Burden of cardiac arrhythmias in patients with acute myocardial infarction and their impact on hospitalization outcomes: insights from China acute myocardial infarction (CAMI) registry.

BACKGROUND: The coexistence of cardiac arrhythmias in patients with acute myocardial infarction (AMI) usually exhibits poor prognosis. However, there are few contemporary data available on the burden of cardiac arrhythmias in AMI patients and their impact on in-hospital outcomes. METHODS: The present study analyzed data from the China Acute Myocardial Infarction (CAMI) registry involving 23,825 consecutive AMI patients admitted to 108 hospitals from January 2013 to February 2018. Cardiac arrhythmias were defined as the presence of bradyarrhythmias, sustained atrial tachyarrhythmias, and sustained ventricular tachyarrhythmias that occurred during hospitalization. In-hospital outcome was defined as a composite of all-cause mortality, cardiogenic shock, re-infarction, stroke, or heart failure. RESULTS: Cardiac arrhythmia was presented in 1991 (8.35%) AMI patients, including 3.4% ventricular tachyarrhythmias, 2.44% bradyarrhythmias, 1.78% atrial tachyarrhythmias, and 0.73% ≥2 kinds of arrhythmias. Patients with arrhythmias were more common with ST-segment elevation myocardial infarction (83.3% vs. 75.5%, P < 0.001), fibrinolysis (12.8% vs. 8.0%, P < 0.001), and previous heart failure (3.7% vs. 1.5%, P < 0.001). The incidences of in-hospital outcomes were 77.0%, 50.7%, 43.5%, and 41.4%, respectively, in patients with ≥ 2 kinds of arrhythmias, ventricular tachyarrhythmias, bradyarrhythmias, and atrial tachyarrhythmias, and were significantly higher in all patients with arrhythmias than those without arrhythmias (48.9% vs. 12.5%, P < 0.001). The presence of any kinds of arrhythmia was independently associated with an increased risk of hospitalization outcome (≥ 2 kinds of arrhythmias, OR 26.83, 95%CI 18.51-38.90; ventricular tachyarrhythmias, OR 8.56, 95%CI 7.34-9.98; bradyarrhythmias, OR 5.82, 95%CI 4.87-6.95; atrial tachyarrhythmias, OR4.15, 95%CI 3.38-5.10), and in-hospital mortality (≥ 2 kinds of arrhythmias, OR 24.44, 95%CI 17.03-35.07; ventricular tachyarrhythmias, OR 13.61, 95%CI 10.87-17.05; bradyarrhythmias, OR 7.85, 95%CI 6.0-10.26; atrial tachyarrhythmias, OR 4.28, 95%CI 2.98-6.16). CONCLUSION: Cardiac arrhythmia commonly occurred in patients with AMI might be ventricular tachyarrhythmias, followed by bradyarrhythmias, atrial tachyarrhythmias, and ≥ 2 kinds of arrhythmias. The presence of any arrhythmias could impact poor hospitalization outcomes. REGISTRATION: Clinical Trial Registration: Identifier: NCT01874691.

Association between living alone and all-cause mortality of young and middle-aged patients with acute myocardial infarction: analysis of the China Acute Myocardial Infarction (CAMI) registry.

BACKGROUND: Lack of social support is a known predictor of the prognosis after acute myocardial infarction (AMI). Although as a common factor associated with social support, there are limited data on long-term prognostic impact of living status in young and middle-aged patients with AMI. METHODS: We analyzed data from the China Acute Myocardial Infarction (CAMI) Registry, consecutive AMI young and middle-aged patients admitted at 108 hospitals in China between January 2013 and September 2014 were included. Eligible patients were assigned to living alone and not living alone groups based on their living status. The primary endpoint was 2-year all-cause mortality. The secondary endpoints included in-hospital mortality and 2-year major adverse cardiac and cerebrovascular events (MACCEs; a composite of all-cause mortality, MI, or stroke). Multilevel logistic and multilevel Cox regression models were used to evaluate the effect of living status on short-term and long-term outcomes. RESULTS: A total of 8307 consecutive AMI young and middle-aged patients were included, 192 (2.3%) patients were living alone. Of the analyzed patients, living alone was associated with 2-year all-cause mortality and MACCEs among all analyzed patients after multivariate adjustment (adjusted hazard ratio [HR] = 2.171 [1.210-3.895], P = 0.009; adjusted HR = 2.169 [1.395-3.370], P = 0.001), but not with poorer in-hospital mortality. CONCLUSIONS: The analysis suggested that living alone was associated with both 2-year all-cause mortality and MACCEs in AMI young and middle-aged patients but did not show an extra effect on the in-hospital mortality after covariate adjustment. TRIAL REGISTRATION: Trial registration number: NCT01874691; Registered 31 October 2012.

