Acute Coronary Syndrome In China Research Articles

The mediating effects of resilience in the relationship between social support and posttraumatic growth in patients with acute coronary syndrome in China.

Posttraumatic growth has a positive impact on patients diagnosed with acute coronary syndrome (ACS). Patients with acute coronary syndrome in China report low to moderate levels of posttraumatic growth. Additionally, there is a dearth of research exploring the associations between resilience, social support, and posttraumatic growth in this specific patient population. This study examined whether resilience serves as a mediator between social support and posttraumatic growth in patients with acute coronary syndrome who had been discharged for 1 to 6 months and were being followed up in clinics. A descriptive correlational study design was utilized. A systematic sampling technique was used to recruit 121 patients with acute coronary syndrome who had been discharged for 1 to 6 months from cardiovascular clinics of a tertiary care hospital in Jiangsu Province, China. The research instruments included the demographic characteristics questionnaire, the Connor-Davidson Resilience Scale, the Multidimensional Scale of Perceived Social Support, and the Posttraumatic Growth Inventory. The data were collected between August 2022 and November 2022 and were analyzed using descriptive statistics and regression analyses to determine the mediating effects. The level of posttraumatic growth among patients with acute coronary syndrome attending follow-up clinic visits was moderate (Mean = 60.58, SD = 14.13). Resilience had a direct and positive impact on posttraumatic growth (β = 0.361, p <0.001). Moreover, resilience fully mediated the relationship between social support and posttraumatic growth (indirect effect = 0.203, 95% CI [0.076, 0.331]; direct effect = 0.162, p = 0.101). Patients with acute coronary syndrome in China experience moderate posttraumatic growth after discharge. Resilience mediates the relationship between social support and posttraumatic growth. Therefore, nursing interventions focusing on promoting social support and resilience should be developed to encourage posttraumatic growth in patients with acute coronary syndrome.

Regional variations in management and outcomes of patients with acute coronary syndrome in China: Evidence from the National Chest Pain Center Program

Regional variations in acute coronary syndrome (ACS) management and outcomes have been an enormous public health issue. However, studies have yet to explore how to reduce the variations. The National Chest Pain Center Program (NCPCP) is the first nationwide, hospital-based, comprehensive, continuous quality improvement program for improving the quality of care in patients with ACS in China. We evaluated the association of NCPCP and regional variations in ACS healthcare using generalized linear mixed models and interaction analysis. Patients in the Western region had longer onset-to-first medical contact (FMC) time and time stay in non-percutaneous coronary intervention (PCI) hospitals, lower rates of PCI for ST-elevation myocardial infarction (STEMI) patients, and higher rates of medication usage. Patients in Central regions had relatively lower in-hospital mortality and in-hospital heart failure rates. Differences in the door-to-balloon time (DtoB) and in-hospital mortality between Western and Eastern regions were less after accreditation (β = −8.82, 95% confidence interval (CI) −14.61 to −3.03; OR = 0.79, 95%CI 0.70 to 0.91). Similar results were found in differences in DtoB time, primary PCI rate for STEMI between Central and Eastern regions. The differences in PCI for higher-risk non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients among different regions had been smaller. Additionally, the differences in medication use between Eastern and Western regions were higher after accreditation. Regional variations remained high in this large cohort of patients with ACS from hospitals participating in the NCPCP in China. More comprehensive interventions and hospital internal system optimizations are needed to further reduce regional variations in the management and outcomes of patients with ACS.

Sex differences in the management of patients with suspected acute coronary syndrome in China.

Few studies have assessed sex differences in the management of suspected acute coronary syndrome (ACS). We aimed to compare the evaluation, treatment, and outcomes between males and females with suspected ACS in the emergency department. Data were obtained from a prospective registry of acute chest pain involving 21 emergency departments in Shandong Province, China. The primary endpoint was 30-day major adverse cardiac events (MACEs). Overlap propensity score weighting was used to address potential confounding. A total of 8046 patients were analysed (42.8% female). Overlap-weighted analysis showed no significant association of female sex with 30-day MACEs (odds ratio, 0.91; 95% CI 0.75 to 1.11; P = 0.363). Secondary analyses found that women were less likely to be identified as high risk at first presentation (odds ratio, 0.86; 95% CI 0.78 to 0.94; P < 0.001). In the emergency department, women were less likely to undergo antiplatelet therapy (odds ratio, 0.87; 95% CI 0.79 to 0.96; P = 0.004) or coronary angiography (odds ratio, 0.78; 95% CI, 0.69 to 0.88; P < 0.001). Women had a longer length of stay in the emergency department and were less likely to be admitted to a ward at disposition. These sex differences existed only in the non-ST-elevation subgroup and were independent of risk stratification. Women with non-ST-elevation chest pain in China received suboptimal treatment in the emergency department. However, their clinical outcomes were not significantly different from those of men. Further studies are needed to determine the causes and impacts of these sex differences.

