The impact of cerebral small vessel disease burden on prognosis in patients with acute coronary syndrome

Background Acute coronary syndrome(ACS)presents with a variable prognosis,posing significant public health challenges.This study investigated the potential link between cerebral small vessel disease(CSVD)burden and outcomes in patients with ACS.Methods In this retrospective cohort study,ACS patients admitted to Beijing Friendship Hospital,Capital Medical Universi-ty,Beijing,China from January 2020 to October 2021,were analyzed.CSVD burden was assessed using magnetic resonance ima-ging markers,including white matter lesions,lacunar infarcts,cerebral microbleeds,and enlarged perivascular spaces.The correl-ation between CSVD burden and clinical outcomes,including major adverse cardiovascular and cerebrovascular events,myocar-dial infarction(MI),target vessel revascularization,stroke,and mortality was examined over a one-year follow-up.Results Out of 248 patients,216 patients were categorized into the low score group(LSG-CSVD)and 32 patients were categor-ized into the high score group(HSG-CSVD).Patients in the HSG-CSVD group exhibited significantly worse prognosis,with an el-evated risk of major adverse cardiovascular and cerebrovascular events,MI,and target vessel revascularization.After adjusting for age,sex,hypertension,troponin T,and estimated glomerular filtration rate,a significantly higher risk of MI was observed in the HSG-CSVD group(HR=4.51,95%CI:1.53-13.26,P=0.006).Subgroup analysis by age and sex consistently demonstrated in-creased adverse outcomes in the HSG-CSVD.Conclusions The study highlights a direct association between increased CSVD burden and poorer ACS outcomes,particular-ly in MI risk.These findings underscore the importance of considering CSVD burden as a crucial prognostic factor in ACS manag-ement,facilitating risk stratification and guiding personalized treatment strategies.

Real world effectiveness of PCSK-9 inhibitors combined with statins versus statins-based therapy among patients with very high risk of atherosclerotic cardiovascular disease in China(RWE-PCSK study)

BACKGROUND The efficacy and safety of proprotein convertase subtilisin/kexin type 9(PCSK-9) inhibitors were confirmed by several clinical trials, but its effectiveness in routine clinical practice in China has not been evaluated. This study aims to describe the real world effectiveness of PCSK-9 inhibitors combined with statins compared with statins-based therapy among patients with very high risk of atherosclerotic cardiovascular disease(ASCVD).METHODS This is a multi-center observational study, enrolled patients from 32 hospitals who underwent percutaneous coronary intervention(PCI) from January to June in 2019. There are 453 patients treated with PCSK-9 inhibitors combined with statins in PCSK-9 inhibitor group and 2,610 patients treated with statins-based lipid lowering therapies in statins-based group. The lipid control rate and incidence of major adverse cardiovascular events(MACE) over six months were compared between two groups.A propensity score-matched(PSM) analysis was used to balance two groups on confounding factors. Survival analysis using Kaplan-Meier methods was applied for MACE.RESULTS In a total of 3,063 patients, 89.91% of patients had received moderate or high-intensity statins-based therapy before PCI, but only 9.47% of patients had low-density lipoprotein cholesterol(LDL-C) levels below 1.4 mmol/L at baseline. In the PSM selected patients, LDL-C level was reduced by 42.57% in PCSK-9 inhibitor group and 30.81%(P < 0.001) in statins-based group after six months. The proportion of LDL-C ≤ 1.0 mmol/L increased from 5.29% to 29.26% in PCSK-9 inhibitor group and 0.23% to 6.11% in statins-based group, and the proportion of LDL-C ≤ 1.4 mmol/L increased from 10.36% to 47.69% in PCSK-9 inhibitor group and 2.99% to 18.43% in statins-based group(P < 0.001 for both). There was no significant difference between PCSK-9 inhibitor and statins-based treatment in reducing the risk of MACE(hazard ratio = 2.52, 95% CI: 0.49-12.97, P = 0.250).CONCLUSIONS In the real world, PCSK-9 inhibitors combined with statins could significantly reduce LDL-C levels among patients with very high risk of ASCVD in China. The long-term clinical benefits for patients received PCSK-9 inhibitor to reduce the risk of MACE is still unclear and requires further study.

