LFN-G for treatment of UA and preliminarily reveal the potential mechanism of how LFN-G acts. Finally, it will widen treatment options for patients with UA.

Epidemiology of Cardiovascular Disease in China and Opportunities for Improvement: JACC International

The burden of cardiovascular (CV) disease is very high in China, due to highly prevalent and poorly controlled risk factors resulting from changing sociodemographic structure and lifestyles in its large population. Rapid economic development and urbanization have been accompanied by changing patterns, expression, and management of CV disease. However, the health care system in China lacks a hierarchical structure, with a focus on treating acute diseases in hospital while ignoring long-term management, and primary health care is too weak to effectively control CV risk factors. To address these challenges, the Chinese central government has ensured health is a national priority and has introduced reforms that include implementing policies for a healthy environment, strengthening primary care, and improving affordability and accessibility within the health system. Turning the inverted pyramid of the health care system is essential in the ongoing battle against CV disease.

Sex Differences in 1-Year Health Status Following Percutaneous Coronary Intervention in Patients Without Acute Myocardial Infarction: Results From the China PEACE Prospective Study

Background

Sex differences in health status outcomes after percutaneous coronary intervention among patients without acute myocardial infarction are not well described.

Methods and Results

A total of 2237 patients (33.4% women) without acute myocardial infarction undergoing percutaneous coronary intervention were enrolled from 39 Chinese tertiary hospitals in the PEACE (China Patient‐centered Evaluative Assessment of Cardiac Events) prospective percutaneous coronary intervention study. Data were collected immediately before and 1 year following percutaneous coronary intervention. Health status was measured using the disease‐specific Seattle Angina Questionnaire (SAQ) Angina Frequency and Quality of Life domains, as well as the SAQ Summary Score. Among the study population, women were older, more often single, had lower levels of education, and had a higher prevalence of cardiac risk factors such as hypertension and diabetes mellitus. Women had lower mean 1‐year SAQ Angina Frequency scores (mean±SD, 91.0±17.3 versus 93.9±13.3; P<0.01), SAQ Quality of Life scores (mean±SD, 67.3±23.0 versus 70.6±21.6; P<0.01), and SAQ Summary Scores (mean±SD, 81.6±13.8 versus 84.8±11.9; P<0.01), a difference of marginal clinical significance that persisted after multivariable adjustment. A slightly larger improvement in the SAQ Summary Score was observed in women as compared with men (20.9±22.6 versus 18.5±21.3; P=0.007) in unadjusted analysis. However, women were less likely to achieve clinically significant improvement in SAQ Angina Frequency (adjusted odds ratio, 0.67; 95% CI, 0.45–1.00) and SAQ Quality of Life (adjusted odds ratio, 0.73; 95% CI, 0.56–0.96) after adjustment.

Conclusions

There were no clinically significant differences in 1‐year health status outcomes and improvement in health status by sex among patients without acute myocardial infarction following percutaneous coronary intervention. However, female sex was associated with poorer 1‐year health status and a lower likelihood of experiencing clinically improvement in health status.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01624922.

Association between admission lactate levels and mortality in patients with acute coronary syndrome: a retrospective cohort study

OBJECTIVE

Hyperlactatemia at admission is associated with poor outcome in critically ill patients. However, data on the prognostic value of blood lactate level in patients with acute coronary syndrome (ACS) are limited. The present study assessed the prognostic effect of admission lactate level in a large population of patients with ACS.

MATERIALS AND METHODS

This was a retrospective observational study including patients with ACS who were admitted to the Coronary Care Unit of the First Affiliated Hospital of Wenzhou Medical University between 2014 and 2017. Patients were divided into tertiles of lactate level (T1: <1.8; T2: 1.8-2.6; T3: ≥2.7 mmol/l). The clinical outcomes were 30-day and 180-day mortality from hospital admission. Cox proportional hazards models were used to evaluate the association between lactate level and survival.

RESULTS

A total of 1865 consecutive patients with ACS were enrolled. Significant positive associations were observed between admission lactate level and both 180-day and 30-day mortality, with highest risk for lactate greater than or equal to 2.7 mmol/l. The adjusted hazard ratio for 180-day mortality was 2.09 [95% confidence interval (CI): 1.18-3.71, P=0.011] for T3 and 1.53 (95% CI: 0.86-2.72, P=0.147) for T2 compared with T1 (P for trend=0.006), and 1.10 (95% CI: 1.02-1.18, P=0.010) for each unit increase in lactate level. Similar trends were observed for 30-day mortality. The association was highly consistent across all subgroups studied (all P for interaction >0.05).

CONCLUSION

In patients with ACS, elevated admission lactate level is an independent predictor of 30-day and 180-day all-cause mortality.

Identifying patients with refusal of percutaneous coronary intervention for acute myocardial infarction: a classification and regression tree analysis

The purpose of the present study is to develop and validate a prediction tool to identify patients who refuse to receive percutaneous coronary intervention (PCI) rapidly. We developed a risk stratification model using the derivation cohort of 288 patients with ST segment elevation myocardial infarction (STEMI) in our hospital and validated it in a prospective cohort of 115 patients. There were 52 (18.1%) patients and 18 (15.7%) patients who refused PCI among derivation and validation cohort, respectively. A classification and regression tree (CART) analysis and multivariate logistic regression were used for statistical analysis. The decision-making factors for refusal of PCI were also investigated. The CART analysis and logistic regression both showed that self-rated mild symptom was the most significant predictor of not choosing PCI. The model generated three risk groups. The high-risk group included: self-rated mild symptoms; self-rated severe symptom, glomerular filtration rate < 60 ml/min/1.73m². The intermediate-risk group included: self-rated severe symptom, glomerular filtration rate ≥ 60 ml/min/1.73m² and age ≥ 75 years. The low-risk group included: self-rated severe symptom, glomerular filtration rate ≥ 60 ml/min/1.73m² and age < 75 years. The prevalence for refusal of PCI of the three groups were 45%-44%, 18% and 4%, respectively. The sensitivity was 88% and the negative predictive value was 96%. And similar results were obtained when this prediction tool was applied prospectively to the validation cohort. Patients at low and high risk can be easily identified for refusal of PCI by the prediction tool using common clinical data. This practical model might provide useful information for rapid recognition and early response for this kind of crowd.

Beijing's diagnosis-related group payment reform pilot: Impact on quality of acute myocardial infarction care

In 2012, China's first diagnosis-related group (DRG) payment system was piloted in Beijing. This study explored whether this payment pilot improved quality and reduced costs of acute myocardial infarction (AMI) care in hospitals implementing DRG payment as compared to control hospitals. A difference-in-difference study design was used with regression and considered several quality indicators including aspirin at arrival, aspirin at discharge, β-blocker at arrival, β-blocker at discharge, statin at discharge, in-hospital mortality, and 30-day readmission rates. DRG payment mechanisms without specific mechanisms to promote care quality did not improve quality of AMI care. Future studies should study the impact of cost control mechanisms together with quality improvement efforts to assess how quality of care may be improved within the Chinese healthcare system. These lessons would be helpful to share with lower-middle-income countries undergoing rapid development that are transitioning to a significantly higher burden of non-communicable diseases.