Sex Disparities in Management and Outcomes Among Patients With Acute Coronary Syndrome

Sex disparities in the management and outcomes of acute coronary syndrome (ACS) have received increasing attention. To evaluate the association of a quality improvement program with sex disparities among patients with ACS. The National Chest Pain Centers Program (NCPCP) is an ongoing nationwide program for the improvement of quality of care in patients with ACS in China, with CPC accreditation as a core intervention. In this longitudinal analysis of annual (January 1, 2016, to December 31, 2020) cross-sectional data of 1 095 899 patients with ACS, the association of the NCPCP with sex-related disparities in the care of these patients was evaluated using generalized linear mixed models and interaction analysis. The robustness of the results was assessed by sensitivity analyses with inverse probability of treatment weighting. Data were analyzed from September 1, 2021, to June 30, 2022. Hospital participation in the NCPCP. Differences in treatment and outcomes between men and women with ACS. Prehospital indicators included time from onset to first medical contact (onset-FMC), time from onset to calling an emergency medical service (onset-EMS), and length of hospital stay without receiving a percutaneous coronary intervention (non-PCI). In-hospital quality indicators included non-PCI, use of statin at arrival, discharge with statin, discharge with dual antiplatelet therapy, direct PCI for ST-segment elevation myocardial infarction (STEMI), PCI for higher-risk non-ST-segment elevation ACS, time from door to catheterization activation, and time from door to balloon. Patient outcome indicators included in-hospital mortality and in-hospital new-onset heart failure. Data for 1 095 899 patients with ACS (346 638 women [31.6%] and 749 261 men [68.4%]; mean [SD] age, 63.9 [12.4] years) from 989 hospitals were collected. Women had longer times for onset-FMC and onset-EMS; lower rates of PCI, statin use at arrival, and discharge with medication; longer in-hospital delays; and higher rates of in-hospital heart failure and mortality. The NCPCP was associated with less onset-FMC time, more direct PCI rate for STEMI, lower rate of in-hospital heart failure, more drug use, and fewer in-hospital delays for both men and women with ACS. Sex-related differences in the onset-FMC time (β = -0.03 [95% CI, -0.04 to -0.01), rate of direct PCI for STEMI (odds ratio, 1.11 [95% CI, 1.06-1.17]), time from hospital door to balloon (β = -1.38 [95% CI, -2.74 to -0.001]), and rate of in-hospital heart failure (odds ratio, 0.90 [95% CI, 0.86-0.94]) were significantly less after accreditation. In this longitudinal cross-sectional study of patients with ACS from hospitals participating in the NCPCP in China, sex-related disparities in management and outcomes were smaller in some aspects by regionalization between prehospital emergency and in-hospital treatment systems and standardized treatment procedures. The NCPCP should emphasize sex disparities to cardiologists; highlight compliance with clinical guidelines, particularly for female patients; and include the reduction of sex disparities as a performance appraisal indicator.

Real-Word Effectiveness of Early Start-Up and Short-Term Use of PCSK9 Inhibitor in the Treatment of Acute Coronary Syndrome in China

Real-Word Effectiveness of Early Start-Up and Short-Term Use of PCSK9 Inhibitor in the Treatment of Acute Coronary Syndrome in China

Low-density lipoprotein cholesterol levels and lipid-lowering treatment status among young and middle-aged ultra-high-risk patients with acute coronary syndrome in China

