ST-segment Elevation Myocardial Infarction In China Research Articles

Cardiac arrest and cardiogenic shock complicating ST-segment elevation myocardial infarction in China: A retrospective multicenter study

BackgroundData on the effect of cardiac arrest (CA), cardiogenic shock (CS), and their combination on the prognosis of Chinese patients with ST-segment elevation myocardial infarction (STEMI) are limited. The present study sought to evaluate the clinical outcomes of STEMI complicated by CA and CS, and to identify the risk factors for CA or CS. MethodsThis study included 7468 consecutive patients with STEMI in China. The patients were divided into 4 groups (CA + CS, CA only, CS only, and No CA or CS). The endpoints were 30-day all-cause death and major adverse cardiovascular events. A Cox proportional hazards regression analysis was performed. ResultsCA, CS, and their combination were noted in 332 (4.4 %), 377 (5.0 %), and 117 (1.6 %) among all patients. During the 30-day follow-up, 817 (10.9 %) all-cause deaths and 964 (12.9 %) major adverse cardiovascular events occurred, and the incidence of all-cause mortality (3.6 %, 62.3 %, 74.1 %, 83.3 %) and major adverse cardiovascular events (5.4 %, 67.1 %, 75.0 %, and 87.2 %) significantly increased in the No CA or CS, CS only, CA only, and CA + CS groups, respectively. In the multivariate Cox regression models, compared with the No CA or CS group, the CA + CS, CA, and CS-only groups were associated with an increased risk of all-cause death and major adverse cardiovascular events. Patients with CA + CS had the highest risk of all-cause death (hazard ratio [HR], 25.259 [95 % confidence interval (CI) 19.221–33.195]) and major adverse cardiovascular events (HR 19.098, 95%CI 14.797–24.648). ConclusionsCA, CS, and their combination were observed in approximately 11 % of Chinese patients with STEMI, and were associated with increased risk for 30-day mortality and major adverse cardiovascular events in Chinese patients with STEMI.

Pre-hospital delay in patients with acute myocardial infarction in China: findings from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project.

OBJECTIVETo describe the duration of the pre-hospital delay time and identify factors associated with prolonged pre-hospital delay in patients with acute myocardial infarction (AMI) in China.METHODSData were collected from November 2014 to December 2019 as part of the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project. A total of 33,386 patients with AMI admitted to the index hospitals were included in this study. Two-level logistic regression was conducted to explore the factors associated with the pre-hospital delay and the associations between different pre-hospital delay and in-hospital outcomes.RESULTSOf the 33,386 patients with AMI, 70.7% of patients arrived at hospital ≥ 2 h after symptom onset. Old age, female, rural medical insurance, symptom onset at early dawn, and non-use of an ambulance predicted a prolonged pre-hospital delay (all P < 0.05). Hypertension and heart failure at admission were only significant in predicting a longer delay in patients with ST-segment elevation myocardial infarction (STEMI) (all P < 0.05). A pre-hospital delay of ≥ 2 h was associated with an increased risk of mortality [odds ratio (OR) = 1.36, 95% CI: 1.09–1.69, P = 0.006] and major adverse cardiovascular events (OR = 1.22, 95% CI: 1.02–1.47, P = 0.033) in patients with STEMI compared with a pre-hospital delay of < 2 h. CONCLUSIONSProlonged pre-hospital delay is associated with adverse in-hospital outcomes in patients with STEMI in China. Our study identifies that patient characteristics, symptom onset time, and type of transportation are associated with pre-hospital delay time, and provides focuses for quality improvement.

Abstract 10950: Real-World Practice of Reperfusion and Revascularization in Patients with St-Segment Elevation Myocardial Infarction in China: Findings from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project