Contemporary invasive management and in-hospital outcomes of patients with non-ST-segment elevation myocardial infarction in China: Findings from China Acute Myocardial Infarction (CAMI) Registry

BACKGROUND

Few studies have investigated the use of invasive strategy for patients with non-ST-segment elevation myocardial infarction (NSTEMI) in China. We aimed to describe the contemporary pattern of management, medically and invasively, in patients with NSTEMI across China.

METHODS

Using data of China Acute Myocardial Infarction Registry, we analyzed the baseline characteristics, in-hospital medication, index coronary angiography (CAG) and revascularization by stratification of gender, age, and risk assessment. Primary outcomes included in-hospital major adverse cardio-cerebral events (MACCE, a composite of all-cause death, myocardial (re)infarction, and stroke) and length of stay (LOS).

RESULTS

A total of 10,266 NSTEMI patients were enrolled between January 2013 and November 2016. Dual antiplatelet therapy and statins were prescribed in 92.9% and 92.1% of overall patients respectively. CAG was performed in 45.6% of these patients, and 40.9% had an index revascularization. Female, older or higher risk patients were less likely to receive CAG or revascularization. The rates of CAG were 67.9% in the provincial-level, 46.2% in the prefectural, and 12.1% in the county-level hospitals. Of those patients undergoing revascularization, 77.0% (1,156/1,501) very-high-risk patients received urgent revascularization and 16.2% (440/2,699) high-risk patients underwent early revascularization as recommended. The overall in-hospital MACCE was 6.7%, and the median LOS was 10 (6) days. Revascularization was associated with reduction for in-hospital MACCE regardless of risk and age.

CONCLUSION

Invasive management was underused and profoundly deferred among patients with NSTEMI in China. The risk-treatment paradox, procedure deferral and medical resources distribution imbalance may represent opportunities for improvement.

Prognostic value of fibrinogen-to-albumin ratio in predicting 1-year clinical progression in patients with non-ST elevation acute coronary syndrome undergoing percutaneous coronary intervention

Previous studies have indicated that fibrinogen and low serum albumin levels are associated with poor cardiovascular outcomes. The objective of the present study was to examine whether the fibrinogen-to-albumin ratio (FAR) was able to predict the 1-year prognosis of patients with non-ST elevation acute coronary syndrome (NSTE-ACS) following percutaneous coronary intervention (PCI). A total of 1,352 patients with NSTE-ACS undergoing PCI were included in this prospective study and were divided into a low-FAR group (FAR ≤8.713, n=901) and a high-FAR group (FAR>8.713, n=451). FAR was defined as the concentration ratio of fibrinogen (mg/dl) to albumin (mg/dl) multiplied by 100. The endpoint was the incidence of major adverse cardiovascular events (MACEs), including all-cause mortality, cardiac mortality, non-fatal myocardial reinfarction and unscheduled repeat revascularisation. The predictive performance was validated by receiver-operator characteristic (ROC) curve analysis. A total of 127 MACEs were noted during the 1-year follow-up period. Multivariate Cox analysis suggested that a high FAR was an independent predictor of all-cause mortality (hazard ratio=2.223, 95% confidence interval: 1.002-4.931, P=0.049). Regarding the predictor of MACEs, the FAR exhibited an area under the ROC curve of 0.676 with a sensitivity of 0.630 and a specificity of 0.726. The cut-off value was 9.114. The FAR was an independent prognostic factor in NSTE-ACS. The present results suggest that the FAR may serve as a potential prognostic indicator for patients with NSTE-ACS undergoing PCI (approval no. NCT02667548; January 29, 2016; Shengjing Hospital of China Medical University).

Protocol of the China ST-segment elevation myocardial infarction (STEMI) Care Project (CSCAP): a 10-year project to improve quality of care by building up a regional STEMI care network

INTRODUCTION

Successful ST-segment elevation myocardial infarction (STEMI) management is time-sensitive and is based on prompt reperfusion mainly to reduce patient mortality. It has evolved from a single hospital care to an integrated regional network approach over the last decades. This prospective study, named the China STEMI Care Project (CSCAP), aims to show how implementation of different types of integrated regional STEMI care networks can improve the reperfusion treatment rate, shorten the total duration of myocardial ischaemia and lead to mortality reduction step by step.

METHODS AND ANALYSIS

The CSCAP is a prospective, multicentre registry study of three phases. A total of 18 provinces, 4 municipalities and 2 autonomous regions in China were included. Patients who meet the third universal definition of myocardial infarction and the Chinese STEMI diagnosis and treatment guidelines are enrolled. Phase 1 (CSCAP-1) focuses on the in-hospital process optimisation of primary percutaneous coronary intervention (PPCI) hospitals, phase 2 (CSCAP-2) focuses on the PPCI hospital-based regional STEMI care network construction together with emergency medical services and adjacent non-PPCI hospitals, while phase 3 (CSCAP-3) focuses on the whole-city STEMI care network construction by promoting chest pain centre accreditation. Systematic data collection, key performance index assessment and subsequent improvement are implemented throughout the project to continuously improve the quality of STEMI care.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Ethics Committee of Peking University First Hospital. Ranking reports of quality of care will be generated available to all participant affiliations. Results will be disseminated via peer-reviewed scientific journals and presentations at congresses.

TRIAL REGISTRATION NUMBER

NCT03821012.

YINGLONG: A Multicenter, Prospective, Non-Interventional Study Evaluating the Safety and Tolerability of Ticagrelor in Chinese Patients with Acute Coronary Syndrome

INTRODUCTION

Ticagrelor is an oral, reversible, direct-acting P2Y12 receptor inhibitor approved for the prevention of cardiovascular events in acute coronary syndrome (ACS). In China, drug intensive monitoring regulations for new drugs require additional safety data post-approval.

METHODS

YINGLONG, a single-arm, phase-IV, 1-year, non-interventional study, described the safety of ticagrelor 90 mg twice daily in Chinese patients (≥ 18 years) with ACS treated with ≥ 1 dose of ticagrelor. Primary outcomes were the incidence of adverse events (AEs), in particular, PLATelet inhibition and patient Outcomes (PLATO)-defined bleeding AEs, and other serious AEs during the 1-year follow-up. Key secondary outcomes were the incidence of major cardiovascular events.

RESULTS

Patients (n = 1041, median age 61.0 years) had started ticagrelor and had post-dose data. Median duration of ticagrelor treatment was 357 days; 577 patients (55.4%) completed 1-year ticagrelor treatment; 973 patients (93.5%) completed 1-year follow-up. Overall, 38.7% of patients reported an AE during treatment. The most common AEs were dyspnea (n = 37, 3.6%), petechiae (n = 30, 2.9%), and chest discomfort (n = 28, 2.7%). Serious AEs, excluding bleeding, were reported in 9.8% of patients during treatment. Incidence of PLATO-defined major bleeding events was 1.1% (n = 11). Of the 21 deaths that occurred during the study (8 post-treatment), 1 was a fatal bleed. Major cardiovascular events were reported in 37 patients (3.6%).

CONCLUSIONS

Ticagrelor was well tolerated with a low rate of PLATO-defined major bleeding events in Chinese ACS patients. Safety results were consistent with the known ticagrelor profile.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02430493.

FUNDING

AstraZeneca Investment (China) Co., Ltd.

Performance on management strategies with Class I Recommendation and A Level of Evidence among hospitalized patients with non-ST-segment elevation acute coronary syndrome in China: Findings from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project

BACKGROUND

This study aimed to examine hospital performance on evidence-based management strategies for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and variations across hospitals.