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.

The impact of fasting stress hyperglycemia ratio, fasting plasma glucose and hemoglobin A1c on in-hospital mortality in patients with and without diabetes: findings from the China acute myocardial infarction registry.

BACKGROUND: Stress hyperglycemia was positively associated with poor prognosis in individuals with acute myocardial infarction (AMI). However, admission glucose and stress hyperglycemia ratio (SHR) may not be the best indicator of stress hyperglycemia. We performed this study to evaluate the comparative prognostic value of different measures of hyperglycemia (fasting SHR, fasting plasma glucose [FPG], and hemoglobin A1c [HbA1c]) for in-hospital mortality in AMI patients with or without diabetes. METHODS: In this prospective, nationwide, multicenter China Acute Myocardial Infarction (CAMI) registry, 5,308 AMI patients including 2081 with diabetes and 3227 without diabetes were evaluated. Fasting SHR was calculated using the formula [(first FPG (mmol/l))/(1.59×HbA1c (%)-2.59)]. According to the quartiles of fasting SHR, FPG and HbA1c, diabetic and non-diabetic patients were divided into four groups, respectively. The primary endpoint was in-hospital mortality. RESULTS: Overall, 225 (4.2%) patients died during hospitalization. Individuals in quartile 4 had a significantly higher rate of in-hospital mortality compared with those in quartile 1 in diabetic cohort (9.7% vs. 2.0%; adjusted odds ratio [OR] 4.070, 95% CI 2.014-8.228) and nondiabetic cohort (8.8% vs. 2.2%; adjusted OR 2.976, 95% CI 1.695-5.224). Fasting SHR was also correlated with higher in-hospital mortality when treated as a continuous variable in diabetic and nondiabetic patients. Similar results were observed for FPG either as a continuous variable or a categorical variable. In addition, fasting SHR and FPG, rather than HbA1c, had a moderate predictive value for in-hospital mortality in patients with diabetes (areas under the curve [AUC] for fasting SHR: 0.702; FPG: 0.689) and without diabetes (AUC for fasting SHR: 0.690; FPG: 0.693). The AUC for fasting SHR was not significantly different from that of FPG in diabetic and nondiabetic patients. Moreover, adding fasting SHR or FPG to the original model led to a significant improvement in C-statistic regardless of diabetic status. CONCLUSIONS: This study indicated that, in individuals with AMI, fasting SHR as well as FPG was strongly associated with in-hospital mortality regardless of glucose metabolism status. Fasting SHR and FPG might be considered as a useful marker for risk stratification in this population. TRIAL REGISTRATION: ClinicalTrials.gov NCT01874691.

Naphthyl-Poly(S-((2-carboxyethyl)thio)-l-cysteine) Peptide Amphiphiles with Different Degrees of Polymerization: Synthesis, Self-Assembly, pH/Reduction-Triggered Drug Release, and Cytotoxicity.

Four peptide amphiphiles (PA1-4) with different degrees of polymerization (DP = 40, 15, 10, and 6) were synthesized by Fuchs-Farthing and ring-opening polymerization followed by post-polymerization modification, as fully characterized by 1H NMR, FT-IR, gel permeation chromatography, and circular dichroism (CD) spectroscopy. It was found that PAs could self-assemble to form regular spherical micelles in low-concentration (about 1 mg/mL) aqueous solution, which had different contents of secondary structures and mainly adopted random coil conformations. The water solubility of PAs increases with the increase of DP, the polypeptide chain stretches randomly in water, the ß-sheets decrease, and the random coil conformations dominate. When the pH of PA solution decreases or increases, intramolecular hydrogen bonds break, and molecular chains stretch, leading to a decrease of α-helix, turn conformations, and an increase of ß-sheets. Meanwhile, the particle size of micelles increases. At around 0.4 mg/mL, the hemolysis ability of PA2 is negligible at pH 7.4 and 6.5 and about 33% at pH 5.5. Cisplatin (CDDP) was linked to micelles by coordination bonds to explore their potential as drug carriers, exhibiting controlled pH and reduction in dual drug release effects. MTT assay showed that the HeLa cell viability was 78% when cultured in the 13.5 µg/mL PA2 blank micelles for 2 days, while the cell viability was 60% in the CDDP-loaded micelles. Furthermore, a high concentration of PA2 (about 100 mg/mL) could self-assemble into a fibrous hydrogel at pH 5.5, which self-healed 2 h after incision and self-degraded 71% within 14 days. The CDDP-loaded fiber hydrogel exhibited a sustained release effect similar to the CDDP-loaded micelles. The cytotoxicity of CDDP-loaded fibers at 48 h was detected to be the same as that of the same amount of CDDP, and the cell viability was 7%. Therefore, we provide a new strategy for the synthesis of amphiphilic peptides with potential applications in nano-drug carriers and cancer therapy.