Introduction: Reperfusion and revascularization therapies are key treatments of ST-segment elevation myocardial infarction (STEMI). However, little is known about the contemporary practice among Chinese patients with STEMI. We aimed to explore the recent practice of reperfusion and revascularization among hospitalized patients with STEMI in China. Methods: A total of 59442 STEMI patients admitted to 159 tertiary hospitals from 30 provinces in China were included in the Improving Care for Cardiovascular Disease in China (CCC)-ACS project from November 2014 to December 2019. The practice of reperfusion and revascularization were assessed. Associations between therapies and in-hospital MACE after 1 day of admission were examined with multivariate Cox regression. Results: Among the 59442 patients, 48897 (82.3%) underwent reperfusion/ revascularization, including 28280 (47.6%) received pPCI within 12 hours, 4649 (7.8%) received pPCI between 12 to 24 hours, 1314 (2.2%) received fibrinolysis alone, and 1751 (2.9%) received pharmaco-invasive strategy. A total of 12903 patients (21.7%) received elective PCI, among which 1486 (11.5%) initially received fibrinolysis. Overall, 37480 patients (63.1%) received reperfusion therapy, including 32929(55.4%) received pPCI, which was 7.2-fold higher than that of fibrinolysis (4551, 7.7%). Among patients receiving fibrinolysis, only 38.4% (1751/4551) received pharmaco-invasive strategy, including 25.2% for pharmaco-invasive PCI and 13.3% for rescue PCI. All PCI strategies, but not fibrinolysis alone, were associated with decreased risk of in-hospital MACE compared with no reperfusion/ revascularization, with the adjusted HR (95% CI) of 0.46(0.38, 0.56) for pPCI&lt;12h, 0.38(0.27, 0.55) for pPCI 12-24h, 0.38(0.16, 0.95) for rescue PCI, 0.27(0.13, 0.59) for pharmaco-invasive PCI, 0.28(0.21, 0.37) for elective PCI, and 0.86(0.57, 1.29) for fibrinolysis alone. Conclusions: Revascularization therapies are widely used in patients with STEMI in China. However, there are notable gaps between guideline recommendations and the clinical practice in terms of timely reperfusion, especially pharmaco-invasive strategy. Early reperfusion therapies should be further strengthened.

Changes in ST segment elevation myocardial infarction hospitalisations in China from 2011 to 2015

ObjectiveAccess to acute cardiovascular care has improved and health services capacity has increased over the past decades. We assessed national changes in (1) patient characteristics, (2) in-hospital management and (3)...

Analysis of potential factors contributing to refusal of invasive strategy after ST-segment elevation myocardial infarction in China

Background:Reduced application of percutaneous coronary intervention (PCI) is associated with higher mortality rates after ST-segment elevation myocardial infarction (STEMI). We aimed to evaluate potential factors contributing to the refusal of PCI in STEMI patients in China.Methods:We studied 957 patients diagnosed with STEMI in the emergency departments (EDs) of six public hospitals in China. The differences in baseline characteristics and 30-day outcome were investigated between patients who refused PCI and those who underwent PCI. Multivariable logistic regression was used to evaluate the potential factors associated with refusing PCI.Results:The potential factors contributing to refusing PCI were older than 65 years (odds ratio [OR] 2.66, 95% confidence interval [CI] 1.56–4.52, P < 0.001), low body mass index (BMI) (OR 0.91, 95% CI 0.84–0.98, P = 0.013), not being married (OR 0.29, 95% CI 0.17–0.49, P < 0.001), history of myocardial infarction (MI) (OR 2.59, 95% CI 1.33–5.04, P = 0.005), higher heart rate (HR) (OR 1.02, 95% CI 1.01–1.03, P = 0.002), cardiac shock in the ED (OR 5.03, 95% CI 1.48–17.08, P = 0.010), pre-hospital delay (>12 h) (OR 3.31, 95% CI 1.83–6.02, P < 0.001) and not being hospitalized in a tertiary hospital (OR 0.45, 95% CI 0.27–0.75, P = 0.002). Compared to men, women were older, were less often married, had a lower BMI and were less often hospitalized in tertiary hospitals.Conclusions:Patients who were older, had lower economic or social status, and had poorer health status were more likely to refuse PCI after STEMI. There was a sex difference in the potential predictors of refusing PCI. Targeted efforts should be made to improve the acceptance of PCI among patients with STEMI in China.

Switching from ticagrelor to clopidogrel in patients with ST-segment elevation myocardial infarction undergoing successful percutaneous coronary intervention in real-world China: Occurrences, reasons, and long-term clinical outcomes.