METHODS

Improving Care for Cardiovascular Disease in China (CCC)-ACS project is an ongoing registry and quality improvement project, with 150 tertiary hospitals recruited across China. We examined hospital performance on nine management strategies (Class I Recommendations with A Level of Evidence) based on established guidelines. We also evaluated the proportion of patients receiving defect-free care, which was defined as the care that included all the required management strategies for which the patient was eligible. The hospital-level variations in the performance were examined.

RESULTS

From 2014 to 2018, 28,170 NSTE-ACS patients were included. Overall, 16% of patients received defect-free care. Higher-performing metrics were statin at discharge (93%), cardiac troponin measurement (92%), dual antiplatelet therapy (DAPT) within 24 hours (90%), and DAPT at discharge (85%). These were followed by metrics of β-blocker at discharge (69%), angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) at discharge (59%), and risk stratification (56%). Lower-performing metrics were smoking cessation counseling (35%) and percutaneous coronary intervention (PCI) within recommended times (33%). The proportion of patients receiving defect-free care substantially varied across hospitals, ranging from 0% to 58% (Median (interquartile range):12% (7%-21%)). There were large variations across hospitals in performance on risk stratification, smoking cessation counseling, PCI within recommended times, ACEI/ARB at discharge and β-blocker at discharge.

CONCLUSIONS

About one in six NSTE-ACS patients received defect-free care, and the performance varied across hospitals.

Applying WCACG modified process is beneficial on reduced door-to-balloon time of acute STEMI patients

Background: Various systems have employed with the objective to reduce the time from emergency medical services contact to balloon inflammation for ST-elevation myocardial infraction (STEMI) patients. The WCACG message system was used to an alternative communication platform to improve confirmation of the diagnosis and movement to treatment, resulted in shorten the door-to-balloon (D-to-B) time for STEMI patients.

Methods: We collected 366 STEMI patients admitted at the Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People’s Hospital, Department of Cardiology, during the period from June 2013 to October 2015. The patients were divided into two groups one underwent the current GC processes and the other group was handled using WCACG system. We compared between two groups with several indicators including D-to-B time, duration of hospitalization, associated costs, and incidence of adverse cardiovascular events.

Results: The results show that the new method with WCACG system significantly reduced the average D-to-B time (from 100.42 ± 25.14 mins to 79.81 ± 20.51 mins, P < 0.05) compared to the GC processes, and also reduced the duration, costs and undesirable cardiac incidence during hospitalization.

Conclusions: The modified WCACG process is an applicable system to save pieces of time and efficiently integrate the opinions of experts in emergency.

Sex differences in health outcomes at one year following acute myocardial infarction: A report from the China Patient-Centered Evaluative Assessment of Cardiac Events prospective acute myocardial infarction study

BACKGROUND

We examined sex differences in long-term health outcomes following acute myocardial infarction in China, including mortality, major adverse cardiac events and health status (symptoms, functioning, quality of life).

METHODS

A total of 3415 acute myocardial infarction patients (23.2% women) aged ⩾18 years were enrolled across 10 geographic regions in China (2012-2014) in the China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE) study. Clinical data was abstracted from medical records. Generic (Euro-Quality of Life Scale) and disease-specific (Seattle Angina Questionnaire) health status was obtained through interviews at baseline and one year.

RESULTS

At one year, women with acute myocardial infarction had a higher risk of death from all causes ( p<0.001), but had similar rates of major adverse cardiac events ( p=0.2). Women had lower mean generic (Euro-Quality of Life Scale utility index score: 0.90±0.13 vs 0.94±0.11) and disease specific health scores indicating poorer functioning (Seattle Angina Questionnaire summary score: 75.3±11.4 vs 78.4±9.7) and higher rates of daily/weekly angina (Seattle Angina Questionnaire angina frequency score ⩽60 vs >60: 9.1% vs 4.7%; all p<0.001). In multivariable analysis, there was a significant association between female sex and mortality (β=0.45, standard error=0.21, p=0.03) but not for major adverse cardiac events (β=-0.02, standard error=0.14, p=0.89). The association between female sex and worse generic health status persisted (β=-0.02, standard error=0.01, p=0.003), but was no longer significant between sexes for disease-specific health status (β=-0.82, standard error=0.58, p=0.154) or daily/weekly angina (odds ratio=1.39; 95% confidence interval 0.88-2.21).

CONCLUSION

Women in China have higher crude rates of all-cause/cardiovascular death versus men, as well as worse generic/disease specific health status at one-year post-acute myocardial infarction. The association between female sex and worse generic health status persisted following adjustment.

I-CARE randomized clinical trial integrating depression and acute coronary syndrome care in low-resource hospitals in China: Design and rationale

Depression and acute coronary syndromes (ACS) are both common public health challenges. Patients with ACS often develop depression, which in turn adversely affects prognosis. Low-cost, sustainable, and effective service models that integrate depression care into the management of ACS patients to reduce depression and improve ACS outcomes are critically needed. Integrating Depression Care in ACS patients in Low Resource Hospitals in China (I-CARE) is a multicenter, randomized controlled trial to evaluate the efficacy of an 11-month integrated care (IC) intervention compared to usual care (UC) in management of ACS patients. Four thousand inpatients will be recruited and then randomized in a 1:1 ratio to an IC intervention consisting of nurse-led risk factor management, group-based counseling supplemented by individual problem-solving therapy, and antidepressant medications as needed, or to UC. The primary outcomes are depression symptoms measured by the Patient Health Questionnaire-9 at 6 and 12 months. Secondary endpoints include anxiety measured by the Generalized Anxiety Disorder-7; quality of life measured by the EQ-5D at 6 and 12 months; and major adverse events including the combined end point of all-cause death, suicide attempts, nonfatal myocardial infarction, nonfatal stroke, and all-cause rehospitalization at yearly intervals for a median follow-up of 2 years. Analyses of the cost-effectiveness and cost-utility of IC also will be performed. I-CARE trial will be the largest study to test the effectiveness of an integrated care model on depression and cardiovascular outcomes among ACS patients in resource-limited clinical settings.

Fragmented QRS (fQRS) Complex Predicts Adverse Cardiac Events of ST-Segment Elevation Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention and Thrombolysis

BACKGROUND ST-segment elevation myocardial infarction (STEMI) is an acute and life-threatening disease. Adverse cardiac events (ACEs) are defined as cardiovascular death or worsening congestive heart failure in STEMI patients. The present study investigated the predictive role of fragmented QRS complex (fQRS) in risks of ACEs in STEMI. MATERIAL AND METHODS This study was a retrospective analysis involving patients who underwent percutaneous coronary intervention (PCI) or thrombolysis. STEMI patients were divided into the fQRS group (259 cases) and the non-fQRS group (161 cases). Basic information and clinical parameters were evaluated. ACEs, including hemodynamic instability, electrical instability (ventricular tachycardia event, ventricular fibrillation or atrioventricular heart-block) and death, were observed. The 12-lead ECG was used to obtain fQRS recordings. Thrombolytic recanalization was evaluated to confirm clinical outcomes of PCI and thrombolysis therapy. RESULTS Hemodynamic instability rates, electrical instability rates, and death in the fQRS group were significantly higher compared to the non-fQRS group (P=0.002, 0.000, and 0.010, respectively). PCI triggered significantly fewer ACEs compared to thrombolytic therapy in the fQRS group (P=0.000, 0.000, and 0.019, respectively). The fQRS group had higher thrombolysis failure rates and three-vessel lesion of coronary artery rates compared to the non-fQRS group (P=0.009 and 0.029, respectively). There were no differences between fQRS and non-fQRS groups in death rates of STEMI patients undergoing PCI and thrombolytic therapy. GRACE scores more than 140, EF less than 35%, and fQRS illustrated predictive potential for ACEs of STEMI patients. CONCLUSIONS fQRS is an independent predictor for the adverse cardiac events of STEMI patients undergoing PCI or thrombolysis.