Fibrinolytic therapy use for ST-segment elevation myocardial infarction and long-term outcomes in China: 2-year results from the China Acute Myocardial Infarction Registry.

BACKGROUND: Data on fibrinolytic therapy use for ST-segment elevation myocardial infarction (STEMI) and long-term clinical outcomes in developing countries are limited. We aimed to investigate the management and 2-year mortality of fibrinolytic-treated patients in China. METHODS: A total of 19,112 patients with STEMI from 108 hospitals participated in the China Acute Myocardial Infarction registry between January 2013 and September 2014. We investigated the 2-year all-cause mortality among patients treated with fibrinolysis. Non-invasive clinical indexes were used to diagnose successful fibrinolysis or not. RESULTS: Only 1823 patients (9.5%) enrolled in the registry underwent fibrinolysis and 679 (37.2%) could be treated within 3 h after symptom onset. The overall use of rescue percutaneous coronary intervention was 8.9%. Successful fibrinolysis, which could be achieved in 1428 patients (78.3%), was related to types of fibrinolytic agents, symptom to needle time, infarction site, and Killip class. Follow-up data were available for 1745 patients (95.7%). After multivariate adjustment, successful fibrinolysis was strongly associated with a decreased risk of death compared with failed fibrinolysis at 2 years (8.5% vs. 29.0%, hazard ratio: 0.27, 95% confidence interval: 0.20-0.35). CONCLUSION: Within a minority of STEMI patients in the CAMI registry underwent fibrinolysis, most of them could achieve successful clinical reperfusion, presenting a much benign 2-year survival outcome than those with failed fibrinolysis. Quality improvement initiatives focusing on fibrinolysis are warranted to achieve its promise fully. TRIAL REGISTRATION: URL: https// www. CLINICALTRIALS: gov . Unique identifier: NCT01874691. Registered 11/06/2013.

Number of standard modifiable risk factors and mortality in patients with first-presentation ST-segment elevation myocardial infarction: insights from China Acute Myocardial Infarction registry.

BACKGROUND: Recent publications reported a paradoxical finding that there was an inverse association between the number of standard modifiable risk factors (SMuRFs; smoking, hypertension, diabetes, and hyperlipidemia) and mortality in patients with myocardial infarction. However, the current evidence is only limited to those highly developed countries with advanced medical management systems. METHODS: The China Acute Myocardial Infarction registry is a prospective observational study including patients with acute myocardial infarction from three-level hospitals across 31 administrative regions throughout mainland China. A total of 16,228 patients with first-presentation ST-elevation myocardial infarction (STEMI) admitted to hospitals from January 2013 to September 2014 were enrolled in the current analysis. Cox proportional hazard models adjusting for baseline characteristics, clinical profiles at presentation, and in-hospital treatments were used to assess the association of the number of SMuRFs with all-cause mortality at 30 days after STEMI presentation. RESULTS: A total of 1918 (11.8%), 11,503 (70.9%), and 2807 (17.3%) patients had 0, 1-2, and 3-4 SMuRFs at presentation, respectively. Patients with fewer SMuRFs were older and more likely to be females, experienced longer pre-hospital delays, and were less likely to receive primary percutaneous coronary intervention and evidence-based medications. Compared with those without any SMuRF, patients with 1-2 SMuRFs and 3-4 SMuRFs were associated with an HR of 0.74 (95% CI, 0.63-0.87) and 0.63 (0.51-0.77) for all-cause mortality up to 30 days in the unadjusted model (Ptrend < 0.0001). However, after multivariate adjustment, the number of SMuRFs was positively associated with increased mortality risk (HR for 1-2 SMuRFs, 1.15 [0.95-1.39]; HR for 3-4 SMuRFs, 1.31 [1.02-1.68]; Ptrend = 0.03), and the association was only significant among patients admitted to hospitals beyond 12 h from onset (HR for 1-2 SMuRFs, 1.39 [1.03-1.87]; HR for 3-4 SMuRFs, 2.06 [1.41-3.01]) but not their counterparts (Pinteraction = 0.01). CONCLUSIONS: The increased crude mortality risk among patients without SMuRFs is explained by confounding factors related to their poor risk profiles (old age, longer pre-hospital delays, and poor clinical management). After multivariate adjustment, a higher risk-factor burden was associated with poor prognosis among patients with STEMI.

