The Effect of Home-Based Cardiac Rehabilitation on Functional Capacity,Behavior,and Risk Factors in Patients with Acute Coronary Syndrome in China

Aim:To investigate the effect of home-based cardiac rehabilitation on functional capacity,health behavior,and risk factors in patients with acute coronary syndrome in China.Methods:Eighty patients with acute coronary syndrome were enrolled in this prospective randomized controlled study.Patients in the cardiac rehabilitation group(n=52)received home-based cardiac rehabilitation with a heart manual and a home exercise video for 3 months and patients in the control group(n=28)received only routine secondary prevention.The 6-min walk distance,laboratory test results,healthy behavior(questionnaire),quality of life(12-item Short Form Health Survey),anxiety(7-item Generalized Anxiety Disorder Questionnaire),and depression(9-item Patient Health Questionnaire)were evaluated at the beginning and after treatment for 3 months.Results:Compared with baseline data,52 patients who participated in cardiac rehabilitation had longer 6-min walk distance(515.26±113.74 m vs 0.445.30±97.92 m,P<0.0002),higher proportions of“always exercise”(78.26% vs.28%,P<0.05),“always limit food with sugar”(65.22% vs 12%,P<0.05),“always eat fruits 200–400 g every day”(82.61% vs.4%,P<0.05).and“always eat vegetables 300–500 g every day”(21.74%vs.12%,P<0.06)after treatment for 3 months.The low-density lipoprotein cholesterol control rate(52.17% vs.28%,P<0.05)and the systolic blood pressure control rate(100%vs.68%,P<0.05)were also signifi cantly increased after treatment for 3 months in the cardiac rehabilitation group.No signifi cant increase was found in the control group after treatment for 3 months.No cardiac-event related to home exercise was reported in both groups.Conclusion:Home-based cardiac rehabilitation is a feasible and available cardiac rehabilitation mode in China.

Editorial by the Founding Editor

When China opened its doors to the world 26 years ago,there were very few cardiology meetings organized in China with an international outlook.Shortly thereafter,in 1990,the Great Wall International Congress of Cardiology(GW-ICC)held its inaugural meeting.In its fi rst few years,the main focus of the GW-ICC was promoting research and education within the Chinese cardiology community,and on promulgating techniques such as catheter ablation of tachyarrhythmias and balloon angioplasty.Even from this early stage,the GW-ICC became a great social and scientifi c success.The reason for this success was that the GW-ICC offered opportunities for Chinese cardiologists to make direct contact with their US and European colleagues who in turn loved to come to China and learn about the issues facing cardiologists here.

Dyslipidemia and Management of Atherosclerotic Cardiovascular Diseases in China:New Evidence and New Guidelines

The 2016 revision of the“Chinese Guidelines on Prevention and Treatment of Dyslipidemia in Adults”is the outcome of the joint efforts of the members of an expert panel for more than 1 year,and is based on the 2007 guidelines.There is no doubt that the release of the 2007 guidelines greatly facilitated the management of dyslipidemia and the prevention and treatment of atherosclerotic cardiovascular diseases(ASCVDs)in China.However,an update of the guidelines for the management of dyslipidemia in Chinese adults is urgently needed since huge changes have occurred in the concepts of dyslipidemia research and control during the last decade.

In Memoriam:C.Richard Conti,MD(1934–2022),Founding Editor-in-Chief of Cardiovascular Innovations and Applications

In February 2022,we were deeply shocked and sad-dened to hear of the death of Dr C.Richard Conti,a legendary cardiovascular educator,researcher,and Co-Editor-in-Chief of Cardiovascular Innovations and Applications.Dr Conti was a fi rst-class editor who led CVIA with great commitment.The Editorial Board members wish to express their great sad-ness about the passing of Dr Conti;his enthusias-tic and passionate work for the journal will not be forgotten.