Increased Cystatin C Level in ST-Elevation Myocardial Infarction Predisposes the Prognosis of Angioplasty

BACKGROUND

The study aimed to evaluate the prognostic value of cystatin C in ST-elevation acute myocardial infarction (STEMI) patients who underwent elective percutaneous coronary intervention (PCI).

METHODS

A retrospective study was conducted on 664 STEMI patients from 7 centers who were treated with elective PCI. These patients were divided into 3 groups according their admission cystatin C levels as < 0.84, 0.84-1.03 and ≥1.04mg/L. The all-cause mortalities and the composite endpoints, including mortality, reinfarction, rehospitalization for heart failure and angina or repeat target vessel revascularization were observed for up to 5 years.

RESULTS

As cystatin C levels from low to high, all-cause mortalities were progressively increased 0.9%, 3.7% and 9.5% (P < 0.001), as well as the composite endpoints, 11.1%, 21.7% and 40.7%, respectively (P < 0.001). When patients had the level of cystatin C ≥0.84mg/L, their risks of composite endpoints increased 2- to 3-fold of those with <0.84mg/L, with the adjusted hazard ratio of 2.096 (95% CI: 1.047-4.196, P = 0.037) and 3.608 (95% CI: 1.939-6.716, P < 0.001), respectively.

CONCLUSIONS

Increased cystatin C levels may be associated with enhanced risks of composite endpoints in patients with STEMI undergoing elective PCI.

Clinical characteristics and improvement of the guideline-based management of acute myocardial infarction in China: a national retrospective analysis

Objective

This study is to document the clinical characteristics and improvement in management of acute myocardial infarction (AMI) in Chinese population.

Results

This study included 64,654 patients (23,805 patients in 2011, 40,849 patients in 2013), of which STEMI and NSTEMI account for 85.09% and 14.91%, respectively. From 2011 to 2013, significant improvement has been achieved in the recanalization rate of PCI (96.01% vs. 98.63%, P < 0.001) and in-hospital deaths (4.52% vs. 3.55%, P = 0.038). Although the time of door-to-balloon and the duration of PCI were satisfactorily controlled within 90min and 60min, respectively, the onset-to-FMC time (≈3.5h) and door-to-thrombolysis time (≈1.1h) limited the efficiency of management. The total cost of medical care showed no increase from 2011 to 2013, but the patient's paid Portion decreased from 20.33% to 13.96%.

Materials and Methods

The AMI patients admitted in the general hospitals in 2011 and 2013 were retrospectively analyzed according to the data reported to the Single Disease Quality Control Information Systemissued by Chinese Hospital Association.

Conclusion

Compared to the Western countries, STEMI accounted for a larger portion of AMI, and the AMI management in China basically meets the standards of the quality control of guidelines. With improvement of management, there was no increase in the total medical cost, while the patient's paid portion was actually reduced. In future, improvement of transportation strategy and the public medical education are recommended to shorten the onset-to-FMC time to further improve the outcome of AMI patients.

Usefulness of plasma matrix metalloproteinase-9 levels in prediction of in-hospital mortality in patients who received emergent percutaneous coronary artery intervention following myocardial infarction

The aim of the present study was to investigate the predictive value of the plasma matrix metalloproteinase-9 (MMP-9) level at admission for in-hospital mortality in patients who received emergency percutaneous coronary intervention (PCI) following AMI. A single blood sample was collected at admission from 155 consecutive AMI patients who underwent emergent PCI. The plasma levels of MMP-9 value (528.9±191.6 ng/ml) were significantly higher in the patients who died (n=24) than in the survivors (385.4±236.0 ng/ml) during 14 days of hospitalization (P=0.005). The age, left ventricle wall motion score index (WMIS), Global Registry of Acute Coronary Events (GRACE) score and B-type natriuretic peptide (BNP) levels and GENSINI score at admission were significantly different between the patients who died and those who survived (P<0.001, P=0.004, P<0.001 and P<0.001, respectively). Cut-off concentrations for prediction of death was identified from receiver operator characteristic (ROC) curves. Using the cut-off value (MMP-9 level 398.2 ng/ml) to stratify the patients into two groups, the group with higher MMP-9 levels had a greater rate of in-hospital mortality than the lower level group (P<0.001). With the exception of the GRACE score, among all biomarkers measured, in stepwise multiple logistic regressions, only the MMP-9 level predicted the risk of in-hospital death after adjustment for all other risk factors (odds ratio 5.02, 95% CI 1.44 to 17.55). In conclusion, a higher MMP-9 level is an independent predictor of in-hospital death in AMI patients who received emergency PCI.

The dose-response association between estimated glomerular filtration rate and prognosis of patients with ST-segment elevation myocardial infarction from rural areas of China's Liaoning province

We aimed to investigate the dose-response associations between chronic kidney disease (CKD), and short and long-term cardiovascular outcomes, to characterize these associations by drawing dose-response curves based on a Chinese rural ST-segment elevation myocardial infarction (STEMI) population.In all, 1067 patients with STEMI were consecutively enrolled from 12 secondary hospitals of China's Liaoning province (from June 2009 to June 2010 and January 2015 to December 2015). The follow-up was regularly performed by telephone. Patients were grouped by estimated glomerular filter rate (eGFR): normal, eGFR ≥90 mL/min/1.73 m; mild CKD, 60 to 90 mL/min/1.73 m; CKD, <60 mL/min/1.73 m. Adjusted logistic or Cox regression models were employed to compare short and long-term cardiovascular outcomes across different eGFR groups. Dose-response curves were plotted using restricted cubic spline functions.About 18.46% of the STEMI patients had CKD. Patients with CKD were more likely to suffer from other comorbidities, but less likely to receive evidence-based therapies. CKD was independently associated with in-hospital mortality and major adverse cardiac events (MACE) as compared with patients with normal renal function (for in-hospital mortality, adjusted odds ratio [OR] 2.39, 95% confidence interval [CI] 1.18-4.85, P = .02; for in-hospital MACE, adjusted OR 2.01, 95% CI 1.09-3.70, P < .01). Likewise, CKD was significantly associated with long-term mortality as well (CKD vs normal, adjusted hazard ratio 2.55, 95% CI 1.17-5.57, P = .02). The dose-response associations between eGFR, and short and long-term cardiovascular outcomes were found to be linear (all with P values for nonlinear associations >.05).CKD is an independent predictor of worse in-hospital and long-term clinical outcomes. The assessment of eGFR is essential to enable risk stratification, tailored therapy, and early and aggressive management.

