The association of grip strength with cardiovascular diseases and all-cause mortality in people with hypertension:Findings from the Prospective Urban Rural Epidemiology China Study

Background:Both hypertension and grip strength(GS)are predictors of mortality and cardiovascular disease(CVD),but whether these risk factors interact to affect CVD and all-cause mortality is unknown.This study sought to investigate the associations of GS with the risk of major CVD incidence,CVD mortality,and all-cause mortality in patients with hypertension.Methods:GS was measured using a Jamar dynamometer(Sammons Preston,Bolingbrook,IL,USA)in participants aged 3570 years from 12 provinces included in the Prospective Urban Rural Epidemiology China Study.Cox frailty proportional hazards models were used to examine the associations of GS and hypertension and the outcomes of all-cause mortality and CVD incidence/mortality.Results:Among 39,862 participants included in this study,15,964 reported having hypertension,and 9095 had high GS at baseline.After a median follow-up of 8.9 years(interquartile range,6.79.9 years),1822 participants developed major CVD,and 1250 deaths occurred(388 as a result of CVD).Compared with normotensive participants with high GS,hypertensive patients with high GS had a higher risk of major CVD incidence(hazard ratio(HR)=2.39;95%confidence interval(95%CI):1.863.06;p<0.001)or CVD mortality(HR=3.11;95%CI:1.596.06;p<0.001)but did not have a significantly increased risk of all-cause mortality(HR=1.24;95%CI:0.921.68;p=0.159).These risks were further increased if hypertensive participants whose GS level was low(major CVD incidence,HR=3.31,95%CI:2.604.22,p<0.001;CVD mortality,HR=4.99,95%CI:2.649.43,p<0.001;and all-cause mortality,HR=1.93,95%CI:1.472.53,p<0.001).Conclusion:The present study demonstrates that low GS is associated with the highest risk of major CVD incidence,CVD mortality,and all-cause mortality among hypertensive patients.High levels of GS appear to mitigate long-term mortality risk among hypertensive patients.

Routine diagnosis of intestinal tuberculosis and Crohn's disease in Southern India

AIM:To investigate whether routinely measured clinical variables could aid in differentiating intestinal tuberculosis(ITB)from Crohn’s disease(CD).METHODS:ITB and CD patients were prospectively included at four South Indian medical centres from October 2009 to July 2012.Routine investigations included case history,physical examination,blood biochemistry,ileocolonoscopy and histopathological examination of biopsies.Patients were followed-up after 2 and 6 mo of treatment.The diagnosis of ITB or CD was re-evaluated after 2 mo of antituberculous chemotherapy or immune suppressive therapy respectively,based on improvement in signs,symptoms and laboratory variables.This study was considered to be an exploratory analysis.Clinical,endoscopic and histopathological features recorded at the time of inclusion were subject to univariate analyses.Disease variables with sufficient number of recordings and P<0.05 were entered into logistic regression models,adjusted for known confounders.Finally,we calculated the odds ratios with respective confidence intervals for variables associated with either ITB or CD.RESULTS:This study included 38 ITB and 37 CD patients.Overall,ITB patients had the lowest body mass index(19.6 vs 22.7,P=0.01)and more commonly reported weight loss(73%vs 38%,P<0.01),watery diarrhoea(64%vs 33%,P=0.01)and rural domicile(58%vs 35%,P<0.05).Endoscopy typically showed mucosal nodularity(17/31 vs 2/37,P<0.01)and histopathology more frequently showed granulomas(10/30vs 2/35,P<0.01).The CD patients more frequently reported malaise(87%vs 64%,P=0.03),nausea(84%vs 56%,P=0.01),pain in the right lower abdominal quadrant on examination(90%vs 54%,P<0.01)and urban domicile(65%vs 42%,P<0.05).In CD,endoscopy typically showed involvement of multiple intestinal segments(27/37 vs 9/31,P<0.01).Using logistic regression analysis we found weight loss and nodularity of the mucosa were independently associated with ITB,with adjusted odds ratios of 8.6(95%CI:2.1-35.6)and 18.9(95%CI:3.5-102.8)respectively.Right lower abdominal quadrant pain on examination and involvement of≥3 intestinal segments were independently associated with CD with adjusted odds ratios of 10.1(95%CI:2.0-51.3)and 5.9(95%CI:1.7-20.6),respectively.CONCLUSION:Weight loss and mucosal nodularity were associated with ITB.Abdominal pain and excessive intestinal involvement were associated with CD.ITB and CD were equally common.