Objective: To assess low-density lipoprotein cholesterol (LDL-C) levels and use of lipid-lowering treatment among young and middle-aged ultra-high-risk patients with acute coronary syndrome (ACS) in China. Methods: The study was based on the"Improving Care for Cardiovascular Disease in China (CCC)-ACS"project, a collaborative registry by and Chinese Society of Cardiology (CSC) and the American Heart Association. Hospitalized-patients with ACS were consecutively enrolled from 159 tertiary and 82 secondary hospitals across China, related clinical information was collected. This study included young and middle-aged hospitalized patients (18-59 years) with ACS from November 2014 to December 2019 registered in CCC-ACS project. Ultra-high-risk was defined according to Chinese expert consensus on lipid management of ultra-high-risk atherosclerotic cardiovascular disease (ASCVD) patients of CSC. The mean LDL-C levels at admission, pre-hospital lipid-lowering therapy and proportion of patients with LDL-C target achieved were analyzed. Results: A total of 42 230 patients younger than 60 years with ACS were included in this study. The mean age was (50.4±6.9) years, and 86.8% (36 676/42 230) of the ACS patients were male. Among them, 86.9% (36 687/42 230) met the criteria of ultra-high-risk. The mean level of LDL-C at admission was (2.8±1.0)mmol/L, only 5.3 % (1 948/36 687) patients achieved the targeted goal of LDL-C<1.4 mmol/L. Among the ultra-high-risk ASCVD patients, 17.5% (6 430/36 687) received lipid-lowering drugs before hospitalization, 96.4% (6 198/6 430) of whom received statins monotherapy. Among patients receiving pre-hospital statins, only 9.9% (626/6 323) patients reached an LDL-C<1.4 mmol/L at admission. Conclusions: The majority of young and middle-aged hospitalized patients with ACS are ultra-high-risk patients for ASCVD in China. Pre-hospital lipid-lowering drugs use is lower in these ultra-high-risk ASCVD patients and most patients do not reach the new LDL-C target level at admission.

The Level of Remnant Cholesterol and Implications for Lipid-Lowering Strategy in Hospitalized Patients with Acute Coronary Syndrome in China: Findings from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project.

Elevated remnant cholesterol is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). We aimed to evaluate the concentrations and general distribution of remnant cholesterol at admission in patients hospitalized for acute coronary syndrome (ACS), and those in patients who reached the low-density lipoprotein cholesterol (LDL-C) target or non-high-density lipoprotein cholesterol (non-HDL-C) target. Patients with ACS who were enrolled in the Improving Care for Cardiovascular Disease in China—ACS project from 2014 to 2019 were included. Elevated remnant cholesterol concentrations were defined as ≥1.0 mmol/L. Among 94,869 patients, the median (interquartile range) remnant cholesterol concentration at admission was 0.6 mmol/L (0.4–0.9 mmol/L) and 19.2% had elevated remnant cholesterol concentrations. Among patients with LDL-C concentrations < 1.4 mmol/L, 24.4% had elevated remnant cholesterol concentrations, while the proportion was 13.3% among patients with LDL-C concentrations between 1.4 and 1.7 mmol/L. Among patients with non-HDL-C concentrations < 2.6 mmol/L, 2.9% had elevated remnant cholesterol concentrations but 79.6% had LDL-C concentrations ≥ 1.4 mmol/L. Even among patients with LDL-C < 1.4 mmol/L and non-HDL-C < 2.6 mmol/L, 10.9% had elevated remnant cholesterol. In conclusion, one fifth of patients with ACS have elevated remnant cholesterol concentrations at admission. Elevated remnant cholesterol concentrations are present in patients with LDL-C or/and non-HDL-C concentrations within the target, which represents an unmet need to add remnant cholesterol as a target for the secondary prevention of ASCVD.

Associated factors for discontinuation of statin use one year after discharge in patients with acute coronary syndrome in China

ObjectivesTo determine the associated factors for discontinuation of statin use 1 year after discharge in patients who survived from acute coronary syndrome (ACS) in China.Settings75 hospitals across China.DesignA cohort follow-up...

Assessment of Clinical Features in HIV-Infected Patients with Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention in China.