Evaluation of metoprolol standard dosing pathway in Chinese patients with acute coronary syndrome:a prospective multicenter single-arm interventional study

OBJECTIVE To evaluate the feasibility and tolerability of metoprolol standard dosing pathway(MSDP)in Chinese patients with acute coronary syndrome(ACS).METHODS In this multicenter,prospective,open label,single-arm and interventional study that was conducted from February 2018 to April 2019 in fifteen Chinese hospitals.A total of 998 hospitalized patients aged≥18 years and diagnosed with ACS were included.The MSDP was applied to all eligible ACS patients based on the standard treatment recommended by international guidelines.The primary endpoint was the percentage of patients achieving the target dose at discharge(V2).The secondary endpoints included the heart rate and blood pressure at V2 and four weeks after discharge(V4),and percentage of patients experiencing bradycardia(heart rate<50 beats/min),hypotension(blood pressure<90/60 mmHg)and transient cardiac dysfunction at V2 and V4.RESULTS Of the 998 patients,29.46%of patients achieved the target dose(≥95 mg/d)at V2.The total population was divided into two groups:target group(patients achieving the target dose at V2)and non-target group(patients not achieving the target dose at V2).There was significant difference in the reduction of heart rate from baseline to discharge in the two groups(-4.97±11.90beats/min vs.-2.70±9.47 beats/min,P=0.034).There was no significant difference in the proportion of bradycardia that occurred in the two groups at V2(0 vs.0,P=1.000)and V4(0.81%vs.0.33%,P=0.715).There was no significant difference in the proportion of hypotension between the two groups at V2(0.004%vs.0.004%,P=1.000)and V4(0 vs.0.005%,P=0.560).No transient cardiac dysfunction occurred in two groups during the study.A total of five adverse events(1.70%)and one serious adverse event(0.34%)were related to the pathway in target group.CONCLUSIONS In Chinese ACS patients,the feasibility and tolerability of the MSDP have been proved to be acceptable.

Long-term Prognosis of Patients with Acute non-ST-segment Elevation Myocardial Infarction undergoing Different Treatment Strategies

Background： In cardiology, it is controversial whether different therapy strategies influence prognosis after acute coronary syndrome. We examined and compared the long-term outcomes of invasive and conservative strategies in patients with non-ST-segment elevation myocardial infarction （NSTEMI） and characterized the patients selected for an invasive approach. Methods： A total of 976 patients with acute NSTEMI were collected from December 2006 to October 2012 in the First Affiliated Hospital of Dalian Medical University Hospital. They are divided into conservative strategy （586 patients） and invasive strategy （390 patients） group. Unified tbllow-up questionnaire was performed by telephone contact （cut-off date was November, 2013）. The long-term clinical events were analyzed and related to the different treatment strategies. Results： The median follow-up time was 29 months. Mortality was 28.7% （n = 168） in the conservative group and 2.1% （n = 8） in the invasive management at long-term clinical follow-up. The secondary endpoint （the composite endpoint） was 59.0% （n = 346） in the conservative group and 30.3% （n = 118） in the invasive management. Multivariate analysis showed that patients in the conservative group had higher all-cause mortality rates than those who had the invasive management （adjusted risk ratio [RR] = 7.795; 95% confidence interval [CI]： 3.796 16.006, P 〈 0.001）, and the similar result was also seen in tile secondary endpoint （adjusted RR ： 2.102; 95% （7： 1.694-2.610, P 〈 0.001 ）. In the subgroup analysis according to each Thrombolysis in Myocardial Infarction risk score （TRS）, log-rank analysis showed lower mortality and secondary endpoint rates in the invasive group with the intermediate and high-risk patients （TRS 3-7）. Conclusions： An invasive strategy could improve long-term outcomes for NSTEMI patients, especially for intermediate and high-risk ones （TRS 3- 7）.