关于长期补充维生素E对心血管事件和癌症影响的随机对照试验

Context: Experimental and epidemiological data suggest that vitamin E supplementation may prevent cancer and cardiovascular events. Clinical trials have generally failed to confirm benefits, possibly due to their relatively short duration. Objective: To evaluate whether long-term supplementation with vitamin E decreases the risk of cancer, cancer death, and major cardiovascular events. Design, Setting, and Patients: A randomized, double-blind, placebo-controlled international trial(the initial Heart Outcomes Prevention Evaluation[HOPE] trial conducted between December 21, 1993, and April 15,1999) of patients at least 55 years old with vascular disease or diabetes mellitus was extended(HOPE-The Ongoing Outcomes[HOPE-TOO]) between April 16,1999, and May 26, 2003. Of the initial 267 HOPE centers that had enrolled 9541 patients, 174 centers participated in the HOPE-TOO trial. Of 7030 patients enrolled at these centers, 916 were deceased at the beginning of the extension, 1382 refused participation, 3994 continued to take the study intervention, and 738 agreed to passive follow-up. Median duration of follow-up was 7.0 years. Intervention: Daily dose of natural source vitamin E(400 IU) or matching placebo. Main Outcome Measures: Primary outcomes included cancer incidence, cancer deaths, and major cardiovascular events(myocardial infarction, stroke, and cardiovascular death). Secondary outcomes included heart failure, unstable angina, and revascularizations. Results: Among all HOPE patients, there were no significant differences in the primary analysis: for cancer incidence, there were 552 patients(11.6%) in the vitamin E group vs 586(12.3%) in the placebo group(relative risk[RR], 0.94; 95%confidence interval[CI], 0.84-1.06; P=.30); for cancer deaths, 156(3.3%) vs 178(3.7%), respectively(RR, 0.88; 95%CI, 0.71-1.09; P=.24); and for major cardiovascular events, 1022(21.5%) vs 985(20.6%), respectively(RR, 1.04; 95%CI, 0.96-1.14; P=.34). Patients in the vitamin E group had a higher risk of heart failure(RR, 1.13; 95%CI, 1.01-1.26; P=.03) and hospitalization for heart failure(RR, 1.21; 95%CI, 1.00-1,47; P=.045). Similarly, among patients enrolled at the centers participating in the HOPE-TOO trial, there were no differences in cancer incidence, cancer deaths, and major cardiovascular events, but higher rates of heart failure and hospitalizations for heart failure. Conclusion: In patients with vascular disease or diabetes mellitus, longterm vitamin E supplementation does not prevent cancer or major cardiovascular events and may increase the risk for heart failure.