Predicting In-Hospital Mortality in Patients With Acute Coronary Syndrome in China

Currently available risk scores (RSs) were derived from populations with very few participants from China. We aimed to develop an RS based on data from patients with acute coronary syndrome in China and to compare its performance with the commonly promoted Global Registry of Acute Coronary Events (GRACE) RS. Clinical Pathways for Acute Coronary Syndromes-Phase 2 was a trial of a quality improvement intervention in China. Patients recruited from 75 hospitals from October 2007 to August 2010 were divided into training and validation sets based on immediate or delayed implementation. A Clinical Pathways for Acute Coronary Syndromes (CPACS) RS for in-hospital mortality was developed separately by gender, using the training set (6,790 patients). Discrimination and calibration of the CPACS RS and GRACE RS were compared on the validation set (3,801 patients). Although discrimination of the GRACE RS was acceptable, this was improved with the CPACS RS (c-statistic 0.82 vs 0.87, p = 0.012 for men; c-statistic 0.78 vs 0.85, p = 0.006 for women). The absolute bias was significantly lower with CPACS RS for both genders (7.6% vs 97.5% in men and 21.5% vs 77.2% in women), compared with the GRACE RS, which systematically overestimated risk. The CPACS RS underestimated risk in women, but only in those already above threshold levels currently used to define a clinical high-risk population. In conclusion, the GRACE RS substantially overestimates the risk of in-hospital death in patients presenting to the hospital with a suspected acute coronary syndrome in China. We have developed and independently validated a new RS utilizing data from Chinese patients.

Six-month adherence to Statin use and subsequent risk of major adverse cardiovascular events (MACE) in patients discharged with acute coronary syndromes

BACKGROUND

The evidence of adherence to statin decreasing risk of major adverse cardiovascular events (MACEs) is still lack among patients discharged with acute coronary syndrome (ACS). Our objective is to determine the relationship between six-month adherence to statins and subsequent risk of MACEs in patients discharged with ACS.

METHODS

Using two prospective registry cohorts (CPACS-1 and -2), we analyzed data from 12,516 consecutive patients with ACS who were prescribed statin at hospital discharge and survived beyond 6 months without recurrent myocardial infarction (MI) or stroke. Adherence to statin was defined as good (using statin at discharge and 6 months without declined dosage) and poor adherence groups (using statin at discharge but declining dosage or stopping at 6 months). We compared the hazard ratios of all-cause mortality and MACE in subsequent 6 months between groups, using Cox-regression models, adjusting for multiple potential confounders.

RESULTS

Seventy two percent of patients adhered to statin therapy at 6 months. The incident MACE in the poor adherence group was significantly higher than in good adherence group (2.7% vs. 1.8%, p = 0.002). Compared with poor adherence group, the good adherence group showed a 27% lower relative risk of MACE during the 6 month follow up (fully-adjusted hazard ratio (HR) = 0.73; 95%CI: 0.56-0.97). The protective effects of good adherence were similar in groups with different statin dose as well as groups by other baseline clinical characteristics and treatments (p > 0.05 for interaction).

CONCLUSION

Our study highlights the importance of adherence to statin therapy in prevention of MACE and clinicians should aim to achieve higher dosage if tolerable.

CLINICAL TRIAL REGISTRATION

CPACS2 was registered on URL: http://www.anzctr.org.au/default.aspx and unique identifier is ACTRN12609000491268 . CPACS1 was not a clinical trial and thus not registered.

Are non-ST-segment elevation myocardial infarctions missing in China?

Aims

ST-segment elevation myocardial infarctions (STEMI) in China and other low- and middle-income countries outnumber non-ST-segment elevation myocardial infarctions (NSTEMI). We hypothesized that the STEMI predominance was associated with lower biomarker use and would vary with hospital characteristics.

Methods and results

We hypothesized that the STEMI predominance was associated with lower biomarker use and would vary with hospital characteristics. Using data from the nationally representative China PEACE-Retrospective AMI Study during 2001, 2006, and 2011, we compared hospital NSTEMI proportion across categories of use of any cardiac biomarker (CK, CK-MB, or troponin) and troponin, as well as across region, location, level, and teaching status. Among 15 416 acute myocardial infarction (AMI) patients, 14% had NSTEMI. NSTEMI patients were older, more likely female, and to have comorbidities. Median hospital NSTEMI proportion in each study year was similar across categories of any cardiac biomarker use, troponin, region, location, level, and teaching status. For instance, in 2011 the NSTEMI proportion at hospitals without troponin testing was 11.2% [inter quartile range (IQR) 4.4–16.7%], similar to those with ≥ 75% troponin use (13.0% [IQR 8.7–23.7%]) (P-value for difference 0.77). Analysed as continuous variables there was no relationship between hospital NSTEMI proportion and proportion biomarker use. With troponin use there was no relationship in 2001 and 2006, but a modest correlation in 2011 (R = 0.16, P = 0.043). Admissions for NSTEMI increased from 0.3/100 000 people in 2001 to 3.3/100 000 people in 2011 (P-value for trend < 0.001).

Conclusion

STEMI is the dominant presentation of AMI in China, but the proportion of NSTEMI is increasing. Biomarker use and hospital characteristics did not account for the low NSTEMI rate.

Clinical trial registration

www.clinicaltrials.gov (NCT01624883).

Current Trends for ST-segment Elevation Myocardial Infarction during the Past 5 Years in Rural Areas of China's Liaoning Province: A Multicenter Study

Background:

Since 2010, two versions of National Guidelines aimed at promoting the management of ST-segment elevation myocardial infarction (STEMI) have been formulated by the Chinese Society of Cardiology. However, little is known about the changes in clinical characteristics, management, and in-hospital outcomes in rural areas.

Methods:

In the present multicenter, cross-sectional study, participants were enrolled from rural hospitals located in Liaoning province in Northeast China, during two different periods (from June 2009 to June 2010 and from January 2015 to December 2015). Data collection was conducted using a standardized questionnaire. In total, 607 and 637 STEMI patients were recruited in the 2010 and 2015 cohorts, respectively.

Results:

STEMI patients in rural hospitals were older in the second group (63 years vs. 65 years, P = 0.039). We found increases in the prevalence of hypertension, prior percutaneous coronary intervention (PCI), and prior stroke. Over the past 5 years, the cost during hospitalization almost doubled. The proportion of STEMI patients who underwent emergency reperfusion had significantly increased from 42.34% to 54.47% (P < 0.0001). Concurrently, the proportion of primary PCI increased from 3.62% to 10.52% (P < 0.0001). The past 5 years have also seen marked increases in the use of guideline-recommended drugs and clinical examinations. However, in-hospital mortality and major adverse cardiac events did not significantly change over time (13.01% vs. 10.20%, P = 0.121; 13.34% vs. 13.66%, P = 0.872).

Conclusions:

Despite the great progress that has been made in guideline-recommended therapies, in-hospital outcomes among rural STEMI patients have not significantly improved. Therefore, there is still substantial room for improvement in the quality of care.

Treatment and outcomes of acute coronary syndromes in women: An analysis of a multicenter quality improvement Chinese study

BACKGROUND

Variations in care and outcomes by sex in patients with acute coronary syndrome (ACS) have been reported worldwide. The aims of this study are to describe ACS management according to sex in China and the effects of a quality improvement program in Chinese male and female ACS patients.

