贾宣
中国医学科学院阜外医院 统计中心
Importance:The incidence of acute myocardial infarction has increased over the past decades in China, and management challenges include an unbalanced economy, disparate resources, and variable access to medical care across the nation.Objective:To examine the variations in care and outcomes of patients with ST-segment elevation myocardial infarction among 3 levels of hospitals in the typical Chinese public hospital model.Design, Setting, and Participants:This cross-sectional study used data from the China Acute Myocardial Infarction Registry to compare the differences in care and outcomes among patients at 108 hospitals from 31 provinces and municipalities throughout mainland China. Participants included patients with ST-segment elevation myocardial infarction directly admitted to hospitals between January 2013 and September 2014. Data analyses were performed from June 2015 to June 2019.Exposures:Care in province-level, prefecture-level, or county-level hospitals in China.Main Outcomes and Measures:The primary outcome was in-hospital mortality. Secondary outcomes included presentation, treatments, and major complications.Results:A total of 12 695 patients (9593 men [75.6%]; median [interquartile range] age, 63 [54-72] years) were included; 3985 were at province-level hospitals, 6731 were at prefecture-level hospitals, and 1979 were at county-level hospitals. Compared with patients admitted to province-level hospitals, those admitted to prefecture-level and county-level hospitals were older (median [interquartile range] age, 61 [52-70] years vs 63 [54-72] years and 65 [57-75] years) and more likely to be women (815 women [20.5%] vs 1620 women [24.1%] and 667 women [33.7%]). Patients in prefecture-level and county-level hospitals were less likely to use ambulances compared with patients at province-level hospitals (11.6% [95% CI, 10.8%-12.4%] and 12.0% [95% CI, 10.6%-13.5%] vs 19.4% [95% CI, 18.1%-20.7%]; P < .001) and were less likely to experience early presentation, with onset-to-arrival times less than 12 hours for 75.3% (95% CI, 73.9%-76.6%) of patients at province-level hospitals, 70.8% (95% CI, 69.7%-71.9%) of patients at prefecture-level hospitals, and 69.8% (95% CI, 67.7%-71.8%) of patients at county-level hospitals (P < .001). The rates of reperfusion therapy were significantly lower in low-level hospitals (54.3% [95% CI, 53.1%-55.5%] for prefecture-level hospitals and 45.8% [95% CI, 43.6%-48.1%] for county-level hospitals) compared with province-level hospitals (69.4% [95% CI, 67.9%-70.8%]; P < .001). There was a progressively higher rate of in-hospital mortality at the 3 levels of hospitals: 3.1% (95% CI, 2.6%-3.7%) for province-level hospitals, 5.3% (95% CI, 4.8%-5.9%) for prefecture-level hospitals, and 10.2% (95% CI, 8.9%-11.7%) for county-level hospitals (P for trend < .001). After adjustment for patient characteristics, presentation, hospital facility, and treatments, the odds of death remained higher in prefecture-level (odds ratio, 1.39 [95% CI, 1.06-1.84]) and county-level (odds ratio, 1.43 [95% CI, 0.97-2.11]) hospitals compared with province-level hospitals (P for trend = .04).Conclusions and Relevance:These findings suggest that there are significant variations in care and outcomes of patients among the 3 levels of hospitals in China. More efforts should be made to address the identified gaps, particularly in the prefecture-level and county-level hospitals. This work can inform national quality improvements efforts in China and in other developing countries.
JAMA network open 2020
BACKGROUND:Identification and treatment of hypertension in China remain suboptimal despite high prevalence of hypertension and increasing incidence of stroke and myocardial infarction.OBJECTIVE:This study reported blood pressure levels, prevalence, awareness, treatment, and control rates of hypertension, in addition to drug treatments in China.METHODS:This is a country-specific analysis of 45 108 individuals, average age 51.4 (standard deviation 9.6) (35-70) years, enrolled between 2005 and 2009, from 70 rural and 45 urban communities in 12 provinces.RESULTS:Among 18 915 (41.9% overall population) hypertensive participants, 7866 (41.6%) were aware, 6503 (34.4%) treated but only 1545 (8.2%) controlled. Prevalence of hypertension was higher, but awareness, treatment, and control were lower in rural than urban residents. Prevalence of hypertension was highest in eastern (44.3%), intermediate in central (39.3%), and lowest in western regions (37.0%). Awareness was higher in central (44.3%) and eastern (42.4%) but lower in western regions (37.0%). Similar patterns were observed in treatment rates, 37.7% central, 35.2% eastern, and 26.7% in western regions with control rates of 8.3% in eastern, 7.6% central, and 5.3% west regions. Of 4744 participants receiving documented treatments, 37.5% received traditional combination drugs alone, 55.4% western drugs alone and 7.1% combination of traditional combination drug in addition to western drugs.CONCLUSION:In China, hypertension is common, and while recent studies suggest some improvements, more than half of affected individuals were unaware that they had hypertension. Rates of control remain low. National programs effective in preventing and controlling hypertension in China are urgently needed.