血管疾病患者应用叶酸及B族维生素降低同型半胱氨酸水平治疗

BACKGROUND: In observational studies, lower homocysteine levels are associated with lower rates of coronary heart disease and stroke. Folic acid and vitamins B6 and B12 lower homocysteine levels. We assessed whether supplementation reduced the risk of major cardiovascular events in patients with vascular disease. METHODS: We randomly assigned 5522 patients 55 years of age or older who had vascular disease or diabetes to daily treatment either with the combination of 2.5 mg of folic acid, 50 mg of vitamin B6, and 1 mg of vitamin B12 or with placebo for an average of five years. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, and stroke. RESULTS: Mean plasma homocysteine levels decreased by 2.4 μmol per liter(0.3 mg per liter) in the active-treatment group and increased by 0.8 μmol per liter(0.1 mg per liter) in the placebo group. Primary outcome events occurred in 519 patients(18.8 percent) assigned to active therapy and 547(19.8 percent) assigned to placebo(relative risk, 0.95; 95 percent confidence interval, 0.84 to 1.07; P=0.41). As compared with placebo, active treatment did not significantly decrease the risk of death from cardiovascular causes(relative risk, 0.96; 95 percent confidence interval, 0.81 to 1.13), myocardial infarction(relative risk, 0.98; 95 percent confidence interval, 0.85 to 1.14), or any of the secondary outcomes. Fewer patients assigned to active treatment than to placebo had a stroke(relative risk, 0.75; 95 percent confidence interval, 0.59 to 0.97). More patients in the active-treatment group were hospitalized for unstable angina(relative risk, 1.24; 95 percent confidence interval, 1.04 to 1.49). CONCLUSIONS: Supplements combining folic acid and vitamins B6 and B12 did not reduce the risk of major cardiovascular events in patients with vascular disease.

ACCORD试验中的血糖治疗方案

高血糖与心血管疾病(CVD)之间存在独立的流行病学递增关系,然而,以当前应用的疗法降低血糖水平是否可降低CVD事件发生率仍不明确。ACCORD试验被设计用于解决2型糖尿病高危患者中的这一问题。ACCORD试验中。

Fondaparinux和依诺肝素治疗急性冠状动脉综合征的比较

BACKGROUND: The combined use of anticoagulants, antiplatelet agents, and invasive coronary procedures reduces ischemic coronary events but also increases bleeding in patients with acute coronary syndromes. We therefore assessed whether fondaparinux would preserve the anti-ischemic benefits of enoxaparin while reducing bleeding. METHODS: We randomly assigned 20,078 patients with acute coronary syndromes to receive either fondaparinux(2.5 mg daily) or enoxaparin(1 mg per kilogram of body weight twice daily) for a mean of six days and evaluated death, myocardial infarction, or refractory ischemia at nine days(the primary outcome); major bleeding; and their combination. Patients were followed for up to six months. RESULTS: The number of patients with primary outcome events was similar in the two groups(579 with fondaparinux[5.8 percent] vs. 573 with enoxaparin[5.7 percent]; hazard ratio in the fondaparinux group, 1.01; 95 percent confidence interval, 0.90 to 1.13), satisfying the noninferiority criteria. The number of events meeting this combined outcome showed a nonsignificant trend toward a lower value in the fondaparinux group at 30 days(805 vs. 864, P=0.13) and at the end of the study(1222 vs. 1308, P=0.06). The rate of major bleeding at nine days was markedly lower with fondaparinux than with enoxaparin(217 events[2.2 percent] vs. 412 events[4.1 percent]; hazard ratio, 0.52; P< 0.001). The composite of the primary outcome and major bleeding at nine days favored fondaparinux(737 events[7.3 percent] vs. 905 events[9.0 percent]; hazard ratio, 0.81; P< 0.001). Fondaparinux was associated with a significantly reduced number of deaths at 30 days(295 vs. 352, P=0.02) and at 180 days(574 vs. 638, P=0.05). CONCLUSIONS: Fondaparinux is similar to enoxaparin in reducing the risk of ischemic events at nine days, but it substantially reduces major bleeding and improves long term mortality and morbidity.

有危及生命的室性心律失常病史的老年患者中埋藏式除颤器的作用

目的:埋藏式除颤器(ICD)能够降低有危及生命室性心律失常病史患者的心律失常性死亡率以及全因死亡率。然而,在老年患者中非心律失常性死亡的风险同样较高,因此ICD在老年患者中的临床效果尚不确定。方法和结果:汇总来自三项比较ICD与胺碘酮的二级预防试验的患者资料。根据年龄将患者分为<75岁和≥75岁两组。报道患者的特征并确定各组中ICD对全因死亡和心律失常性死亡的影响。通过评价交互作用项(年龄与治疗)确定年龄对这些结果的影响。

Roux-en-Y gastric bypass or sleeve gastrectomy for obstructive sleep apnea:A systematic review and meta-analysis