METHODS AND RESULTS

Clinical Pathways for Acute Coronary Syndromes - Phase 2 (CPACS-2) was a cluster randomized trial to test whether a clinical pathways-based intervention would improve ACS management in China. The study enrolled 15,141 hospitalized patients [4631 (30.6%) were women] from 75 hospitals throughout China between October 2007 and August 2010. The intervention included clinical pathway implementation and performance measurement using standardized indicators with 6 monthly audit-feedback cycles. Eight key performance indicators reflecting in hospital management of ACS were measured. After adjustment for differences in patient characteristics and comorbidities at presentation, women were significantly less likely to undergo coronary angiography when indicated (RR 0.88 [0.85 to 0.92], P<0.001), less likely to receive guideline recommended medical therapies at discharge (RR 0.94 [0.91 to 0.98], P=0.003) and more likely to be hospitalized for shorter (mean difference -0.42 [-0.73 to -0.12] days, P=0.007). However, in-hospital clinical outcomes did not differ by sex. There was no evidence of heterogeneity in the relative effects of the quality improvement initiative by sex.

CONCLUSIONS

Sex disparities were apparent in some key quality of care indicators for patients with suspected with ACS presenting to hospitals in China. The beneficial effect of the quality improvement program was consistent in women and men.

CLINICAL TRIAL REGISTRATION

http://www.anzctr.org.au/default.aspx. Unique identifier: ACTRN12609000491268.

Effect of high-dose rosuvastatin loading before percutaneous coronary intervention in Chinese patients with acute coronary syndrome: A systematic review and meta-analysis

Background

Acute coronary syndrome (ACS) is an important disease threatening human life and health. Many studies have shown that the loading dose of atorvastatin can significantly improve the prognosis of patients with ACS, and reduce the mortality. However, this conclusion is not consistent. Thus, we aimed to evaluate the effect of high-dose rosuvastatin loading before percutaneous coronary intervention (PCI) in Chinese patients with ACS using a meta-analysis based on a systematic review of published articles.

Methods

We systematically reviewed published studies, evaluating the effect of high-dose rosuvastatin loading before percutaneous coronary intervention in Chinese patients with ACS. The retrieval time is limited from inception to 2 November 2016, and the retrieved databases included PubMed, Embase, the Cochrane Library, Web of Science, CBM, CNKI, the VIP database and the Wang Fang database. Two researchers independently assessed the quality of the included studies and then extracted the data. Stata 11.0 was used for data analysis.

Results

In total, 11 articles, which included 802 patients, were included in our meta-analysis. Among these patients, 398 patients were in the high-dose group (20 mg/day) and 404 patients were in the conventional dose group (10 mg/day). Meta-analysis results showed that compared with the conventional dose group: 1) The loading dose of rosuvastatin can significantly reduce the hs-CRP level after PCI, including at 24 hours (SMD = -0.65, 95%CI -0.84 ~ -0.47, P = 0.000), 48 hours (SMD = -0.40, 95%CI -0.68 ~ -0.11, P = 0.006), and four weeks (SMD = -1.64, 95%CI -2.01 ~ -1.26, P = 0.000). 2) The loading dose of rosuvastatin can significantly reduce the levels of LDL-C and cTnT, including the level of LDL-C at 30 d after PCI (SMD = -0.89, 95%CI -1.10 ~ -0.69, P = 0.000), and the level of cTnT at 24 h after PCI (SMD = -1.93, 95%CI -2.28 ~ -1.59, P = 0.000), and increase the level of HDL-C at 48 h after PCI (SMD = 0.61, 95%CI 0.34 ~ 0.88, P = 0.000). 3) The loading dose of rosuvastatin can significantly reduce the levels of TG and TC, including the level of TG at 30 d after PCI (SMD = -0.94, 95%CI -1.17 ~ -0.71, P = 0.000), the level of TC at 48 h after PCI (SMD = -0.35, 95%CI -0.68 ~ -0.01, P = 0.043), and the level of TC at 30 d after PCI (SMD = -0.77, 95%CI -0.98 ~ -0.56, P = 0.000).

Conclusions

Our systematic review and meta-analysis showed that, compared with the conventional dose, the loading dose of rosuvastatin was more beneficial to patients with ACS in China and is suitable for clinical application. Due to the limitations of the quality and quantity of included articles, this conclusion still needs to be confirmed by multicenter clinical trials.

China Patient-centered Evaluative Assessment of Cardiac Events Prospective Study of Acute Myocardial Infarction: Study Design

Background:

Despite the rapid growth in the incidence of acute myocardial infarction (AMI) in China, there is limited information about patients’ experiences after AMI hospitalization, especially on long-term adverse events and patient-reported outcomes (PROs).

Methods:

The China Patient-centered Evaluative Assessment of Cardiac Events (PEACE)-Prospective AMI Study will enroll 4000 consecutive AMI patients from 53 diverse hospitals across China and follow them longitudinally for 12 months to document their treatment, recovery, and outcomes. Details of patients’ medical history, treatment, and in-hospital outcomes are abstracted from medical charts. Comprehensive baseline interviews are being conducted to characterize patient demographics, risk factors, presentation, and healthcare utilization. As part of these interviews, validated instruments are administered to measure PROs, including quality of life, symptoms, mood, cognition, and sexual activity. Follow-up interviews, measuring PROs, medication adherence, risk factor control, and collecting hospitalization events are conducted at 1, 6, and 12 months after discharge. Supporting documents for potential outcomes are collected for adjudication by clinicians at the National Coordinating Center. Blood and urine samples are also obtained at baseline, 1- and 12-month follow-up. In addition, we are conducting a survey of participating hospitals to characterize their organizational characteristics.

Conclusion:

The China PEACE-Prospective AMI study will be uniquely positioned to generate new information regarding patient's experiences and outcomes after AMI in China and serve as a foundation for quality improvement activities.

Atrial fibrillation in patients hospitalized with acute myocardial infarction: analysis of the china acute myocardial infarction (CAMI) registry

Background

The incidence, clinical outcomes and antithrombotic treatment spectrum of atrial fibrillation (AF) in patients hospitalized with acute myocardial infarction (AMI) have not been well studied in Chinese population.

Methods

Twenty-six thousand five hundred ninety-two consecutive patients diagnosed with AMI were enrolled in CAMI registry from January 2013 to September 2014. After excluding 343 patients with uncertain AF status and 1,591 patients transferred out during hospitalization, 24,658 patients were finally included in this study and involved in analysis.

Results

In the CAMI registry, 740 (3.0%) patients were recorded with AF prevalence during hospitalization. Higher-risk baseline clinical profile was observed in patients with AF. These patients were less likely to receive reperfusion/revascularization than those without AF. The in-hospital mortality (including death and treatment withdrawal) was significantly higher in patients with AF than that of without AF (25.2% vs. 7.2%, respectively; p < 0.01). The case of composite of adverse events was similar, which included death, treatment withdrawal, re-infarction, heart failure or stroke (42.1% vs. 16.0%, p <0.01). In multivariate logistic regression analysis, AF was an independent predictor for in-hospital mortality (odds ratio, 1.88; 95% confidence interval: 1.27–2.78) and the composite of adverse events (odds ratio, 2.11; 95% CI: 1.63–2.72). Only 5.1% of patients with AF were treated with warfarin, and 1.7% were treated with both warfarin and dual antiplatelet therapy.

Conclusions

The analysis was based on the CAMI registry in China. The patients hospitalized for AMI who developed AF were at significantly higher risk for in-hospital mortality and other adverse events. However, the anticoagulants including warfarin have been largely underused post hospital discharge.

Trial registration

Clinical Trial Registration: Identifier: NCT01874691.