Changes in process and outcome for ST elevation myocardial infarction in central China from 2011 to 2018

Background:Limited data are available on the changes in the quality of care for ST elevation myocardial infarction(STEMI)during China’s health system reform from 2009 to 2020.This study aimed to assess the changes in care processes and outcome for STEMI patients in Henan province of central China between 2011 and 2018.Methods:We compared the data from the Henan STEMI survey conducted in 2011-2012(n=1548,a cross-sectional study)and the Henan STEMI registry in 2016-2018(n=4748,a multicenter,prospective observational study).Changes in care processes and in-hospital mortality were determined.Process of care measures included reperfusion therapies,aspirin,P2Y12 antagonists,β-blockers,angiotensin-converting enzyme inhibitors or angiotensin receptor blockers,and statins.Therapy use was analyzed among patients who were considered ideal candidates for treatment.Results:STEMI patients in 2016-2018 were younger(median age:63.1 vs.63.8 years)with a lower proportion of women(24.4%[1156/4748]vs.28.2%[437/1548])than in 2011-2012.The composite use rate for guideline-recommended treatments increased significantly from 2011 to 2018(60.9%[5424/8901]vs.82.7%[22,439/27,129],P<0.001).The proportion of patients treated by reperfusion within 12 h increased from 44.1%(546/1237)to 78.4%(2698/3440)(P<0.001)with a prolonged median onset-to-first medical contact time(from 144 min to 210 min,P<0.001).The use of antiplatelet agents,statins,andβ-blockers increased significantly.The risk of in-hospital mortality significantly decreased over time(6.1%[95/1548]vs.4.2%[198/4748],odds ratio[OR]:0.67,95%confidence interval[CI]:0.50-0.88,P=0.005)after adjustment.Conclusions:Gradual implementation of the guideline-recommended treatments in STEMI patients from 2011 to 2018 has been associated with decreased in-hospital mortality.However,gaps persist between clinical practice and guideline recommendation.Public awareness,reperfusion strategies,and construction of chest pain centers need to be further underscored in central China.

A Multicentre Prospective Evaluation of the Impact of Renal Insufficiency on In-hospital and Long-term Mortality of Patients with Acute ST-elevation Myocardial Infarction

Background：Numerous previous studies have shown that renal insufficiency （RI） in patients with acute coronary syndrome is associated with poor cardiovascular outcomes.These studies do not well address the impact of RI on the long-term outcome of patients with acute ST-elevation myocardial infarction （STEMI） in China.The aim of this study was to investigate the association of admission RI and inhospital and long-term mortality of patients with acute STEMI.Methods：This was a multicenter,observational,prospective-cohort study.718 consecutive patients were admitted to 19 hospitals in Beijing within 24 hours of onset of STEMI,between January 1,2006 and December 31,2006.Estimation of glomerular filtration rate （eGFR） was calculated using the modified abbreviated modification of diet in renal disease equation-based on the Chinese chronic kidney disease patients.The patients were categorized according to eGFR,as normal renal dysfunction （eGFR ≥ 90 ml·min^-1·1.73 m^-2）,mild RI （60 ml·min^-1· 1.73 m^-2 〈 eGFR 〈 90 ml·min^-1· 1.73 m^2） and moderate or severe RI （eGFR 〈 60 ml·min^-1· 1.73 m^2）.The association between RI and inhospital and 6-year mortality of was evaluated.Results：Seven hundred and eighteen patients with STEMI were evaluated.There were 551 men and 167 women with a mean age of 61.0 ＆#177; 13.0 years.Two hundred and eighty patients （39.0%） had RI,in which 61 patients （8.5%） reached the level of moderate or severe RI.Patients with RI were more often female,elderly,hypertensive,and more patients had heart failure and stroke with higher killip class.Patients with RI were less likely to present with chest pain.The inhospital mortality （1.4% vs.5.9% vs.22.9%,P 〈 0.001）,6-year all-cause mortality （9.5% vs.19.8 vs.45.2%,P 〈 0.001） and 6-year cardiac mortality （2.9% vs.12.2% vs.23.8%,P 〈 0.001） were markedly increased in patients with RI.After adjusting for other confounding factors,classification of admission renal function was an independent predictor of inhospital mortality （Odd ratio,1.966; 95% confidence interval [CO,1.002-3.070,P =0.019）,6-year all-cause mortality （relative risk [RR] =1.501,95% CI：1.018-4.373,P =0.039） and 6-year cardiac mortality （RR =1.663,95% CI：1.122-4.617,P =0.042）.Conclusions：RI is very common in STEMI patients.RI evaluated by eGFR is an important independent predictor of short-term and long-term outcome in patients with acute STEMI.