Objective:Bariatric surgery has been shown to be an effective method of treatment for obstructive sleep apnea(OSA)with long-term benefits,however,the mechanisms of action and the optimum operative procedure remains unclear.The aim of this systemic review was to compare the efficacy of laparoscopic sleeve gastrectomy(LSG)and Roux-en-Y gastric bypass(RYGB)in resolving OSA.Methods:A comprehensive search of MEDLINE,Pubmed,Embase,and OVID was performed.Studies that reported OSA resolution in obese patients with BMI>30 kg/m2 were included in the study.RCTs,comparative prospective and matched cohort studies comparing RYGB with LSG were considered for this study.Results:Five studies(309 participants)were included:4 cohort studies and 1 RCT;all with low risk of bias.At 12 months follow-up,there was a trend towards improved resolution of OSA with LSG(OR 0.47,95%CI[0.20 to 1.06];p=0.07)when compared to RYGB.In contrast,there was a trend to poorer weight loss in the LSG group(SMD 3.83,95%CI[-1.82 to 9.48];p=0.18).Similarly,at 36 months follow-up,there was a trend towards better resolution of OSA with LSG(OR 0.52,95%CI[0.16 to 1.71];p=0.28)and a significantly poorer weight loss in LSG when compared to RYGB(SMD 8.25,95%CI[2.91 to 13.58];p=0.002).Conclusion:Despite poorer weight loss following LSG,there is a trend towards increased resolution of sleep apnea post-LSG.These findings suggest the possibility of weight loss independent factors causing OSA resolution,which should be further investigated.Registration:PROSPERO:CRD42018090367.

Hepatitis B virus subgenotype A1 predominates in liver disease patients from Kerala,India

AIM:To molecularly characterize hepatitis B virus(HBV)isolates from Kerala and to relate them to the clinical manifestation of infection.METHODS:Sera and clinical data were collected from91 patients diagnosed with chronic HBV infection and HBV-related hepatocellular carcinoma(HCC).HBV from44 HCC,22 cirrhotic and 25 chronic hepatitis patients were genotyped by sequencing of the complete S region or by restriction fragment length polymorphism assays.The basic core promoter/precore region was sequenced.The complete surface DNA sequences were assembled and aligned manually,and then compared with the sequences of HBV of genotypes(A-J)from GenBank.The evolutionary history was inferred using the Neighbor-Joining method and the evolutionary distances computed using the Kimura 2-parameter method.Bootstrapping was performed using 1000 replicates.The TaqMan BS-1 probe was used to quantify HBV DNA at a lower detection limit of approximately20 IU/mL.Continuous variables were compared using an independent Student’s t test.Theχ2test or Fisher’s exact test was used to compare categorical variables.The differences were considered statistically significant at P<0.05.RESULTS:Irrespective of disease status,the predominant genotype was A(72%);95%belonging to subgenotype A1,followed by genotypes D(27%)and C(1%).HCC patients infected with subgenotype A1were significantly younger than those infected with D.Mutation A1762T/G1764A was significantly associated with HCC in both genotypes A and D.Mutation G1862T was more frequent in subgenotype A1(P<0.0001),and in combination with A1762T/G1764A,it was significantly associated with HBV from HCC patients.Mutation C1766T/T1768A was significantly associated with genotype A(P=0.05)and HCC(P=0.03).The preS2start codon M1T/I mutation was unique to genotype A strains(15.6%)from all disease groups and occurred at a higher frequency in isolates from HCC patients(P=0.076).A higher frequency of preS deletion mutants(33.3%)was observed in genotype A from HCC compared with non-HCC patients,but did not reach statistical significance.The preS2:F22L mutation was found in genotypes A and D.CONCLUSION:Kerala is the first Indian state in which subgenotype A1 has been found to predominate in liver disease patients who developed HCC at a relatively young age.