Objectives We aimed to compare coronary risk factors, burden of coronary artery disease (CAD), and 1-year prognosis of people living with HIV (PLWH) and HIV-negative controls who underwent percutaneous coronary intervention (PCI) for acute coronary syndromes (ACSs). Background Cardiovascular disease is drawing more and more attention in PLWH since effective antiretroviral therapy (ART) has been available. Clinical characteristics and outcomes of PLWH undergoing PCI for ACS in China remain unknown. Methods We compared demographic characteristics, angiographic features, and 1-year outcomes of 48 PLWH versus 48 HIV-negative controls matched for age (±2 years), sex, diabetes mellitus, and year of PCI (±2 years) in Beijing Ditan Hospital, Capital Medical University from January 2008 to November 2020. Results In PLWH (mean age: 53.6 ± 10.6 years, 95.8% male, and 79.2% on ART), high-density lipoprotein cholesterol was lower than in HIV-negative controls; however, the statin use was more common, the incidence of hypertension was lower, and low-density lipoprotein cholesterol, and the body mass index were significantly lower than in controls. Two groups had a similar extent of coronary atherosclerosis as measured by the presence of multivessel diseases and the median Gensini score; however, lesions of PLWH were longer and were more likely to locate at the proximal segment of the coronary artery. In addition, the risk of major adverse cardiac and cerebrovascular events at 1 year was similar in both groups. Conclusion PLWH undergoing PCI displayed similar CAD burden and 1-year prognosis compared with HIV-negative patients. Early detection of cardiovascular risk factors and appropriate secondary prevention of CAD in PLWH might alleviate the risk of severe adverse cardiovascular events.

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

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

Pharmacokinetics, mass balance, and metabolism of [14C]vicagrel, a novel irreversible P2Y12 inhibitor in humans.

Vicagrel, a novel irreversible P2Y12 receptor inhibitor, is undergoing phase III trials for the treatment of acute coronary syndromes in China. In this study, we evaluated the pharmacokinetics, mass balance, and metabolism of vicagrel in six healthy male Chinese subjects after a single oral dose of 20 mg [14C]vicagrel (120 µCi). Vicagrel absorption was fast (Tmax = 0.625 h), and the mean t1/2 of vicagrel-related components was ~38.0 h in both plasma and blood. The blood-to-plasma radioactivity AUCinf ratio was 0.55, suggesting preferential distribution of drug-related material in plasma. At 168 h after oral administration, the mean cumulative excreted radioactivity was 96.71% of the dose, including 68.03% in urine and 28.67% in feces. A total of 22 metabolites were identified, and the parent vicagrel was not detected in plasma, urine, or feces. The most important metabolic spot of vicagrel was on the thiophene ring. In plasma pretreated with the derivatization reagent, M9-2, which is a methylated metabolite after thiophene ring opening, was the predominant drug-related component, accounting for 39.43% of the radioactivity in pooled AUC0-8 h plasma. M4, a mono-oxidation metabolite upon ring-opening, was the most abundant metabolite in urine, accounting for 16.25% of the dose, followed by M3-1, accounting for 12.59% of the dose. By comparison, M21 was the major metabolite in feces, accounting for 6.81% of the dose. Overall, renal elimination plays a crucial role in vicagrel disposition, and the thiophene ring is the predominant metabolic site.

Smoking and Provision of Smoking Cessation Interventions among Inpatients with Acute Coronary Syndrome in China: Findings from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project.

HighlightsOver half of male acute coronary syndrome patients were smokers in China.Smoking was associated with higher risk of critical cardiac symptoms at admission.Only 35.3% of smoking patients received smoking cessation interventions in China.Background:Smoking cessation is recognized as an effective and cost-effective strategy for improving the prognosis of patients with coronary heart disease. Despite this, few studies have evaluated the smoking prevalence and provision of smoking cessation interventions among patients with acute coronary syndrome (ACS) in China.Objectives:To evaluate the smoking prevalence, clinical conditions and in-hospital outcomes associated with smoking, and the provision of smoking cessation interventions among ACS patients in China.Methods:This registry study was conducted using data from the Improving Care for Cardiovascular Disease in China project, a collaborative nationwide registry of the American Heart Association and the Chinese Society of Cardiology. Our study sample comprised 92,509 ACS inpatients admitted between November 2014 and December 2018. A web-based data collection platform was used to report required data.Results:Smoking prevalence among male and female ACS patients was 52.4% and 8.0%, respectively. Patients younger than 45 years had the highest smoking rate (men: 68.0%; women: 14.9%). Compared with non-smokers, smokers had an earlier onset age of ACS and a greater proportion of severe clinical manifestations at admission, including ST-elevation myocardial infarction (67.8% versus 54.8%; p < 0.001) and substantially elevated myocardial injury markers (86.1% versus 83.0%; p < 0.001). After multivariable adjustment, smoking was associated with higher risk of critical cardiac symptoms at admission (OR = 1.14, 95% CI: 1.08–1.20; p < 0.001) and had no direct association with in-hospital outcomes (OR = 0.93, 95% CI: 0.84–1.02; p = 0.107) of ACS patients. Of 37,336 smokers with ACS, only 35.3% received smoking cessation interventions before discharge. There was wide variation in provision of smoking cessation interventions across hospitals (0%–100%).Conclusions:Smoking is highly prevalent among ACS patients in China. However, smoking cessation interventions are not widely adopted in clinical practice in China as part of formal treatment strategies for ACS patients, indicating an important target for quality improvement.Clinical Trial Registration:URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616.