Examining the Impact of Rehospitalization on Healthcare Cost of Myocardial Infarction Patients in Beijing: A Retrospective Observational Study

INTRODUCTION

To examine the impact of rehospitalization on the healthcare expenditure of myocardial infarction (MI) patients in Beijing.

METHODS

Retrospective data of MI patients were retrieved from the Beijing Medical Insurance Database, an administrative database of social medical reimbursement activities for the urban population in Beijing, China. Ten percent of patients diagnosed with MI from January 1 to December 31, 2012 were randomly selected and their first hospitalization was considered as the index event. Their hospital utilization after the index event was extracted till September 30, 2013. Rehospitalization was defined as an event of hospital admission due to the same diagnosis and with a time interval of at least 14 days from the most recent admission. The healthcare cost of patients was analyzed, including inpatient cost and outpatient cost. Patients' demographic characteristics, co-morbidities, and length of hospital stay were also collected from the database.

RESULTS

Of the 1235 MI patients identified, 335 (mean age of 66.14 ± 15.04 years; 84.18% males) had rehospitalization. The rate of MI recurrence was 27.13%. The annual healthcare expense was significantly higher for MI patients with rehospitalization compared to MI patients without rehospitalization (99,920.43 ± 84,113.52 CNY vs. 58,877.89 ± 93,942.90 CNY; P < 0.001). The significant positive predictors of incurring healthcare expenditure were male gender, age 45 years old or more, length of stay at first hospital admission, whether having rehospitalization (yes/no), co-morbidity (heart failure and diabetes), and admission to a tertiary hospital at first hospital admission.

CONCLUSION

There was a high risk of MI recurrence for patients in Beijing. The annual healthcare cost of MI patients with rehospitalization was significantly higher than MI patients without rehospitalization. Male patients of 45 years old or more with heart failure and diabetes are likely to incur higher healthcare expenditure.

Management of ST-segment elevation myocardial infarction in predominantly rural central China: A retrospective observational study

The degree of adherence to current guidelines for clinical management of ST-segment elevation myocardial infarction (STEMI) is known in developed countries and large Chinese cities, but in predominantly rural areas information is lacking. We assessed the application of early reperfusion therapy for STEMI in secondary and tertiary hospitals in Henan province in central China.Data were retrospectively collected from 5 secondary and 4 tertiary hospitals in Henan concerning STEMI patients treated from January 2011 to January 2012, including management strategy, delay time, and inhospital mortality.Among 1311 STEMI patients, 613 and 698 were treated at secondary and tertiary hospitals, respectively. Overall, 460 (35.1%) patients received early reperfusion therapy including thrombolysis in 383 patients and primary percutaneous coronary intervention in 77. Compared with secondary centers, early (37.2% vs 32.6%) and successful reperfusion (34.5% vs 25.1%) was significantly higher, whereas thrombolysis was lower in the tertiary hospitals (26.4% vs 32.5%). Median symptom onset-to-first medical contact, and door-to-needle and door-to-balloon time was 168, 18, and 60 minutes, respectively. Delay times closely approached recommended guidelines, especially in secondary centers. Use of recommended pharmacotherapy was low, particularly in secondary hospitals. Inhospital mortality was 5.8%, and similar between secondary and tertiary hospitals (6.0% vs 5.6%; P = 0.183).Two-thirds of STEMI patients did not receive early reperfusion, and tertiary hospitals mostly failed to take advantage of around-the-clock primary percutaneous coronary intervention. Actions such as referrals are warranted to shorten prehospital delay, and the concerns of patients and doctors regarding reperfusion risk should be addressed.

Prevention and Control of Cardiovascular Disease in the Rapidly Changing Economy of China

With one-fifth of the world's total population, China's prevention and control of cardiovascular disease (CVD) may affect the success of worldwide efforts to achieve sustainable CVD reduction. Understanding China's current cardiovascular epidemic requires awareness of the economic development in the past decades. The rapid economic transformations (industrialization, marketization, urbanization, globalization, and informationalization) contributed to the aging demography, unhealthy lifestyles, and environmental changes. The latter have predisposed to increasing cardiovascular risk factors and the CVD pandemic. Rising CVD rates have had a major economic impact, which has challenged the healthcare system and the whole society. With recognition of the importance of health, initial political steps and national actions have been taken to address the CVD epidemic. Looking to the future, we recommend that 4 priorities should be taken: pursue multisectorial government and nongovernment strategies targeting the underlying causes of CVD (the whole-of-government and whole-of-society policy); give priority to prevention; reform the healthcare system to fit the nature of noncommunicable diseases; and conduct research for evidence-based, low-cost, simple, sustainable, and scalable interventions. By pursuing the 4 priorities, the pandemic of CVD and other major noncommunicable diseases in China will be reversed and the global sustainable development goal achieved.

Testing a Model to Reveal the Predictive Mechanism of Care-Seeking Decisions Among Patients With Acute Myocardial Infarction

BACKGROUND

Extensive research has been conducted to examine the factors affecting care-seeking decisions in patients with acute myocardial infarction (AMI). Such a decision-making process is multifactorial, and its underlying mechanism is yet to be determined.

OBJECTIVES

Our aim was to test a theoretically integrated model to identify the mechanisms underlying patients' care-seeking decisions in the context of AMI.

METHODS

On the basis of both empirical and theoretical evidence, we proposed that patients' care-seeking decisions are driven by 2 sequential perceptual-cognitive processes concerned with illness labeling and interpretation, as well as the contextual influences of perceived barriers to care seeking and cues from others. A sample of 301 patients was recruited to test this model using structural equation modeling.

RESULTS

The model testing revealed good fit with the data (χ = 38.48, df = 30, P = .72; root-mean-square error of approximation = 0.03, normed fit index = 0.96, nonnormed fit index = 0.98, and comparative fit index = 0.99) and explained 46% of the variance in AMI care-seeking delay. Successful action relied on whether patients could correctly attribute the symptom experience to AMI, were aware of their own susceptibility to the condition, and had a good understanding of how the disease manifested itself. Lowering perceived barriers and positive cues from others in advising care seeking played favorable roles to promote care-seeking behaviors.

CONCLUSIONS

This integrative theoretical model is shown to be valid in explaining care-seeking delay among AMI patients and can guide the development of interventions to promote appropriate care-seeking behaviors among high-risk individuals.

The China Acute Myocardial Infarction (CAMI) Registry: A national long-term registry-research-education integrated platform for exploring acute myocardial infarction in China

BACKGROUND

Acute myocardial infarction (AMI) has become a major cause of hospitalization and mortality in China. There has been limited data to date available to characterize AMI presentation, contemporary patterns of medical care, and outcomes in China.

AIMS

The CAMI Registry is a national project with the objectives to timely obtain real-world knowledge about AMI patients and to provide the platform for clinical research, guide preventive measures and care quality improvement efforts in China.

METHODS AND PROGRESS

The CAMI registry is a prospective, nationwide, multicenter observational study for AMI patients. The registry includes three levels of hospitals (representing typical Chinese governmental and administrative models) from all provinces and municipalities throughout Mainland China except Hong Kong and Macau. Sites were instructed to enroll consecutive patients with a primary diagnosis of AMI. Clinical data, treatments, outcomes and cost are collected by local investigators and captured electronically, with a standardized set of variables and standard definitions, and rigorous data quality control. Post-discharge patient follow-up to 2 years is planned. The CAMI Registry was launched in January 2013. A total of 108 hospitals have participated in the registry so far. As of September 2014, 26,103 patients with AMI were registered.