Understanding organizational context and heart failure management in long term care homes in Ontario, Canada

Objective: To assess current heart failure (HF) care processes and organizational context in long-term care (LTC) homes as a prelude to adapting the Canadian Cardiovascular Society (CCS) HF guidelines for use in these settings. Methods: This research reports on the results of thirteen focus groups (N = 83 participants;average of 60 minutes duration) conducted in three Ontario LTC homes to better understand how HF was managed and how organizational context impacted care. Participants included physicians, nurse practitioners, registered nurses, registered practical nurses, and personal support workers. Results: Focus group findings revealed that the complexity of the LTC environment presents challenges for managing HF. Most residents have multiple advanced chronic conditions that must be managed simultaneously. Culturally, LTC is first and foremost a resident’s home where residents may choose not to comply with care recommendations. Staff routines, scopes of practice, professional hierarchies, available resources and government regulations limit flexibility in providing care. Staff lacked knowledge, skills and resources for managing HF. Nevertheless, all staff viewed LTC as the preferred place for managing HF, avoiding residents’ hospitalizations wherever possible. These data suggest that strategies for improving LTC staff communication and education, strengthening existing relationships between staff, family, residents and community resources, and acquiring additional resources in LTC homes have the potential to improve HF management in this setting. Conclusion: LTC is a complex and dynamic environment that presents many challenges for providing care for residents. This research provides the foundation for subsequent work to develop and test implementation strategies to manage HF in LTC, which are consistent with the CCS HF guidelines and are feasible within LTC staff’s work routines, capacities and resources.

INTERHEART研究的52个国家中烟草使用与心肌梗死风险的关系:一项病例对照研究

背景:烟草使用是心血管疾病可避免的主要原因之一。本研究的目的是评估全世界范围内与烟草使用(吸烟和非吸烟)和吸二手烟(SHS)相关的风险。方法:对52个国家的27098例参与者(12461例患者,14637例对照者)进行一项关于急性心肌梗死(AMI)的标准化病例对照研究。评估AMI风险与当前或曾经吸烟、烟草类型、吸烟量、无烟烟草作用及SHS暴露的关系。校正诸如吸烟者和不吸烟者之间生活方式差异的混杂因素。

低分子量肝素——瑞肝素——对急性心肌梗死伴ST段抬高患者的死亡率、再梗死和脑卒中的作用

Context: Although reperfusion therapy, aspirin, β-blockers, and angiotensin-converting enzyme inhibitors reduce mortality when used early in patients with acute myocardial infarction(MI), mortality and morbidity remain high. No antithrombotic or newer antiplatelet drug has been shown to reduce mortality in acute MI. Objective: To evaluate the effects of reviparin, a low-molecular-weight heparin, when initiated early and given for 7 days in addition to usual therapy on the primary composite outcome of death,myocardial reinfarction, or strokes at 7 and 30 days. Design, Setting, and Patients: A randomized, doubleblind, placebo-controlled trial(Clinical Trial of Reviparin and Metabolic Modulation in Acute Myocardial Infarction Treatment Evaluation [CREATE]) of 15570 patients with ST-segment elevation or new left bundle-branch block, presenting within 12 hours of symptom onset at 341 hospitals in India and China from July 2001 through July 2004. Intervention: Reviparin or placebo subcutaneously twice daily for 7 days. Main Outcome Measure: Primary composite outcome of death, myocardial reinfarction, or stroke at 7 and 30 days. Results: The primary composite outcome was significantly reduced from 854(11.0%) of 7790 patients in the placebo group to 745(9.6%) of 7780 in the reviparin group(hazard ratio [HR], 0.87; 95%CI, 0.79-0.96; P=.005). These benefits persisted at 30 days(1056 [13.6%] vs 921 [11.8%] patients; HR, 0.87; 95%CI, 0.79-0.95; P=.001) with significant reductions in 30-day mortality(877 [11.3%] vs 766 [9.8%]; HR, 0.87; 95%CI, 0.79-0.96; P=.005) and reinfarction(199 [2.6%] vs 154 [2.0%]; HR, 0.77; 95%CI, 0.62-0.95; P=.01), and no significant differences in strokes(64 [0.8%] vs 80 [1.0%]; P=.19). Reviparin treatment was significantly better when it was initiated very early after symptom onset at 7 days(< 2 hours: HR, 0.70; 95%CI, 0.52-0.96; P=.03; 30/1000 events prevented; 2 to< 4 hours: HR, 0.81; 95%CI, 0.67-0.98; P=.03; 21/1000 events prevented; 4 to< 8 hours: HR, 0.85; 95%CI, 0.73-0.99; P=.05; 16/1000 events prevented; and ≥8 hours:HR,1.06; 95%CI, 0.86-1.30; P=.58; P=.04 for trend). There was an increase in lifethreatening bleeding at 7 days with reviparin and placebo(17 [0.2%] vs 7 [0.1%], respectively; P=.07), but the absolute excess was small(1 more per 1000) vs reductions in the primary outcome(18 fewer per 1000) or mortality(15 fewer per 1000). Conclusions: In patients with acute ST-segment elevation or new left bundle-branch block MI, reviparin reduces mortality and reinfarction, without a substantive increase in overall stroke rates. There is a small absolute excess of life-threatening bleeding but the benefits outweigh the risks.