Associations Between Education Level and In-hospital Treatment and Outcomes Among Acute Coronary Syndrome in China

BackgroundPrevious studies have shown an inverse relationship between education and clinical outcomes in coronary heart disease. Whether a similar association exists in patients presenting with suspected acute coronary syndromes (ACS) in China is unknown. MethodsClinical Pathways for Acute Coronary Syndromes – Phase 2 (CPACS-2) was a study to evaluate a quality improvement for ACS management in China which implemented in 75 hospitals between October 2007 and August 2010. All patients was divided into 6 groups by education level. We evaluated clinical managements and outcomes according to level of education. ResultsA total of 14350 patients were enrolled in current analysis. Patients with less education were older, had greater female representation and had a higher Killip class at admission. Compared to patients with lower education levels, more educated patients had a longer length of hospitalization (p for trend <0.001), greater likelihood of receiving appropriate coronary angiography (p for trend <0.001) and appropriate reperfusion therapy for ST-segment elevated myocardial infarction (STEMI) (p for trend <0.001) even after adjustment for differences in patient characteristics and comorbidities at presentation. Patients with less education were at higher risk of death, cardiac death and major adverse cardiovascular events but none of these differences remained statistically significant after adjustment for baseline characteristics. ConclusionIn China, less educated patients with ACS were less likely to receive appropriate coronary angiography and reperfusion therapy. Less educated patients were at higher risk for adverse clinical events; however this was explained by differences in baseline characteristics.

Association of renal insufficiency with treatments and outcomes in patients with acute coronary syndrome in China

BackgroundWe aimed to analyze the association of estimated glomerular filtration rate (eGFR) levels of hospitalized patients with treatment decisions and clinical outcomes in Chinese patients with acute coronary syndrome (ACS). MethodsThis was a secondary analysis study from CPACS-2 Program which was a trial of a quality improvement intervention in China and recruited 15,141 patients from 75 hospitals between October 2007 and August 2010. All patients were divided into three groups by the eGFR level on admission. The primary outcomes were several key performance indicators (KPIs) reflecting the management of ACS and the secondary outcomes were clinical outcomes. ResultsA total of 14,437 ACS patients were enrolled in this analysis. Among patients with reduced eGFR levels, fewer patients received appropriate medical therapy (p for trend <0.001) and fewer high-risk patients received coronary angiography (p for trend <0.001) compared to patients with a normal eGFR. Furthermore, 436 cases of death, 357 cases of cardiac death, 686 cases of major adverse cardiovascular events, and 198 cases of major bleeding episodes were reported. Patients with a worse eGFR level had significantly higher rates of death (p for trend <0.001), cardiac death (p for trend <0.001), major adverse cardiovascular events (p for trend <0.001) and major bleeding episodes (p for trend <0.001). ConclusionAmong Chinese ACS patients, those with renal insufficiency have a lower percentage of adherence to guideline-recommended treatments and worse clinical prognosis. Renal insufficiency is an important factor affecting guideline implementation in Chinese ACS patients. Clinical trial registrationhttp://www.anzctr.org.au/default.aspx. Unique identifier: ACTRN12609000491268.

Acute Coronary Syndromes and Covid-19: Exploring the Uncertainties.