CONCLUSIONS

The CAMI registry represents a well-supported and the largest national long-term registry-research-education platform for surveillance, research, prevention and care improvement for AMI in China, the world's most populous nation. The broad representation of all provinces and different-level hospitals will allow for the exploration of AMI across diverse geographic regions and economic circumstances.

The china patient-centered evaluative assessment of cardiac events (PEACE) prospective study of percutaneous coronary intervention: Study design

BACKGROUND

The number of percutaneous coronary interventions (PCI) in China has increased more than 20-fold over the last decade. Consequently, there is a need for national-level information to characterize PCI indications and long-term patient outcomes, including health status, to understand and improve evolving practice patterns.

OBJECTIVES

This nationwide prospective study of patients receiving PCI is to: (1) measure long-term clinical outcomes (including death, acute myocardial infarction [AMI], and/or revascularization), patient-reported outcomes (PROs), cardiovascular risk factor control and adherence to medications for secondary prevention; (2) determine patient- and hospital-level factors associated with care process and outcomes; and (3) assess the appropriateness of PCI procedures.

METHODS

The China Patient-centered Evaluative Assessment of Cardiac Events (PEACE) Prospective Study of PCI has enrolled 5,000 consecutive patients during 2012-2014 from 34 diverse hospitals across China undergoing PCI for any indication. We abstracted details of patient's medical history, treatments, and in-hospital outcomes from medical charts, and conducted baseline, 1-, 6-, and 12-month interviews to characterize patient demographics, risk factors, clinical presentation, healthcare utilization, and health status using validated PRO measures. The primary outcome, a composite measure of death, AMI and/or revascularization, as well as PROs, medication adherence and cardiovascular risk factor control, was assessed throughout the 12-month follow-up. Blood and urine samples were collected at baseline and 12 months and stored for future analyses. To validate reports of coronary anatomy, 2,000 angiograms are randomly selected and read by two independent core laboratories. Hospital characteristics regarding their facilities, processes and organizational characteristics are assessed by site surveys.

CONCLUSION

China PEACE Prospective Study of PCI will be the first study to generate novel, high-quality, comprehensive national data on patients' socio-demographic, clinical, treatment, and metabolic/genetic factors, and importantly, their long-term outcomes following PCI, including health status. This will build the foundation for PCI performance improvement efforts in China. © 2016 The Authors. Catheterization and Cardiovascular Interventions. Published by Wiley Periodicals, Inc.

Recent Trends in Hospitalization for Acute Myocardial Infarction in Beijing: Increasing Overall Burden and a Transition From ST-Segment Elevation to Non-ST-Segment Elevation Myocardial Infarction in a Population-Based Study

Comparable data on trends of hospitalization rates for ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) remain unavailable in representative Asian populations.To examine the temporal trends of hospitalization for acute myocardial infarction (AMI) and its subtypes in Beijing.Patients hospitalized for AMI in Beijing from January 1, 2007 to December 31, 2012 were identified from the validated Hospital Discharge Information System. Trends in hospitalization rates, in-hospital mortality, length of stay (LOS), and hospitalization costs were analyzed by regression models for total AMI and for STEMI and NSTEMI separately. In total, 77,943 patients were admitted for AMI in Beijing during the 6 years, among whom 67.5% were males and 62.4% had STEMI. During the period, the rate of AMI hospitalization per 100,000 population increased by 31.2% (from 55.8 to 73.3 per 100,000 population) after age standardization, with a slight decrease in STEMI but a 3-fold increase in NSTEMI. The ratio of STEMI to NSTEMI decreased dramatically from 6.5:1.0 to 1.3:1.0. The age-standardized in-hospital mortality decreased from 11.2% to 8.6%, with a significant decreasing trend evident for STEMI in males and females (P < 0.001) and for NSTEMI in males (P = 0.02). The rate of percutaneous coronary intervention increased from 28.7% to 55.6% among STEMI patients. The total cost for AMI hospitalization increased by 56.8% after adjusting for inflation, although the LOS decreased by 1 day.The hospitalization burden for AMI has been increasing in Beijing with a transition from STEMI to NSTEMI. Diverse temporal trends in AMI subtypes from the unselected "real-world" data in Beijing may help to guide the management of AMI in China and other developing countries.

Fibrinolytic therapy in hospitals without percutaneous coronary intervention capabilities in China from 2001 to 2011: China PEACE-retrospective AMI study

BACKGROUND

Fibrinolytic therapy is the primary reperfusion strategy for ST-segment elevation myocardial infarction in China, and yet little is known about the quality of care regarding its use and whether it has changed over time. This issue is particularly important in hospitals without the capacity for cardiovascular intervention.

METHODS

Using a sequential cross-sectional study with two-stage random sampling in 2001, 2006, and 2011, we characterised the use, timing, type and dose of fibrinolytic therapy in a nationally representative sample of patients with ST-segment elevation myocardial infarction admitted to hospitals without the ability to perform percutaneous coronary intervention.

RESULTS

We identified 5306 patients; 2812 (53.0%) were admitted within 12 hours of symptom onset, of whom 2463 (87.6%) were ideal candidates for fibrinolytic therapy. The weighted proportion of ideal candidates receiving fibrinolytic therapy was 45.8% in 2001, 50.0% in 2006, and 53.0% in 2011 ( P_trend=0.0042). There were no regional differences in fibrinolytic therapy use. Almost all ideal patients (95.1%) were treated after admission to the hospital rather than in the emergency department. Median admission to needle time was 35 minutes (interquartile range 10-82) in 2011, which did not improve from 2006. Underdosing was common. Urokinase, with little evidence of efficacy, was used in 90.2% of patients.

CONCLUSIONS

Over the past decade in China, the potential benefits of fibrinolytic therapy were compromised by underuse, patient and hospital delays, underdosing and the predominant use of urokinase, an agent for which there is little clinical evidence. There are ample opportunities for improvement.

Characteristics of chest pain and its acute management in a low-middle income country: analysis of emergency department surveillance data from Pakistan

BACKGROUND

Chest pain is one of the most frequent causes of emergency department (ED) visits in high-income countries. Little is known about chest pain patients presenting to EDs of low- and middle-income countries (LMICs). The objective of this study was to describe the characteristics of chest pain patients presenting to emergency departments (EDs) of Pakistan and to determine the utilization of ED resources in the management of chest pain patients and their outcomes.

METHODS

This study used pilot active surveillance data from seven major EDs in Pakistan. Data were collected on all patients presenting to the EDs of the participating sites to seek emergency care for chest pain.

RESULTS

A total of 20,435 patients were admitted to the EDs with chest pain. The majority were males (M 60%, F 40%) and the mean age was 42 years (SD+/- 14). The great majority (97%, n = 19,164) of patients were admitted to the EDs of public hospitals compared to private hospitals and only 3% arrived by ambulance. Electrocardiograms (ECGs) were used in more than half of all chest pain patients (55%, n = 10,890) while cardiac enzymes were performed in less than 5% of cases. Chest X-rays were the most frequently performed radiological procedure (21%, n = 4,135); more than half of the admitted chest pain patients were discharged from the EDs and less than 1% died in the ED.

CONCLUSION

Chest pain is a common presenting complaint in EDs in Pakistan. The majority received an ECG and the use of diagnostic testing, such as cardiac enzymes, is quite uncommon.