南亚人与其他国家个体相比早发心肌梗死的危险因素

背景：南亚人中年轻时急性心肌梗死（AMI）的发生率高于其他国家个体，但原因不明。目的：评价并比较南亚本地人和来自其他国家的个体中危险因素与AMI的关系，尤其关注较年轻AMI。设计、地点和参与者：此标准化病例对照研究于1999年2月至2003年3月间纳入研究对象，包括来自5个南亚国家15所医学中心的1732例首发AMI患者和2204例年龄、性别匹配的对照者，以及来自其他国家的10728例患者和12431例对照者。主要观察指标：AMI与危险因素的关系。结果：南亚首发AMI患者的平均年龄低于其他国家（53．0±11．4岁 vs 58．8±12．2岁；P〈0．001）。

Influence of dietary patterns on the risk of acute myocardial infarction in China population： the INTERHEART China study

Background Some dietary patterns are risk factors for acute myocardial infarction （AMI）. Chinese traditional food and habits vary from other cultures. The present study determined whether different dietary patterns were associated with AMI in Chinese people. Methods We conducted a case-control study. There were 1312 cases of first AMI and 2235 control subjects who did not have previous angina, diabetes mellitus, hypertension or stroke. Controls were matched to cases on age and gender. Diet was measured with a validated, 19 item food frequency questionnaire. We identified three major dietary patterns using factor analysis： vitamin and microelement pattern （high intake of vegetables, fruits and tofu）, carbohydrate pattern （high in grain）, and fat and protein pattern （high in meat, fish, eggs and fried foods）. Results After adjusting for all risk factors, the vitamin and microelement pattern was inversely associated with AMI risk （global P value, 0.0001）. Compared with the first quartile, the adjusted ORs of AMI were 0.81 （95% CI： 0.66-1.00） for the second quartile, 0.67 （95% CI： 0.54-0.82） for the third, and 0.70 （95% CI： 0.56-0.88） for the fourth. Several dietary frequencies （serves per week） including vegetables, fruits and tofu were closely associated with decrease of AMI risk. Carbohydrate pattern showed weak relationship with AMI. We observed a U-shaped association between frequencies of fat and protein pattern and AMI risk. Excessive fat intake increased the AMI risk. The adjusted OR of AMI associated with the higher level of green vegetables was 0.37 （95% CI： 0.24-0.57） in women and 0.65 （95% CI： 0.51-0.82） in men （P value for heterogeneity, 0.0140）. Conclusions Unhealthy dietary intake can increase the AMI risk. Improving intake of vegetables, fruits and tofu have the potential to partially prevent the rising epidemic of cardiovascular disease in China.