阿卡波糖心血管评估（ACE）试验依据与设计

心血管疾病（CVD）患者和糖耐量减低（IGT）者患2型糖尿病（T2DM）的风险较高。生活方式的调整或药物干预可以延缓T2DM的进展，但没有证据表明它们能够降低该人群的心血管风险。阿卡波糖是一种α-葡萄糖苷酶抑制剂，能够降低餐后血糖；其被证明能够使T2DM风险降低25％，并有可能降低无CVD的IGT受试者的心血管风险。阿卡波糖心血管评估（ACE）试验是一项随机、安慰剂对照、双盲、二级预防试验，受试者为7500例患有冠心病（定义为既往心肌梗死、不稳定型心绞痛或当前稳定的心绞痛）并伴有IGT且年龄I〉50岁的患者。以1：1的比例将患者随机分组，分别在标准CVD治疗药物基础上服用阿卡波糖50mg，每天3次或相匹配的安慰剂。排除标准包括糖尿病病史、过去3个月内发生过心血管事件、NYHAⅢ／Ⅳ级心力衰竭、重度肝病和重度肾功能损害。本研究在中国内地和中国香港的约150家医院内进行。主要复合心血管终点是至首次发生心血管死亡、非致死性心肌梗塞或非致死性卒中的时间。次要终点包括全因死亡和新发T2DM。ACE是一项对CVD进行二级预防的研究，用于评估冠心病患者和IGT者在标准心血管治疗的基础上加用阿卡波糖的效果。CVD的治疗与干预标准包括合理使用能降低心血管风险因素的药物，例如B肾上腺素能受体阻断剂、血管紧张素转换酶抑制剂、抗血小板药物和降血脂药物。在高血糖症患者中，血糖可能是另一个可调节的风险因素。流行病学证据表明，IGT会导致CVD发病率和死亡率上升，尽管其程度低于T2DM患者。餐后高血糖是餐后血糖代谢障碍的一个指标，它是心血管事件的一个独立的预测因子，因为负荷后血糖值与心血管事件的相关性比空腹血糖值更强，即使在非糖尿病受试者中也是这样。餐后代谢障碍影响动脉粥样硬化与CVD的机制包含多种因素。体内血糖的急性上升会诱导内皮功能障碍，可能是通过氧化应激引起。急性高血糖症也与血栓形成的激活以及炎性级联反应相关。用药物治疗来降低餐后高血糖会导致CVD的替代指标下降。在之前未用药物而被随机分配接受瑞格列奈（一种短效促泌剂，主要对餐后高血糖进行控制）或格列本脲（一种长效磺脲类药物）的患者中，使用瑞格列奈的患者C反应蛋白和白细胞介素-6的下降程度较大，颈动脉内一中膜厚度指标也是如此。阿卡波糖能够通过延缓碳水化合物的消化和吸收，降低餐后高血糖，改善内皮功能障碍，降低炎性指标（包括细胞核因子．xB活化及其核转位以及C反应蛋白），减少凝血因子（纤维蛋白原和凝血素），减少低密度脂蛋白氧化，降低颈动脉内一中膜厚度。相比那格列奈，阿卡波糖餐后血流量介导的血管扩张改善更显著。它也会放大二肽基肽酶4抑制剂阿格列汀的降血糖效应。IGT者中进行的降糖药物临床试验大都集中在预防T2DM上，而对心血管结局鲜有关注。STOP．NIDDM试验（1429名IGT受试者被随机分配阿卡波糖或安慰剂）显示，在平均3．3年的随访期后，阿卡波糖降低T2DM风险25％。后续分析也显示心肌梗死风险以及预先指定的任一心血管事件风险下降，但只有47名受试者发生了CVD。一项关于阿卡波糖的荟萃分析提示，阿卡波糖能显著降低T2DM患者的心肌梗死风险和心血管死亡、卒中、外周动脉疾病、心绞痛、心力衰竭和血管重建的风险。这些数据支持了该假设：使用阿卡波糖降低餐后高血糖能够消除IGT者的高CVD风险。目前为止唯一的有关降低餐后血糖药物的前瞻性CVD结局试验NAVIGATOR显示，那格列奈对心血管结局没有影响。ORIGIN试验（增大基础胰岛素用量以降低IGT者或早期T2DM患者的空腹血糖值）结果也显示对心血管结局没有影响。ACE试验的目的是确定阿卡波糖是否能够减少冠心病患者和IGT者中的心血管事件，其次要结局是T2DM的预防情况。