Although switching between ticagrelor and clopidogrel is common in clinical practice, the efficacy and safety of this de-escalation remain controversial. We assessed the occurrences, reasons, and outcomes of switching from ticagrelor to clopidogrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing successful primary percutaneous coronary intervention (PCI). A total of 653 patients with STEMI were randomly assigned to receive loading dose of ticagrelor or clopidogrel before PCI and then received maintenance dose, respectively, for 12 months follow-up. The primary outcome was major adverse cardiac events (MACE), including cardiovascular death, nonfatal myocardial infarction, and stroke. The secondary outcome included unexpected rehospitalization for angina, coronary revascularization, and stent thrombosis. The safety outcome was bleeding described by the Bleeding Academic Research Consortium (BARC) criteria. A total of 602 participants completed the study. The rate of switching from ticagrelor to clopidogrel was 48.6% and the main reason was financial burden. The rate of secondary ischemic events in the de-escalation group was higher than that in the ticagrelor group (15.1% vs 5.6%, P = 0.008), but lower than that in the clopidogrel group (15.1% vs 24.6%, P = 0.03), while there were no significant differences in MACE among the three groups (P = 0.16). De-escalation, ticagrelor, and clopidogrel did not cause significant differences in the rates of major bleeding among the three groups (BARC ≥ 2, P = 0.34). Switching from ticagrelor to clopidogrel is very common in patients with STEMI in China. De-escalation might be safe but associated with high risk of ischemic events as compared to ticagrelor.

10 year trends in urban–rural disparities in treatments and outcomes after ST-elevation myocardial infarction in China: insights from the China PEACE-Retrospective Acute Myocardial Infarction Study

BackgroundIn response to the epidemic transition, like in many other low-income and middle-income countries, China has been building capacities and improving access to health care in its health-care reform, with the budget favouring rural areas. Yet the trend in disparities between urban and rural areas in treatments and outcomes of ST-segment elevation myocardial infarction (STEMI) have not been well characterised. The aim of this study was to illustrate whether the quality of care for STEMI differed between urban and rural hospitals, and how it changed from 2001 to 2011. MethodsUsing a two-stage random sampling design including two urban and three rural strata in China, we created a nationally representative sample of patients with STEMI in China in 2001, 2006, and 2011. We collected clinical information through centralised medical chart abstraction and did surveys to determine hospital characteristics. We compared a composite outcome as in-hospital mortality or withdrawal from treatment due to a terminal status at discharge. The central ethics committee at the China National Center for Cardiovascular Diseases approved the study, with a waiver of patients' written consent. This study is registered with ClinicalTrials.gov, number NCT01624883. FindingsWe identified 8330 cases of STEMI in 63 urban hospitals and 5485 cases of STEMI in 99 rural hospitals. The admission rate for STEMI remained three-times higher in urban areas than in rural areas (7·4 vs 2·0 per 100 000 population in 2001; 28·1 vs 8·7 per 100 000 population in 2011; both p<0·0001). Despite the difference in 2001, rural–urban differences were attenuated in 2011 for reperfusion therapy (57% vs 54%), use of ACEI/ARB (68% vs 66%), whereas use of beta-blockers was greater in rural areas than in urban areas in 2011 (60% vs 56%). The risk-adjusted rate of in-hospital death or withdrawal from treatment did not differ between patients in rural and urban hospitals in all 3 years, with an adjusted odds ratio of 0·88 (95% CI 0·61–1·29; p=0·5) in 2001, 1·01 (0·79–1·29; p=0·9) in 2006, and 1·07 (0·84–1·36; p=0·6) in 2011. Similar results were observed for in-hospital complications. InterpretationIn the medical records abstraction, definitions of certain clinical conditions and completeness of documentation might differ between urban and rural hospitals. Nevertheless, the stratified random sample in our study provided a unique opportunity to extend the understanding on urban–rural differences in STEMI care and the temporal trends in the largest developing country. Despite enormous opportunities for improvement in both urban and rural areas, urban hospitals with more affluent resources produced no extra benefit for patient. Capacity building alone, as a partial solution, is inadequate to reduce the burden. Accountable measures and improvement initiatives for quality are needed to ensure that the health-care sector achieves its potential values. FundingResearch Special Fund for Public Welfare Industry of Health (201202025) from National Health and Family Planning Commission of China, the National Key Technology R&D Program (2013BAI09B01) from the Ministry of Science and Technology of China, and grant 20131100501 from State Administration of Foreign Experts Affairs of China. HMK is supported by grant U01 HL105270-05 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute. The funders had no role in the conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation or approval of the abstract.