Influence of socioeconomic status on acute myocardial infarction in the Chinese population： the INTERHEART China study

Background Many researches report that low socioeconomic status （SES） is associated with a higher risk of coronary heart disease （CHD）. This study aimed to determine whether levels of education, family income, and other SES were associated with acute myocardial infarction （AMI） in the Chinese population, and to compare the difference in this association between northern and southern regions in China. Methods We conducted a case-control study. Cases were first AMI （n=2909）. Controls （n=2947） were randomly selected and frequency matched to cases on age and sex. SES was measured using education, family income, possessions in the household, and occupation. Results Low levels of education （8 years） were more common in cases compared to controls （53.4% and 44.1%; P=0,0001）. After adjusting all risk factors, the level of education was associated with AMI risk in the Chinese population （P=-0.0005）. The odds ratio （OR） associated with education of 8 years or less, compared with more than 12 years （trade school/college/university） was 1.33 （95% CI 1.12-1.59）, and for education of 9-12 years 1.04 （95% CI 0.88-1.33）. The proportion of higher income population was more in controls than cases （39.4% and 35.3%）. Number of possessions and non-professional occupation were only weakly or not at all independently related to AMI. The adjusted OR associated with the lower education was 2.38 （95% CI 1.67-3.39） in women, and 1.18 （95% CI 0.99-1.42） in men （P=0.0001, for heterogeneity）. The interaction between levels of education and different regions was significant （P=0.0206, for interaction）. Conclusion Several socioeconomic factors including levels of education and income were closely associated with increase of AMI risk in China, most markedly in northeast and southern area. The effect of education was stronger towards AMI in women than men.

Rationale and design of a randomised double-blind 2×2 factorial trial comparing the effect of a 3-month intensive statin and antiplatelet therapy for patients with acute mild ischaemic stroke or high-risk TIA with intracranial or extracranial atherosclerosis(INSPIRES)

Background It remains unclear if intensive antiplatelet and statin treatments begun within 24-72 hours of cerebral ischaemic events from intracranial or extracranial atherosclerosis is effective or safe.Methods The Intensive Statin and Antiplatelet Therapy for High-risk Intracranial or Extracranial Atherosclerosis(INSPIRES)trial is a randomised,double-blind,placebo-controlled,multicentre and 2×2 factorial trial.6100 individuals between the ages of 35 and 80 who have experienced a mild ischaemic stroke or high-risk transient ischaemic attack(TIA)within the previous 72 hours that is attributed to≥50%atherosclerotic stenosis of a major intracranial or extracranial artery or multiple infarctions of atherosclerotic origin will be enrolled in the trial.Eligible subjects will be randomised 1:1:1:1 to one of four groups:(1)intensive antiplatelet therapy(combined clopidogrel and aspirin for days 1-21,then aspirin placebo and clopidogrel for days 22-90)plus immediate intensive statin therapy(atorvastatin at a dose of 80 mg daily for the first 21 days,then 40 mg daily for days 22-90);(2)intensive antiplatelet therapy plus delayed intensive statin therapy(atorvastatin placebo for days 1-3,followed by 40 mg per day of atorvastatin for days 4-90);(3)standard antiplatelet therapy(combination of clopidogrel placebo with aspirin for 90 days)plus immediate intensive statin therapy and(4)standard antiplatelet therapy plus delayed intensive statin therapy.The primary efficacy endpoint is any new stroke(ischaemic or haemorrhagic)within 90 days after randomisation.The primary safety endpoint is moderate to severe bleeding at 90 days.Conclusion The INSPIRES trial will assess the efficacy and safety of intensive antiplatelet therapy and immediate intensive statin therapy begun within 72 hours of onset in decreasing the recurrent stroke at 90 days in patients with acute mild ischaemic stroke or high-risk TIA of intracranial or extracranial atherosclerosis origin.