Stress hyperglycemia ratio and long-term mortality after acute myocardial infarction in patients with and without diabetes: A prospective, nationwide, and multicentre registry.

AIMS: To assess the predictive value of stress hyperglycemia ratio (SHR) for long-term mortality after acute myocardial infarction (AMI) in patients with and without diabetes. MATERIALS AND METHODS: We evaluated 6892 patients with AMI from the prospective, nationwide, multicentre China Acute Myocardial Infarction registry, of which 2820 had diabetes, and the remaining 4072 were nondiabetic patients. Patients were divided into high SHR and low SHR groups according to the optimal cutoff values of SHR to predict long-term mortality for diabetic and nondiabetic patients, respectively. The primary endpoint was all-cause mortality at 2 years. RESULTS: The optimal cutoff values of SHR for predicting 2-year mortality were 1.20 and 1.08 for the diabetic and nondiabetic population, respectively. Overall, patients with high SHR were significantly associated with higher all-cause mortality compared with those with low SHR, in both diabetic patients (18.5% vs. 9.7%; hazard ratio [HR] 2.01, 95% confidence interval 1.63-2.49) and nondiabetic patients (12.0% vs. 6.4%; HR 1.95, 95%CI 1.57-2.41). After the potential confounders were adjusted, high SHR was significantly associated with higher risks of long-term mortality in both diabetic (adjusted HR 1.73, 95%CI 1.39-2.15) and nondiabetic (adjusted HR 1.63, 95%CI 1.30-2.03) patients. Moreover, adding SHR to the original model led to a slight albeit significant improvement in C-statistic, net reclassification, and integrated discrimination regardless of diabetic status. CONCLUSIONS: This study demonstrated a strong positive association between SHR and long-term mortality in patients with AMI with and without diabetes, suggesting that SHR should be considered a useful marker for risk stratification in these patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT01874691.

De-escalation of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome: An Updated Meta-analysis and Trial Sequential Analysis of 21 Studies and 38,741 Patients.

ABSTRACT: Dual antiplatelet therapy (DAPT) is recommended among patients with established acute coronary syndrome. In this meta-analysis, we sought to compare the clinical outcomes between de-escalation versus unchanged DAPT based on both randomized controlled trials (RCTs) and observational studies. The primary outcomes were major adverse cardiovascular events for observational studies and net clinical events for RCTs. Four RCTs and 17 observational studies with a total of 38,741 patients were included. Net clinical events were more common with unchanged DAPT than with de-escalation in RCTs [odd ratio (OR): 1.71; 95% confidence interval (CI), 1.21-2.43; I2 = 69.4%], which was mainly due to higher risks of any bleeding (OR: 1.81; 95% CI, 1.14-2.88; I2 = 75.5%) and major bleeding (OR: 1.58; 95% CI, 1.02-2.46; I2 = 0), without significant differences in ischaemic events. However, trial sequential analysis revealed that sufficient information was obtained just for net clinical events, not for respective ischaemic or bleeding events in RCTs. In the analysis based on real-world observational studies, the risks of myocardial infarction (OR: 0.77; 95% CI, 0.61-0.98; I2 = 0) and stroke (OR: 0.42; 95% CI, 0.22-0.81; I2 = 0) were lower with the unchanged DAPT group. Therefore, de-escalation of DAPT led to a marked reduction in net clinical events compared with unchanged DAPT in RCTs, which was mainly due to reduced bleeding events. However, sufficient information for ischaemic events was not obtained. In the analysis based on real-world observational studies, myocardial infarction and stroke were more common with de-escalation, which should arise our attention.