ST-segment elevation myocardial infarction in China from 2001 to 2011 (the China PEACE-Retrospective Acute Myocardial Infarction Study): a retrospective analysis of hospital data

Despite the importance of ST-segment elevation myocardial infarction (STEMI) in China, no nationally representative studies have characterised the clinical profiles, management, and outcomes of this cardiac event during the past decade. We aimed to assess trends in characteristics, treatment, and outcomes for patients with STEMI in China between 2001 and 2011. In a retrospective analysis of hospital records, we used a two-stage random sampling design to create a nationally representative sample of patients in China admitted to hospital for STEMI in 3 years (2001, 2006, and 2011). In the first stage, we used a simple random-sampling procedure stratified by economic-geographical region to generate a list of participating hospitals. In the second stage we obtained case data for rates of STEMI, treatments, and baseline characteristics from patients attending each sampled hospital with a systematic sampling approach. We weighted our findings to estimate nationally representative rates and assess changes from 2001 to 2011. This study is registered with ClinicalTrials.gov, number NCT01624883. We sampled 175 hospitals (162 participated in the study) and 18,631 acute myocardial infarction admissions, of which 13,815 were STEMI admissions. 12,264 patients were included in analysis of treatments, procedures, and tests, and 11,986 were included in analysis of in-hospital outcomes. Between 2001 and 2011, estimated national rates of hospital admission for STEMI per 100,000 people increased (from 3·5 in 2001, to 7·9 in 2006, to 15·4 in 2011; ptrend<0·0001) and the prevalence of risk factors-including smoking, hypertension, diabetes, and dyslipidaemia-increased. We noted significant increases in use of aspirin within 24 h (79·7% [95% CI 77·9-81·5] in 2001 vs 91·2% [90·5-91·8] in 2011, ptrend<0·0001) and clopidogrel (1·5% [95% CI 1·0-2·1] in 2001 vs 82·1% [81·1-83·0] in 2011, ptrend<0·0001) in patients without documented contraindications. Despite an increase in the use of primary percutaneous coronary intervention (10·6% [95% CI 8·6-12·6] in 2001 vs 28·1% [26·6-29·7] in 2011, ptrend<0·0001), the proportion of patients who did not receive reperfusion did not significantly change (45·3% [95% CI 42·1-48·5] in 2001 vs 44·8% [43·1-46·5] in 2011, ptrend=0·69). The median length of hospital stay decreased from 12 days (IQR 7-18) in 2001 to 10 days (6-14) in 2011 (ptrend<0·0001). Adjusted in-hospital mortality did not significantly change between 2001 and 2011 (odds ratio 0·82, 95% CI 0·62-1·10, ptrend=0·07). During the past decade in China, hospital admissions for STEMI have risen; in these patients, comorbidities and the intensity of testing and treatment have increased. Quality of care has improved for some treatments, but important gaps persist and in-hospital mortality has not decreased. National efforts are needed to improve the care and outcomes for patients with STEMI in China. National Health and Family Planning Commission of China.

Reperfusion times of ST-Segment elevation myocardial infarction in hospitals.

Objective: To investigate the reperfusion time in patients with ST-segment elevation myocardial infarction (STEMI) in Henan Province, China, and discuss the strategies for shortening that period. Methods: The reperfusion times of 1556 STEMI cases in 30 hospitals in Henan Province were analyzed from January 2008 to August 2012, including 736 cases from provincial hospitals, 462 cases from municipal hospitals and 358 cases from country hospitals. The following data: Time period 1 (from symptom onset to first medical contact), Time period 2 (from first medical contact to diagnosis), Time period 3 (from the diagnosis to providing consent), Time period 4 (from the time of providing consent to the beginning of treatment) and Time period 5 (from the beginning of treatment to the patency) were recorded and analyzed. Results: In patients receiving primary percutaneous coronary intervention, the door-to-balloon time of provincial hospitals and municipal hospitals was 172±13 minutes and 251±14 minutes, respectively. The hospitals at both levels had a delay comparison of 90 minutes largely caused by the delay in the time for obtaining consent. In patients receiving thrombolysis treatment, the door-to-needle times of provincial hospitals, municipal hospitals and country hospitals were 86±7, 91±7 and 123±11 minutes, respectively. The hospitals at all levels had delays lasting more than 30 minutes, which was mainly attributed to the delay in the time for providing consent. Compared with the time required by the guidelines, the reperfusion time of patients with STEMI in China is evidently delayed. In terms of China's national conditions, the door-to-balloon time is too general. Therefore, we suggest refining this time as the first medical contact–diagnosis time, consent provision time, therapy preparation time and the start of therapy balloon time. Conclusion: Compared to the time required by the guidelines, the reperfusion time of patients with STEMI in China was obviously greater. In terms of China's national conditions, the door to balloon time is not applicable. So it is suggested to refine it as the first medical contact-diagnosis time, providing consent time, therapy prepare time and the start of therapy – balloon time.