Tumor necrosis factor-a and its role as a mediator in myocardial infarction:A brief review

Tumor necrosis factor-a (TNF-a) contributes to myocardial infarction (MI) injury. Polymorphism of TNF-a gene promoter region and secretion and release of TNF-a and its transformation by a series of signaling pathways are all changed at different points of pathophysiological process in MI. Researches also investigated TNF-a antagonists and their potential therapeutic role in the setting of MI and heart failure at both molecular and clinical level. This article briefly reviews TNF-a and its mechanism as a mediator in MI. Copyright ? 2015, Chinese Medical Association Production. Production and hosting by Elsevier B.V. on behalf of KeAi Communications Co., Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Preferences and attitudes of young Chinese clinicians about using a shared decision making tools for communicating cardiovascular risk

Objective: This study assesses the attitudes and preferences of Chinese clinicians toward their involvement in shared decision making (SDM). Methods: From May 2014 to May 2015, 200 Chinese clinicians from two hospitals were enrolled to complete a survey on their attitude towards SDM. We conducted the survey via face-to-face interviews before and after an educational intervention on SDM among young Chinese clinicians. The clinicians were asked to give the extent of agreement to SDM. They also gave the extent of difficulty in using decision aids (DAs) during the SDM process. The variation in the range of responses to each question before and after the SDM intervention was recorded. The frequency of changed responses was analyzed by using JMP 6.0 software. Data were statistically analyzed using Chi-square and Mann—Whitney U tests, as appropriate to the data type. Multiple logistic regressions were used to test for those factors significantly and independently associated with preference for an approach for each scenario. Results: Of the 200 young Chinese clinicians sampled, 59.0% indicated a preference for SDM and a desire to participate in SDM before receiving education or seeing the DA, and this number increased to 69.0% after seeing the DA with the sample video of the SDM process on Statin Choice. However, 28.5% of the respondents still reported that, in their current practice, they make clinical decisions on behalf of their patients. The clinicians who denied a desire to use the DA stated that the main barriers to implement SDM or DA use in China are lack of time and knowledge of SDM.

Stem cell transplantation dose in patients with acute myocardial infarction:A meta-analysis

Objective: To evaluate whether stem cell transplantation improves global left ventricular ejection fraction (LVEF) in patients with acute myocardial infarction (AMI), and to determine the appropriate stem cell therapy dose as well as the effective period after stem cell transplantation for therapy. Methods: A systematic literature search included Pubmed, MEDLINE, China National Knowledge Infrastructure (CNKI), Chi-nese Biomedical Literature Database (CBM), and Cochrane Evidence-Based Medicine databases. The retrieval time limit ranged from January 1990 to June 2016. We also obtained full texts through manual retrieval, interlibrary loan and document delivery service, or by contacting the authors directly. According to our inclusion and exclusion criteria, data were extracted independently by two evaluators. In case of disagreement, a joint discussion occurred and a third researcher was utilized. Data were analyzed quantitatively using Revman 5.2. Summary results are presented as the weighted mean difference (WMD) with 95%confidence intervals (CIs). We collected individual trial data and conducted a meta-analysis to compare changes in global left ventricular ejection fraction (△LVEF) after stem cell therapy. In this study, four subgroups were based on stem cell dose (≤1 × 107 cells,≤1 × 108 cells,≤1 × 109 cells, and≤1 × 1010 cells) and three subgroups were based on follow-up time (<6 months, 6-12 months, and≥12 months). Results: Thirty-four studies, which included 40 randomized controlled trials, were included in this meta-analysis, and 1927 pa-tients were evaluated. Changes in global LVEF were significantly higher in the stem cell transplantation group than in the control group (95% CI: 2.35-4.26%, P < 0.01). We found no significant differences in △LVEF between the bone marrow stem cells (BMCs) group and control group when the dose of BMCs was≤1 × 107 (△LVEF 95%CI:0.12-3.96%, P=0.04)The△LVEF in the BMCs groups was significantly higher than in the control groups when the dose of BMCs was≤1 × 108 [△LVEF 95%CI:0.95-4.25%, P=0.002] and≤1 × 109 (△LVEF 95%CI:2.31-4.20%, P<0.01)In addition, when the dose of BMCs was between 109 and 1010 cells, we did not observe any significant differences (△LVEF 95%CI:-0.99-11.82%, P=0.10)Our data suggest stem cell therapy improves cardiac function in AMI patients when treated with an appropriate dose of BMCs.Conclusion: Stem cell transplantation after AMI could improve global LVEF. Stem cells may be effectively administered to patients with AMI doses between 108 and 109 cells.