The 11-Year Prognostic Impact of Chronic Total Occlusion in the Noninfarct-Related Coronary Artery on Patients with Acute Myocardial Infarction.

BACKGROUND: The prognostic significance of CTO in the non-IRA in patients with AMI has been under dispute. Relevant long-term follow-up studies are lacking. Hypothesis. CTO in the non-IRA is an independent predictor of poor long-term prognosis in patients with AMI. METHODS: We prospectively enrolled 2336 patients with AMI who received emergent percutaneous coronary intervention successfully from January 2006 to May 2011. Our primary endpoints included death from cardiovascular causes, recurrent myocardial infarction, stroke, and target-vessel revascularization. We adopted Cox regression analysis adjusted for confounders to analyze the impact of CTO in the non-IRA on long-term mortalities. RESULTS: We identified 628 (27.6%) subjects with CTO in the non-IRA among 2282 AMI patients. After a mean follow-up duration of 134.3 months, we found the CTO group had significantly higher MACCE rate than the group without CTO (30.4% versus 24.3%, P=0.004). CTO in the non-IRA independently predicted 11-year MACCE in the male AMI subgroup (hazard ratio 1.28, 95% confidence interval 1.06 to 1.54, P=0.01) and in the male NSTEMI subgroup (hazard ratio 1.53, 95% confidence interval 1.09 to 2.15, P=0.02). In the CTO group, three-vessel disease independently predicted 11 year MACCE (hazard ratio 2.05, 95% confidence interval 1.29 to 3.28, P=0.002). CONCLUSIONS: Our long-term observational study supported the association between CTO in the non-IRA and poorer prognosis in AMI patients undergoing primary PCI. We identified the group with the three-vessel disease as a high-risk subgroup in patients with CTO in the non-IRA.

Effect of Baseline Thrombocytopenia on Long-Term Outcomes in Patients With Acute ST-Segment Elevated Myocardial Infarction　- A Large Propensity Score-Matching Analysis From the China Acute Myocardial Infarction (CAMI) Registry.

BACKGROUND: Data on the association of baseline thrombocytopenia (TP) with long-term outcomes of patients with acute ST-segment elevated myocardial infarction (STEMI) are still limited.Methods and Results:A total of 16,957 consecutive cases of patients with STEMI from multiple centers that participated in the China Acute Myocardial Infarction (CAMI) registry were included in this study. Two-year clinical outcomes were evaluated between patients with TP and those with a normal platelet count (PLT). Cases coexisting with baseline TP accounted for 2.1%. The rates of 2-year all-cause death (21.4% and 11.4%, P<0.001) and major adverse cardiovascular and cerebrovascular events (MACCE) (23.6% and 13.9%, P<0.001) were significantly higher in cases with TP, compared with the normal PLT group. After multivariate adjustment, compared with the control, cases with TP were not independently associated with 2-year all-cause death (HR: 1.21; 95% CI: 0.96-1.52; P=0.110) and MACCE (HR: 1.18; 95% CI: 0.95-1.47; P=0.132). After propensity score matching (PSM), the rates of 2-year all-cause death and MACCE were similar between the 2 groups (20.7% and 17.9%, P=0.317; 23.0% and 19.9%, P=0.288). Multivariable adjustment after PSM showed baseline TP was not independently associated with all-cause death (HR: 1.21; 95% CI: 0.88-1.67; P=0.240) and MACCE (HR: 1.21; 95% CI: 0.89-1.63; P=0.226). CONCLUSIONS: Patients with STEMI and baseline TP had higher rates of all-cause death and MACCE; however, baseline TP was not independently associated with 2-year adverse outcomes in patients with STEMI after multivariate adjustment and controlling for baseline differences.

Evidence-based oral antiplatelet therapy among hospitalized Chinese patients with acute myocardial infarction: results from the Chinese acute myocardial infarction registry.