Journal of hypertension 2016
BACKGROUND:Acute myocardial infarction (AMI) has become a major cause of hospitalization and mortality in China. There has been limited data to date available to characterize AMI presentation, contemporary patterns of medical care, and outcomes in China.AIMS:The CAMI Registry is a national project with the objectives to timely obtain real-world knowledge about AMI patients and to provide the platform for clinical research, guide preventive measures and care quality improvement efforts in China.METHODS AND PROGRESS:The CAMI registry is a prospective, nationwide, multicenter observational study for AMI patients. The registry includes three levels of hospitals (representing typical Chinese governmental and administrative models) from all provinces and municipalities throughout Mainland China except Hong Kong and Macau. Sites were instructed to enroll consecutive patients with a primary diagnosis of AMI. Clinical data, treatments, outcomes and cost are collected by local investigators and captured electronically, with a standardized set of variables and standard definitions, and rigorous data quality control. Post-discharge patient follow-up to 2 years is planned. The CAMI Registry was launched in January 2013. A total of 108 hospitals have participated in the registry so far. As of September 2014, 26,103 patients with AMI were registered.CONCLUSIONS:The CAMI registry represents a well-supported and the largest national long-term registry-research-education platform for surveillance, research, prevention and care improvement for AMI in China, the world's most populous nation. The broad representation of all provinces and different-level hospitals will allow for the exploration of AMI across diverse geographic regions and economic circumstances.
American heart journal 2016
BACKGROUND:No-reflow after emergency percutaneous coronary intervention (PCI) for acute ST segment elevation myocardial infarction (STEMI) is related to the severe prognosis. The aim of this study was to evaluate the efficacy of Tongxinluo, a traditional Chinese medicine, on no-reflow and the infarction area after emergency PCI for STEMI.METHODS:A total of 219 patients (female 31, 14%) undergoing emergency PCI for STEMI from nine clinical centers were consecutively enrolled in this randomized, double-blind, placebo-controlled, multicenter clinical trial from January 2007 to May 2009. All patients were randomly divided into Tongxinluo group (n = 108) and control group (n = 111), given Tongxinluo or placebo in loading dose 2.08 g respectively before emergency PCI with aspirin 300 mg and clopidogrel 300 mg together, then 1.04 g three times daily for six months after PCI. The ST segment elevation was recorded by electrocardiogram at hospitalization and 1, 2, 6, 12, 24 hours after coronary balloon dilation to evaluate the myocardial no-flow; myocardial perfusion scores of 17 segments were evaluated on day 7 and day 180 after STEMI with static single-photon emission computed tomography (SPECT) to determine the infarct area.RESULTS:There was no statistical significance in sex, age, past history, chest pain, onset-to-reperfusion time, Killip classification, TIMI flow grade just before and after PCI, either in the medication treatment during the follow up such as statin, β-blocker, angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) between two groups. There was significant ST segment restoration in Tongxinluo group compared to the control group at 6 hours ((-0.22 ± 0.18) mV vs. (-0.18 ± 0.16) mV, P = 0.0394), 12 hours ((-0.24 ± 0.18) mV vs. (-0.18 ± 0.15) mV, P = 0.0158) and 24 hours ((-0.27 ± 0.16) mV vs. (-0.20 ± 0.16) mV, P = 0.0021) reperfusion; and the incidence of myocardial no-reflow was also reduced significantly at 24-hour reperfusion (34.3% vs. 54.1%, P = 0.0031). The myocardial perfusion scores of 17 segments evaluated by static SPECT was improved significantly on day 7 and day 180 after STEMI in Tongxinluo group compared to the control group (0.61 ± 0.40 vs. 0.76 ± 0.42, P = 0.0109 and 0.51 ± 0.42 vs. 0.66 ± 0.43, P = 0.0115, respectively). There was no significant difference in severe adverse events between two groups.CONCLUSION:Tongxinluo as a kind of traditional Chinese medicine could reduce myocardial no-reflow and infarction area significantly after emergency PCI for STEMI with conventional medicine therapy.