Since an association between myocardial infarction (MI) and respiratory infections has been described for influenza viruses and other respiratory viral agents, understanding possible physiopathological links between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and acute coronary syndromes (ACS) is of the greatest importance. The initial data suggest an underestimation of ACS cases all over the world, but acute MI still represents a major cause of morbidity and mortality worldwide and should not be overshadowed during the coronavirus disease (Covid-19) pandemic. No common consensus regarding the most adequate healthcare management policy for ACS is currently available. Indeed, important differences have been reported between the measures employed to treat ACS in China during the first disease outbreak and what currently represents clinical practice across Europe and the USA. This review aims to discuss the pathophysiological links between MI, respiratory infections, and Covid-19; epidemiological data related to ACS at the time of the Covid-19 pandemic; and learnings that have emerged so far from several catheterization labs and coronary care units all over the world, in order to shed some light on the current strategies for optimal management of ACS patients with confirmed or suspected SARS-CoV-2 infection.

Long-term follow-up of antithrombotic management patterns in patients with acute coronary syndrome in China.

ObjectiveTo describe the long-term antithrombotic management patterns (AMPs) and clinical outcomes of Chinese patients with acute coronary syndrome (ACS).MethodsThis was an observational, multicenter, longitudinal cohort extension study of Chinese patients who had completed the EPICOR Asia 2-year follow-up study post-hospitalization for an ACS event. Changes in AMP and clinical outcomes for up to 5 years post-ACS event were evaluated.ResultsOverall, 2334 patients with ACS were enrolled at 49 sites. The mean age was 61.6 years and 76.3% were men. By study end, 2093 patients completed the 3-year follow-up. At baseline (2 years post-ACS event), 72.4% of patents received one antiplatelet (AP) medication, with aspirin being the preferred one. A small proportion of patients (21.5%) was treated with two or more APs (2+ AP), and even fewer patients (6.1%) did not receive any AP medication at baseline. Upon study completion, the proportion of patients without AP therapy increased to 13.6%, while the percentage of patients on one AP and 2+ AP decreased to 69.3% and 17.1%, respectively. Numerically, a higher incidence of clinical events (composite of all-cause mortality, myocardial infarction, stroke) was observed for the 2+ AP (13.2%) subgroup than for the no AP (10.5%) and one AP (8.6%) subgroups. Furthermore, the 2+ AP subgroup exhibited the greatest number of bleeding events, outpatient visits, and hospitalization rates. Unlike myocardial infarction or stroke, bleeding events prompted an adjustment in AMP.ConclusionMost patients in China received at least one AP medication up to 5 years after an ACS event.

The Hospital Management Practices in Chinese County Hospitals and Its Association with Quality of Care, Efficiency and Finance

Background: County hospitals as the backbone of the China’s healthcare system are providing services for over 70% of the total population. However, the hospital management practice (HMP) and its links with quality of care, efficiency and finance of these hospitals are unknown. Methods: We did two cross-sectional surveys of HMP in 2013 and 2015 among 101 county hospitals participated in the Third Phase of the Clinical Pathways for Acute Coronary Syndromes in China (CPACS-3) Study. A novel HMP rating scale, with 100 as full score, was used to measure the hospital management practice in 17 indicators under four dimensions (target, operation, performance, and talent management) for each hospital. We analyzed the association of HMP score with quality of care, efficiency and finance using general linear models with adjustment for potential confounders. Findings: A total of 83 hospitals responded in both surveys. The overall mean HMP score varied dramatically across the hospitals (from 31.1 to 71.1) and 86% of hospitals scored less than 60 out of 100. The dimension mean HMP score was 38.8 (target), 56.1 (operation), 52.9 (performance) and 55.6 (talent), respectively. The pattern of indicator mean HMP score, however, was almost identical between hospitals with high and low overall HMP score, showing the same ‘strength’ (staff satisfaction, staff performance appraisal, ‘hard wares’, patient-centered services, etc.) and ‘weakness’ indicators (target balance, target setting, continuous quality improvement, penalties on staff with dissatisfied performance, etc.). The overall mean HMP score was not associated with hospital care quality and efficiency but associated significantly with hospital annual revenue. Interpretation: The HMP in Chinese county hospitals scores low in general and was not associated with hospital care quality and efficiency but associated with the total revenue. The current healthcare reform in China should address the issues in hospital management practices. Trial Registration: This study is part of the ancillary study of the Third Phase of the Clinical Pathways for Acute Coronary Syndromes in China (CPACS-3) Program (NCT02195193). Funding Statement: Sanofi (China). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The study was approved by the Peking University Institutional Review Board.