BACKGROUND: Oral antiplatelet therapy is the cornerstone of treatment for acute myocardial infaction (AMI). However, detailed usage data on oral antiplatelet therapy are lacking. METHODS: Using data from a nationally representative sample of patients with AMI, the detailed usage of oral antiplatelet therapy was analyzed in 40,202 consecutive eligible patients. RESULTS: The proportions of patients with AMI taking loading doses of aspirin and P2Y12 inhibitors were relatively low (62.2% and 63.6%, respectively), whereas approximately 90% of patients received maintenance doses of aspirin, P2Y12 inhibitors, and dual antiplatelet therapy. The proportions of patients taking loading doses of aspirin and P2Y12 inhibitors gradually decreased with age. Male sex, an educational level of at least college, an interval from onset to treatment of < 24 h, and primary PCI use were associated with a higher proportion of patients taking a loading dose of antiplatelet therapy, whereas those receiving conservative treatment had a lower rate of antiplatelet use (all P < 0.05). The proportion of patients taking loading doses of aspirin was highest in the western region, and that of patients taking loading doses of P2Y12 inhibitors was highest in the eastern region (P < 0.05). In addition, 76.7% of patients with ST-elevation MI and 91% of patients with non-ST-elevation MI received 300-mg loading dose of clopidogrel. CONCLUSIONS: The proportion of patients with AMI receiving loading doses of aspirin and P2Y12 inhibitors during hospitalization was relatively low, and this rate was affected by many factors, such as age, sex, educational level, region of residence, and the interval from onset to treatment. The underutilization of guideline-based P2Y12 inhibitors was also problematic. Hence, quality improvement initiatives are needed to enhance adherence to guidelines to improve consistent use of oral antiplatelet therapy. Trial registration The Chinese Acute Myocardial Infarction Registry; Trial registration number: ChiCTR-ONC-12002636; Registered 31 October 2012; http://www.chictr.org.cn/showproj.aspx?proj=6916.

China Tongxinluo Study for myocardial protection in patients with Acute Myocardial Infarction (CTS-AMI): Rationale and design of a randomized, double-blind, placebo-controlled, multicenter clinical trial.

Acute ST-segment elevation myocardial infarction (STEMI) remains a serious life-threatening event. Despite coronary revascularization, patients might still suffer from poor outcomes caused by myocardial no-reflow and ischemic/reperfusion injury. Tongxinluo (TXL), a traditional Chinese medicine, has been preliminarily demonstrated to reduce myocardial no-reflow and ischemic/reperfusion injury. We further hypothesize that TXL treatment is also effective in reducing clinical end points for the patients with STEMI. METHODS AND RESULTS: The CTS-AMI trial is a prospective, randomized, double-blind, placebo-controlled, multicenter clinical study in China. An estimated 3,796 eligible patients with STEMI from about 120 centers are randomized 1:1 ratio to TXL or placebo groups. All enrolled patients are orally administrated a loading dose of 8 capsules of TXL or placebo together with dual antiplatelet agents on admission followed by 4 capsules 3 times a day until 12 months. The primary end point is 30-day major adverse cardiovascular and cerebrovascular events, a composite of cardiac death, myocardial reinfarction, emergency coronary revascularization, and stroke. Secondary end points include each component of the primary end point, 1-year major adverse cardiovascular and cerebrovascular events, and other efficacy and safety parameters. CONCLUSIONS: Results of CTS-AMI trial will determine the clinical efficacy and safety of traditional Chinese medicine TXL capsule in the treatment of STEMI patients in the reperfusion era.

Evaluation of a risk index for predicting short-term and long-term outcomes in patients with ST-elevation myocardial infarction.

OBJECTIVE: This study aimed to evaluate the usefulness of the admission risk index (RI) to predict short-term and long-term outcomes in a broad population with ST-elevation myocardial infarction (STEMI) using data from the Chinese Acute Myocardial Infarction Registry. BACKGROUND: The RI was developed as a simple tool to predict risk of death in STEMI patients. The performance in predicting short-term and long-term risk of death in Chinese patients receiving percutaneous coronary intervention and conservative treatment for STEMI remains unclear. METHODS: Age, heart rate (HR), and systolic blood pressure (SBP) were used to calculate RI using (HR×[age/10]2 )/SBP. We used the prediction tool to predict mortality over 12 months. RESULTS: The C-index of the admission RI for predicting in-hospital, 1-, 6-, and 12-months mortality were 0.78, 0.78, 0.78, and 0.77, respectively, compared with 0.75 of the Global Registry in Acute Coronary Events score. Based on the receiver operating characteristic curve analysis, the RI was categorized into quintiles for convenient clinical use, and it revealed a nearly 15-fold gradient of increasing mortality from 2.29 to 32.5% (p < .0001) while RI >34 had the highest mortality. By categorizing into five different risk groups, the short-term and long-term mortality of patients receiving different treatments could be distinguished. CONCLUSIONS: RI based on three routine variables and easily calculated by any medical practitioner is useful for predicting in-hospital and long-term mortality in patients with STEMI at the initial consultation with clinicians.