Chinese medical journal 2010
OBJECTIVE:To compare the difference between 24-h ambulatory blood pressure (ABP) and trough clinic blood pressure (CBP) after 8 weeks of therapy.METHODS:The study used meta-regression analysis to summarize three randomized, double-blind, active controlled trials in order to compare the difference between the magnitude of the reduction in 24-h average ABP and CBP Patients. Chinese patients with seated diastolic blood pressure (SDBP) 95-115 mmHg and ambulatory diastolic blood pressure (ADBP) > or =85 mmHg.RESULTS:The average age of 126 patients was 47.7 +/- 8.3 years, ranging from 25 to 67 (95 males and 31 females). All regimens reduced 24-h ABP and CBP after 8 weeks of treatment. In the 126 patients the baseline 24-h SBP and DBP values (142.7/94.4 mmHg) were markedly lower than those for clinic values (152.6/102.6 mmHg; P<0.0001). Similarly, the 24-h SBP and DBP values (132.7/87.7 mmHg) in week 8 were markedly lower than the clinic values (138.9/92.7 mmHg; P<0.0001). The differences between the treatment-induced reductions in 24-h ABP and CBP were statistically significant (the difference was 3.7/3.3 mmHg for SBP/DBP, P=0.0069/P<0.0001).CONCLUSION:All regimens significantly reduced seated CBP and ABP. The effect of antihypertensive treatment was greater on CBP than that on ABP, suggesting that assessment on effectiveness of an antihypertensive treatment using CBP readings only has to be carefully interpreted, and a more systematic application of ABP monitoring should be adopted.
Biomedical and environmental sciences : BES 2007
OBJECTIVE:In order to provide readers with general concepts and methodology on adaptive designs for clinical trial.METHODS:Definition of adaptive designs for clinical trial and basic idea of adaptive adjustment were introduced through an example.RESULTS:The relationship between adaptive designs and group sequential design was summarized. Ways to embody two basic statistical rules of clinical trial under adaptive adjustments setting were also introduced.CONCLUSION:Adaptive designs provided clinical trial with a great flexibility, which could greatly improve the efficiency of clinical trial.
Zhonghua liu xing bing xue za zhi = Zhonghua liuxingbingxue zazhi 2007
OBJECTIVES:The aims of this study were to evaluate the effects of beta-blockers on neurohormonal factors in patients with chronic left heart failure (CHF).METHODS:44 patients, 33 men and 11 women, with age of 60.1 +/- 10.6 years with chronic left heart failure (ejection fraction less or equal to 40% by UCG) were included in this study. All patients received conventional therapy and were randomly assigned either to a bisoprolol or carvedilol group. The dosage of beta-blockers were increased gradually to target or the tolerant dosages (bisoprolol 10 mg qd, carvedilol 25 mg bid) during 3 months in 36 patients. Maintenance dose was continued for 4 months. Plasma concentrations of renin activity (PRA), angiotensin II (Ang II), aldosterone (Ald) and the N-terminal portion of brain natriuretic (NT-proBNP) were assessed with RIA and ELISA at baseline and 3 and 7 months after staring beta-blocker therapy. Left ventricular ejection fraction (LVEF, Modify SIMPSON) was assessed at baseline and 7 months after starting therapy.RESULTS:(1) In patients with left heart failure, the baseline plasma level of PRA, Ang II and Ald were at normal range. N-terminal BNP concentration was much higher than 200 pg/ml as a result of impaired systolic function, as it elevated with increasing of NYHA grade. (2) The plasma level of NT-proBNP decreased significantly, as compared with that before therapy, but there is no significant change of plasma level of PRA, Ang II and Ald. (3) There were no significant differences between the event group and non-event group for the plasma level of renin-angiotensin and aldosterone during 7 months after starting beta-blocker. The Plasma levels of NT-proBNP were much higher in the event group than non-event group. (4) Multi regression analysis showed that the value of LVEF increased with the decreasing of NT-proBNP levels (beta = -0.389, P = 0.009) and increasing of Ang II level (beta = 0.341, P = 0.020) at baseline. After-therapy LVEF increased with the decreasing of NT-proBNP levels at titration-end (beta = -0.424, P = 0.020).CONCLUSIONS:The plasma level of NT-proBNP is more sensitive and accurate than the plasma level of PRA, Ang II and Ald in evaluation of severity and prognosis of CHF. beta-Blocker administration in patients with CHF decreases circulating levels of NT-proBNP and thus improves left ventricular function, but there is no significant effect on plasma level of PRA, Ang II and Ald.
Zhonghua nei ke za zhi 2005
OBJECTIVE:To investigate whether methylenetetrahydrofolate reductase (MTHFR) gene C677T polymorphism is linked with coronary heart disease (CHD).METHODS:Transmission/disequilibrium test(TDT), sib transmission/disequilibrium test(STDT), and sibship disequilibrium test(SDT) were used. Forty-five CHD pedigrees with at least one CHD patient in the first degree relatives of probands were recruited from Oct. 1998 to Feb. 1999. Among those recruited were 21, 2 and 22 pedigrees with the genotypes of both parents known, one parental genotype unknown and both unknown, respectively. MTHFR genotype was measured by PCR-RFLP technique.RESULTS:Neither the TDT for 23 nuclear families with at least one parental genotype known or the STDT and SDT for 40 sibships found significant difference between the transmitted and untransmitted MTHFR gene 677T allele distributions.CONCLUSION:The above results suggest that MTHFR gene 677T allele is probably not linked with CHD in Chinese population.
Zhonghua yi xue yi chuan xue za zhi = Zhonghua yixue yichuanxue zazhi = Chinese journal of medical genetics 2001