Chinese Guideline on the Primary Prevention of Cardiovascular Diseases

Cardiovascular disease is the leading cause of mortality in China.Primary prevention of cardiovascular disease with a focus on lifestyle intervention and risk factor control has been shown to effectively delay or prevent the occurrence of cardiovascular events.To promote a healthy lifestyle and enhance the detection,diagnosis,and treatment of cardiovascular risk factors such as hypertension,dyslipidemia,and diabetes,and to improve the overall capacity of primary prevention of cardiovascular disease,the Chinese Society of Cardiology of Chinese Medical Association has collaborated with multiple societies to summarize and evaluate the latest evidence with reference to relevant guidelines and subsequently to develop recommendations for primary cardiovascular disease prevention in Chinese adults.The guideline consists of 10 sections:introduction,methodology for developing the guideline,epidemiology of cardiovascular disease in China and challenges in primary prevention,general recommendations for primary prevention,assessment of cardiovascular risk,lifestyle intervention,blood pressure control,lipid management,management of type 2 diabetes,and use of aspirin.The promulgation and implementation of this guideline will play a key role in promoting the practice of primary prevention for cardiovascular disease in China.

Nicotine gum or patch treatment for smoking cessation and smoking reduction： a multi-centre study in Chinese physicians

In China, around 23% of physicians （41% male, 3% female） currently smoke. Pharmacotherapy for tobacco dependence is available, but is not widely used in China. The purpose of this study was to estimate the effectiveness and the safety on smoking cessation of nicotine gum and nicotine patch in Chinese healthcare professionals. Three hundred regular smokers motivated to quit were recruited from six hospitals in China. All subjects were accepted nicotine replacement therapy, and they could choose nicotine gum （2 mg or 4 mg, depending on baseline smoking level） or nicotine patch （15 mg/16 h） for 12 weeks, with a 12-week follow-up. Limited behavioural support was provided. At Week 24, the 2-24 weeks continuous abstinence rate （verified by expired carbon monoxide） was 17%, the point prevalence abstinence rate （no smoking since the previous visit） was 35%, and 38% of subjects had continuously reduced their daily cigarette consumption by at least 50% versus baseline. Compliance with treatment was good, particularly with patch. No serious adverse event was reported, and most adverse events were mild or moderate. The most common treatment-related adverse events were gastro- intestinal （both gum and patch） and local irritation symptoms. Nicotine patch and gum were well tolerated in Chinese smokers. Abstinence rates were comparable to those previously reported with nicotine replacement therapy, and many smokers who did not quit substantially reduced their cigarette consumption.

Implementing the Guideline of the Primary Prevention of Cardiovascular Diseases in China to Daily Practice:Promoting the Transition from“Treatment-Centered”to“People’s Health-Centered”

The first“Chinese guidelines for prevention of cardiovascular diseases”[1]was announced by the Chinese Society of Cardiology(CSC)of the Chinese Medical Association in 2011 and revised in 2017.[2]The“Chinese guideline on the primary prevention of cardiovascular diseases”[3](the new guideline)published in this issue of Cardiology Discovery is focusing on the comprehensive prevention and control of the multiple risk factors for cardiovascular diseases.