Chinese expert consensus on the non-invasive imaging examination pathways of stable coronary artery disease

1 Introduction Early detection and diagnosis of stable coronary artery disease （SCAD） is essential for proactive secondary prevention of myocardial infarction （MI）, control of disease progress, and reduction of mortality. Clinical decision-making in modem medicine is increasingly dependent on cardiovascular imaging techniques. 2012 ACCF/AHA/ACP/AATS/ PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease has been issued by American Heart Association （AHA）. European Society of Cardiology （ESC） has issued 2013 ESC guidelines on the management of stable coronary artery disease.

Clinical, sonographic characteristics and long-term prognosis of valvular heart disease in elderly patients

Background Valvular heart disease(VHD)is expected to become more prevail as the population ages and disproportionately affects older adults.However,direct comparison of clinical characteristics,sonographic diagnosis,and outcomes in VHD patients aged over 65 years is scarce.The objective of this study was to evaluate the differences in clinical characteristics and prognosis in two age-groups of geriatric patients with VHD.Methods We retrospectively enrolled consecutive individuals aged>65 years from Guangdong Provincial Peopled Hospital and screened for VHD using transthoracic echocardiography(TTE)or transesophageal echocardiography(TEE).Finally,260(48.9%)patients were in the 65-74 years group,and 272(51.1%)were in the>75-year group.Factors that affected long-term survival was explored.A multivariable Cox hazards regression was performed to identify the predictors of major adverse cardiac events(MACEs)in each group.Results In our population,the older group were more likely to have chronic obstructive pulmonary disease(COPD),degenerative VHD,but with less rheumatic VHD,aortic stenosis(AS)and mitral stenosis(MS).Compared with those aged 65-74 years,the older group had a higher incidence of all-cause death(10.0%vs.16.5%,P=0.027),ischemic stroke(13.5%vs.20.2%,P=0.038)and MACEs(37.3%vs.48.2%,P=0.011)at long-term follow-up.In multivariable Cox regression analysis,mitral regurgitation,a history of COPD,chronic kidney disease,diabetes,hypertension,atrial fibrillation and New York Heart Association(NYHA)functional class were identified as independent predictors of MACEs in the older group.Conclusion Advanced age profoundly affect prognosis and different predictors were associated with MACEs in geriatric patients with VHD.

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

Objective To describe the long-term antithrombotic management patterns(AMPs)and clinical outcomes of Chinese patients with acute coronary syndrome(ACS).Methods This 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.Results Overall,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.Conclusion Most patients in China received at least one AP medication up to 5 years after an ACS event.

Association of baseline hemoglobin A1c levels with bleeding in patients with non-ST-segment elevation acute coronary syndrome underwent percutaneous coronary intervention:insights of a multicenter cohort study from China

OBJECTIVE To investigate the association between baseline hemoglobin A1c(HbA1c)levels and bleeding in patients with non-ST-segment elevation acute coronary syndrome(NSTE-ACS)who underwent percutaneous coronary intervention(PCI).METHODS This observational cohort study enrolled 6283 consecutive NSTE-ACS patients undergoing PCI from January 1,2010 to December 31,2014.Based on baseline HbA1c levels,the patients were divided into the group with HbA1c<7%(n=4740)and the group with HbA1c≥7%(n=1543).The primary outcomes are major bleeding(BARC grades 3-5)and all-cause death during follow-up.RESULTS Of patients enrolled,4705(74.9%)were male,and 2143(34.1%)had a history of diabetes mellitus,with a mean(SD)age of 64.13(10.32)years.The median follow-up duration was 3.21 years.Compared with the patients with HbA1c<7%,the risk of major bleeding events during follow-up was higher in patients with HbA1c≥7%(adjusted hazard ratio[HR]=1.57;95%con-fidence interval[CI]:1.01-2.44;P=0.044),while the risk of all-cause death during follow-up was not associated with the higher HbA1c levels(adjusted HR=0.88;95%CI:0.66-1.18;P=0.398).CONCLUSIONS Compared with the lower baseline HbA1c levels,the higher baseline HbA1c levels were associated with an increase in long-term bleeding risk in NSTE-ACS patients undergoing PCI,though higher baseline HbA1c levels were not associ-ated with the higher risk in all-cause death.

Genetic and epigenetic predispositions underlying cardiovascular outcomes among patients treated with clopidogrel and aspirin