A Practical Risk Score to Predict 24-Month Post-Discharge Mortality Risk in Patients With Non-ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Risk stratification of patients with non-ST-segment elevation myocardial infarction (NSTEMI) is important in terms of treatment strategy selection. Current efforts have focused on short-term risk prediction after discharge, but we aimed to establish a risk score to predict the 24-month mortality risk in survivors of NSTEMI.Methods and Results:A total of 5,509 patients diagnosed with NSTEMI between January 2013 and September 2014 were included. Primary endpoint was all-cause death at 24 months. A multivariable Cox regression model was used to establish a practical risk score based on independent risk factors of death. The risk score included 9 variables: age, body mass index, left ventricular ejection fraction, reperfusion therapy during hospitalization, Killip classification, prescription of diuretics at discharge, heart rate, and hemoglobin and creatinine levels. The C-statistics for the risk model were 0.83 (95% confidence interval [CI]: 0.81-0.85) and 0.83 (95% CI: 0.79-0.86) in the development and validation cohorts, respectively. Mortality risk increased significantly across groups: 1.34% in the low-risk group (score: 0-58), 5.40% in intermediate group (score: 59-93), and 23.87% in high-risk group (score: ≥94). CONCLUSIONS: The current study established and validated a practical risk score based on 9 variables to predict 24-month mortality risk in patients who survive NSTEMI. This score could help identify patients who are at high risk for future adverse events who may benefit from good adherence to guideline-recommended secondary prevention treatment.

Plasma Magnesium Concentrations and Risk of Incident Cancer in Adults with Hypertension: A Nested Case-Control Study.

OBJECTIVE: The association between plasma magnesium and risk of incident cancer remains inconclusive in previous studies. We aimed to investigate the prospective relationship of baseline plasma magnesium concentrations with the risk of incident cancer and to examine possible effect modifiers. METHODS: A nested case-control study with 228 incident cancer cases and 228 matched controls was conducted using data from the China Stroke Primary Prevention Trial (CSPPT), a randomized, double-blind, controlled trial, conducted from May 2008 to August 2013. Study outcomes included incident cancer and its subtypes. RESULTS: When plasma magnesium concentrations were assessed as quartiles, a significantly higher incident risk of total cancer was found in participants in quartile 1 (<0.76 mmol/L; odds ratio [OR] = 2.70; 95% CI: 1.33-5.49) and quartile 4 (≥0.89 mmol/L; OR = 2.05; 95% CI: 1.12-3.76), compared with those in quartile 3 (0.83 to <0.89 mmol/L). In cancer site-specific analyses, similar trends were found for gastrointestinal cancer, esophageal cancer, gastric cancer, breast cancer, lung cancer, and other cancers. Furthermore, none of the variables, including age, sex, current smoking status, current alcohol intake, BMI, systolic blood pressure, and total cholesterol levels at baseline significantly modified the association between plasma magnesium and cancer risk. CONCLUSIONS: Both low and high plasma magnesium concentrations were significantly associated with an increased incident risk of cancer, compared with the reference concentrations of 0.83 to <0.89 mmol/L among hypertensive adults.

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.

Impact of baseline estimated glomerular filtration rate on inhospital outcomes of patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: A China acute myocardial infarction registry study.