Characterization of chemical profile and quantification of representative components of DanLou tablet, a traditional Chinese medicine prescription, by UHPLC-Q/TOF-MS combined with UHPLC-TQ-MS

DanLou tablet (DLT), a famous traditional Chinese medicine prescription (TCMP) consisting of 10 herbal medicines, is extensively used for the treatment of angina pectoris and acute coronary syndrome in China. However, active chemical constituents responsible for the therapeutic effects still remain unclear, due to the fact that the complex composition in DLT have not been holistically clarified. Therefore, this study aimed to characterize the chemical profile and simultaneously quantify the representative components in DLT. First, 157 chemical constituents including flavonoids, triterpenoids, tanshinones, lactones, phenolic acids, paeoniflorins and the other types of components were detected, among which 39 were exactly identified by comparing their retention times and MS fragmentation behaviors with those of authentic standards by ultra-high performance liquid chromatography coupled with quadrupole time-of-flight tandem mass spectrometry (UHPLC-Q/TOF-MS). Moreover, 33 representative components were simultaneously quantified by ultra-high performance liquid chromatography coupled with triple-quadrupole tandem mass spectrometry (UHPLC-TQ-MS), which were selected based on following three principles: qualitative and quantitative markers in the Chinese Pharmacopeia (2015 edition), bioactive components possessing cardiovascular-related in vivo or in vitro activities and those derived from 10 consisted herbs in DLT with a diversity of representative structure types. The method was validated in terms of linearity, precision, repeatability and recovery and successfully applied for the quality evaluation of 20 batches of DLT samples. Further chemometric analysis indicated that danshensu and salvianolic acid B were the most significant quantitative markers for the content fluctuation of DLT. In summary, the chemical profiles of DLT were systematically characterized and a practical quantitative method combined with chemometrics was developed to evaluate the intrinsic quality of multiple DLT samples in this study. The present work would be helpful for guaranteeing the safety, efficacy, and controllability in clinical medication of DLT.

Statin use and low-density lipoprotein cholesterol levels in patients aged 75 years and older with acute coronary syndrome in China

Objective: To assess the use of statins and low-density lipoprotein cholesterol (LDL-C) levels at admission in hospitalized patients aged 75 years and older with acute coronary syndrome (ACS) in China. Methods: Data used in this study derived from the Improving Care for Cardiovascular Disease in China (CCC)-ACS project, a nationwide registry with 150 tertiary hospitals reporting details of clinical information of ACS patients. This study enrolled patients 75 years and older with ACS in CCC-ACS project from November 2014 to June 2017. Patients were divided into two groups according to the history of atherosclerotic cardiovascular disease (ASCVD). Pre-hospital statin use, LDL-C levels at admission and prescription of statins at discharge were reported. Results: A total of 10 899 patients 75 years and older with ACS were enrolled. The median age was 79 years and 58.7% (6 397 cases) were male. Among patients with history of ASCVD, 33.9% (1 028 cases) of them received statins before hospitalization. Among patients without history of ASCVD, 12.7% (996/7 871) received statins before hospitalization. The mean level of LDL-C was (2.4±0.9) mmol/L and LDL-C was <1.8 mmol/L in 24.7% (747 cases) of patients with history of ASCVD. The mean level of LDL-C was (2.6±0.9) mmol/L and LDL-C was <2.6 mmol/L in 51.7% (4 072 cases) of patients without history of ASCVD. At discharge, 91.2% (9 524/10 488) of patients were prescribed with statins in patients without contraindications for statin. Conclusion: In elderly patients with recurrent ASCVD, there was an inadequate statin use before hospitalization and most patients did not reach the LDL-C target level when they had the recurrent events. In the elderly ACS patients without history of ASCVD, more than half of the patients had an ideal LDL-C level. It seems that ideal LDL-C level for primary prevention of ACS in elderly people needs to be reevaluated with further studies.

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

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