Coronary artery disease(CAD) is a major cause of death and disability worldwide,and consumes a considerable amount of medical resources every year.Clopidogrel is a first-line antiplate.let therapy for CHD,butit is associated with substantial variability in PK and pharmacodynamics re.sponse.To date,gene variants explain only a smallproportion of the variability.The study aimed to identify new genetic loci-modifying antiplatelet response to clopidogrel in Chinese patients with CAD by a systematic analysis combining antiplatelet effects and PK,and further to investigate the PON1 gene promoter DNA methylation and genetic variations possibly influencing clinical outcomes in pa.tients undergoing PCI.We identified novel variants in two transporter genes(SLC14 A2 rs12456693,ATP-binding cassette [ABC]A1 rs2487032) and in N6 AMT1(rs2254638) associated with P2Y12 reaction unit(PRU) and plasma active metabolite(H4) concentration.These new variants dramatically im.proved the predictability of PRU variability to 37.7%.The associations between these loci and PK pa.rameters of clopidogrel and H4 were observed in additional patients,and its function on the activation of clopidogrel was validated in liver S9 fractions(P<0.05).Rs2254638 was further identified to exert a marginal risk effect formajor adverse cardiac events in an independent cohort.Multivariate logistic regression analysis indicated that PON1 methylation level at CpG site-161(OR=0.95;95% CI=0.92–0.98;P<0.01) and the use of angiotensin converting enzyme inhibitors(OR=0.48;95% CI=0.26–0.89;P<0.01) were associated with decreased risk of bleeding events.In conclusion,new genetic variants were systematically identified as risk factors for the reduced efficacy of clopidogrel treatment.The ab.normal expression of DNA methylation-regulating key genes in the pharmacokinetic and pharmacody.namics pathways of clopidogrel and aspirin may modify clinical outcomes in dual antiplatelet-treated patients undergoing PCI.

Effects of Guideline-based Hypertension Management in Rural Areas of Guangdong Province

Background:Despite the improvement in the health care industry,the rates of undetected,untreated,and uncontrolled hypertension (HTN)are still very high,especially in rural areas of China.The aim of this study was to investigate the efficacy and efficiency of a guideline-based HTN management (novel therapy) in population of rural areas of Guangdong Province.Methods:Totally,3113 patients with essential HTN in a rural area of Guangdong Province were enrolled and assigned to two groups,named traditional (n =372) and novel therapeutic (n =2741) groups,respectively.Patients in the traditional group were treated routinely,and patients in the novel group were treated in a novel model characterized by regular educational programs for hypertensive populations,close monitoring of blood pressure in combination with finely tuned antihypertensive medications,strict implementation of lifestyle modification and improving medical knowledge and skill of local medical staff efficiently.After 2 years of follow-up,primary endpoints including magnitude of systolic and diastolic blood pressures (SBP and DBP) decrease,treated and controlled rates,as well as secondary endpoints,were evaluated in both groups.Results:Initially,the treated rate was significantly higher in traditional group than that of novel group (71.15％ vs.64.99％,P ＜ 0.05),while the controlled rates were comparable and insignificant difference between baseline BP in both groups (31.07％ vs.26.88％,P ＞ 0.05).Four variables were significantly different,namely smoking rate,daily vegetable consumption (VC),and serum levels of low-density lipoprotein-cholesterol and fasting blood glucose between these two groups.After 2 years of follow-up,decreases in SBP and DBP were more prominent in the novel group (P ＜ 0.001).Treated and controlled rates in both groups were both increased.Nevertheless,in comparison to the traditional group,controlled rate increased more significantly in the novel group (64.31％ vs.37.85％,P ＜ 0.001).Variables indicating lifestyle modification such as high sodium consumption,percentages of alcohol abuse,daily VC were profoundly improved in the novel group.Conclusions:The guideline-based HTN management implemented in the current study was beneficial for HTN control in rural areas of Guangdong Province.

Association between Contrast Media Volume and 1-Year Clinical Outcomes in Patients Undergoing Coronary Angiography

Background： The excess volume of contrast media （CM） is a marker of a more severe coronary culprit lesion and longer intervention duration in patients undergoing cardiac procedures. However, it is unclear whether the contrast volume is directly correlated with worse clinical outcomes. The aim of this study was to investigate the association between contrast dose and the incidence of 1-year major adverse cardiac and cerebrovascular events （MACCE） and all-cause bleeding events in patients undergoing cardiac catheterization and coronary angiography （CAG）. Methods： We prospectively enrolled 10,961 consecutive patients diagnosed with coronary heart disease expecting CAG from 2012 to 2013. The study population was pursued with a follow-up duration of 1 year. The predictive value of contrast volume, divided into quartiles, for the risk of MACCE and all-cause bleeding events was assessed using logistic regression analysis. Results： The cumulative incidence of 1-year MACCE was 8.65%, which was directly associated with increasing contrast volume. In particular, MACCE was observed in 7.16%, 7.89%, 9.31%, and 11.73% of cases in the contrast volume quartile Q1 （≤100 ml）, Q2 （101-140 m）, Q3 （141-200 ml）, and Q4 （〉200 ml）, respectively （P 〈 0.001）. Moreover, the incidence of 1-year all-cause bleeding events was noted in 4.70%, 5.93%, 7.28%, and 8.21% of patients in Q1, Q2, Q3, and Q4, respectively （P 〈 0.001）. The survival analysis showed that the 1-year MACCE rate was higher in patients using greater CM volume during the CAG. CM volume used 〉140 ml was associated with the occurrence of 1-year MACCE, and the incidence was dramatically elevated in patients exceeding a contrast volume of 200 ml （P = 0.007）. Conclusion： Our data suggested that higher contrast volume was significantly correlated with an increased risk of MACCE and all-cause bleeding events in patients undergoing cardiac catheterization.