血浆置换和糖皮质激素治疗抗中性粒细胞胞质抗体相关性血管炎:临床实践指南

对于抗中性粒细胞胞质抗体(antineutrophil cytoplasmic antibody,ANCA)相关性血管炎(ANCA-associated vasculitis,AAV)患者,血浆置换的作用是什么?接受治疗前6个月糖皮质激素的最佳剂量是多少?一项新发表的随机对照试验(randomised controlled trial,RCT)引起本次指南的制订。

Association of psychological risk factors and acute myocardial infarction in China： the INTER-HEART China study

Background Most data about psychological factors relating to acute myocardial infarction （AMI） were obtained from studies carried out in western countries. Results from small descriptive cross-sectional studies in China were inconclusive. The aim of this study was to explore possible associations between psychological risk factors and AMI among the Chinese population with a large-scale case-control study.Methods This study was part of the INTER-HEART China study, itself part of the large international INTER-HEART study of cardiovascular risk factors. In this case-control study, 2909 cases and 2947 controls were recruited from 17 cities.Psychological stress, negative life events, depression and controllability of life circumstances were assessed.Results Cases reported more psychological stress at home or work and odds ratios （ORs） were 3.2 （95% CI 2.1-4.9）for permanent stress and 2.1 （95% CI 1.5-2.8） for several periods of stress respectively. More cases experienced depression compared with controls （19.6% vs. 9.3%） and ORs were 2.2 （95% CI 1.9-2.6）. Subjects with 1, 2 and 3 or more depressive symptoms had increased risk of AMI by 2.1, 2.2 and 2.6 fold, respectively, i.e., more depressive symptoms were associated with higher risks of AMI （P for trend ＜0.0001）. Women had a greater risk of AMI from depression （OR 3.0, 95% CI 2.2-4.0） compared to men （OR 2.0, 95% CI 1.6-2.4）, P for interaction =0.0364. Negative life events in subjects were associated with increased risk of AMI, OR 1.7 （95% CI 1.4-2.0） for one event and 1.8 （95% CI 1.3-2.4） for two or more events. High levels of controllability of life circumstances reduced the risk for AMI （OR 0.8, 95%CI 0.7-1 .0）.Conclusions Several psychological factors were closely associated with increased AMI risk among Chinese population.Psychological stress had a greater AMI risk in men but depression was more significant among women.

Telmisartan, ramipril, or both in high-risk Chinese patients： analysis of ONTARGET China data

Background The results from the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial （ONTARGET） indicated that the angiotensin-receptor blocker telmisartan was not inferior to the angiotensin-converting-enzyme inhibitor ramipril in reducing the composite endpoint of cardiovascular death, myocardial infarction, stroke or hospitalization for congestive heart failure in high-risk patients, and telmisartan was associated with slightly superior tolerability. The combination of the two drugs was associated with more adverse events without an increase in benefit. This study aimed to analyze the data from ONTARGET obtained from a subgroup of patients enrolled in China and to evaluate the demographic and baseline characteristics, the compliance, efficacy, and safety of the different treatment strategies in randomized patients in China. Methods A total of 1159 high-risk patients were randomized into three treatment groups： with 390 assigned to receive 80 mg of telmisartan, 385 assigned to receive 10 mg of ramipril and 384 assigned to receive both study medications. The median follow-up period was 4.3 years. Results The mean age of Chinese patients was 65.6 years, 73.6% of patients were male. The proportion of patients with stroke/transient ischemic attacks at baseline in China was two times more than the entire study population （47.7% vs 20.9%）. In Chinese patients the proportion of permanent discontinuation of study medication due to cough was 0.5% in the telmisartan group, which was much less than that in the combination or the ramipril group. There were no significant differences in the incidence of primary outcome among three treatment groups of Chinese patients. More strokes occurred in Chinese patients than in the entire study population （8.5% vs. 4.5%）. Greater systolic blood pressure reduction （-9.8 mmHg）, and more renal function failure were noted in the combination treatment group than in the ramipril or telmisartan group （2.6% vs. 1.6% and 1.0%）. Conclusions There was no evidence that the results of ONTARGET differed between Chinese patients and the entire study population with respect to the incidence of primary outcome, particularly safety. Compliance with study medications was good. The evidence from ONTARGET indicated that the treatment strategies in ONTARGET were applicable to patients in China.