OBJECTIVE: To explore the relationship between inhospital outcomes and different estimated glomerular filtration rates (eGFRs) and determine an optimal eGFR cutoff value for predicting risk in patients with renal insufficiency (RI). BACKGROUND: RI is a predictor of poor prognosis in patients with myocardial infarction undergoing primary percutaneous coronary intervention (PCI). However, the cutoff value of the eGFR is questionable. METHODS: We included 10,240 patients with ST segment elevation myocardial infarction (STEMI) undergoing primary PCI from January 2013 to January 2016 who participated in the China Acute Myocardial Infarction registry. RI was defined as eGFR <60 mL/min/1.73 m2 . Patients were stratified into five eGFR groups to determine the optimal cutoff value: <30, 30-45, 45-60, 60-90, and > 90 mL/min/1.73 m2 . RESULTS: Overall, 1,112 (10.9%) patients had eGFR <60 mL/min/1.73 m2 . Patients with eGFR<60 mL/min/1.73 m2 had a significantly higher incidence of all-cause death and major adverse cardiovascular and cerebrovascular events (MACCEs) than those with eGFR >60 mL/min/1.73 m2 . Occurrence trend test analysis revealed that the incidence of inhospital all-cause death and MACCEs increased as the eGFR decreased. In logistic multivariate-adjusted analysis, eGFR <45 mL/min/1.73 m2 was associated with a higher incidence of all-cause death and MACCEs than eGFR >90 mL/min/1.73 m2 . CONCLUSIONS: RI is common among patients with STEMI undergoing primary PCI. A low eGFR is an indicator of worse inhospital prognosis. We suggest an eGFR cutoff value of 45 mL/min/1.73 m2 to predict inhospital deaths and MACCEs.

The association between body mass index and in-hospital outcome among patients with acute myocardial infarction-Insights from China Acute Myocardial Infarction (CAMI) registry.

BACKGROUND: The relationship between body mass index (BMI) and in-hospital mortality risk among patients with acute myocardial infarction (AMI) remains controversial. METHODS AND RESULTS: We included 35,964 patients diagnosed with AMI in China Acute Myocardial Infarction registry between January 2013 and December 2016. Patients were categorized into 4 groups according to BMI level: BMI <18.5, 18.5-24.9, 25-30, and ≥30 kg/m2 for underweight, normal, overweight, and obese groups, respectively. Clinical data were extracted for each patient, and multivariable logistic regression analysis was used to examine the association between BMI level and in-hospital mortality. Compared with normal-weight patients, obese patients were younger, more often current smokers, and more likely to have hypertension, hyperlipidemia, and diabetes. Multivariable regression analysis results demonstrated that compared with normal group, underweight group had significantly higher in-hospital mortality (odds ratio [OR]: 1.34; 95% confidence interval [CI]: 1.06-1.69; p = 0.016), while overweight group (OR: 0.86; 95% CI: 0.77-0.97; p = 0.011) and obese group (OR: 0.65; 95% CI: 0.46-0.91; p = 0.013) had lower mortality. All subgroups showed a trend toward lower in-hospital mortality risk as BMI increased. CONCLUSIONS: Our study provided robust evidence supporting "obesity paradox" in a contemporary large-scale cohort of patients with AMI and demonstrated that increased BMI was independently associated with lower in-hospital mortality.

Association of thrombocytopenia with in-hospital outcome in patients with acute ST-segment elevated myocardial infarction.

This study investigated the association of thrombocytopenia (TP) with in-hospital medication and outcome of patients with acute ST-segment elevated myocardial infarction (STEMI). A total of 16,678 consecutive patients with STEMI from multiple centers that participated in the China Acute Myocardial Infarction registry was included. In-hospital adverse event rates were compared between patients with TP and those with a normal platelet count. Multivariate logistic regression was applied to adjust for confounders. Propensity score matching (PSM) was applied to control for baseline differences. There were 359 patients with baseline TP, accounting for 2.2% of the total cohort. The risk of in-hospital death (11.1% vs 6.0%, P < 0.001); major adverse cardiovascular events (MACE) (11.7% vs 6.4%, P < 0.001); and newly occurred or aggravated heart failure, cardiogenic shock, malignant arrhythmia, acute pulmonary embolism, and bleeding (3.6% vs 1.8%, P = 0.024) were significantly higher in the TP group than in the normal platelet group. After multivariate adjustment, TP was independently associated only with malignant arrhythmia (odds ratio: 1.49; 95% confidence interval: 1.09-2.05, P = 0.014). A total of 289 patients in each group were matched by PSM. The risk of all endpoints was not significantly different between the two matched groups before and after multivariate adjustment. In-hospital outcomes were worse in patients with STEMI and TP than in those with a normal platelet count. However, baseline TP was not independently associated with in-hospital death, MACE, or bleeding risk after multivariate adjustment and controlling for baseline differences.