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Regional variations in acute coronary syndrome (ACS) management and outcomes have been an enormous public health issue. However, studies have yet to explore how to reduce the variations. The National Chest Pain Center Program (NCPCP) is the first nationwide, hospital-based, comprehensive, continuous quality improvement program for improving the quality of care in patients with ACS in China. We evaluated the association of NCPCP and regional variations in ACS healthcare using generalized linear mixed models and interaction analysis. Patients in the Western region had longer onset-to-first medical contact (FMC) time and time stay in non-percutaneous coronary intervention (PCI) hospitals, lower rates of PCI for ST-elevation myocardial infarction (STEMI) patients, and higher rates of medication usage. Patients in Central regions had relatively lower in-hospital mortality and in-hospital heart failure rates. Differences in the door-to-balloon time (DtoB) and in-hospital mortality between Western and Eastern regions were less after accreditation (β = -8.82, 95% confidence interval (CI) -14.61 to -3.03; OR = 0.79, 95%CI 0.70 to 0.91). Similar results were found in differences in DtoB time, primary PCI rate for STEMI between Central and Eastern regions. The differences in PCI for higher-risk non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients among different regions had been smaller. Additionally, the differences in medication use between Eastern and Western regions were higher after accreditation. Regional variations remained high in this large cohort of patients with ACS from hospitals participating in the NCPCP in China. More comprehensive interventions and hospital internal system optimizations are needed to further reduce regional variations in the management and outcomes of patients with ACS., (Copyright © 2024. Published by Elsevier B.V.)

Importance: Sex disparities in the management and outcomes of acute coronary syndrome (ACS) have received increasing attention., Objective: To evaluate the association of a quality improvement program with sex disparities among patients with ACS., Design, Setting, and Participants: The National Chest Pain Centers Program (NCPCP) is an ongoing nationwide program for the improvement of quality of care in patients with ACS in China, with CPC accreditation as a core intervention. In this longitudinal analysis of annual (January 1, 2016, to December 31, 2020) cross-sectional data of 1 095 899 patients with ACS, the association of the NCPCP with sex-related disparities in the care of these patients was evaluated using generalized linear mixed models and interaction analysis. The robustness of the results was assessed by sensitivity analyses with inverse probability of treatment weighting. Data were analyzed from September 1, 2021, to June 30, 2022., Exposure: Hospital participation in the NCPCP., Main Outcomes and Measures: Differences in treatment and outcomes between men and women with ACS. Prehospital indicators included time from onset to first medical contact (onset-FMC), time from onset to calling an emergency medical service (onset-EMS), and length of hospital stay without receiving a percutaneous coronary intervention (non-PCI). In-hospital quality indicators included non-PCI, use of statin at arrival, discharge with statin, discharge with dual antiplatelet therapy, direct PCI for ST-segment elevation myocardial infarction (STEMI), PCI for higher-risk non-ST-segment elevation ACS, time from door to catheterization activation, and time from door to balloon. Patient outcome indicators included in-hospital mortality and in-hospital new-onset heart failure., Results: Data for 1 095 899 patients with ACS (346 638 women [31.6%] and 749 261 men [68.4%]; mean [SD] age, 63.9 [12.4] years) from 989 hospitals were collected. Women had longer times for onset-FMC and onset-EMS; lower rates of PCI, statin use at arrival, and discharge with medication; longer in-hospital delays; and higher rates of in-hospital heart failure and mortality. The NCPCP was associated with less onset-FMC time, more direct PCI rate for STEMI, lower rate of in-hospital heart failure, more drug use, and fewer in-hospital delays for both men and women with ACS. Sex-related differences in the onset-FMC time (β = -0.03 [95% CI, -0.04 to -0.01), rate of direct PCI for STEMI (odds ratio, 1.11 [95% CI, 1.06-1.17]), time from hospital door to balloon (β = -1.38 [95% CI, -2.74 to -0.001]), and rate of in-hospital heart failure (odds ratio, 0.90 [95% CI, 0.86-0.94]) were significantly less after accreditation., Conclusions and Relevance: In this longitudinal cross-sectional study of patients with ACS from hospitals participating in the NCPCP in China, sex-related disparities in management and outcomes were smaller in some aspects by regionalization between prehospital emergency and in-hospital treatment systems and standardized treatment procedures. The NCPCP should emphasize sex disparities to cardiologists; highlight compliance with clinical guidelines, particularly for female patients; and include the reduction of sex disparities as a performance appraisal indicator.

Background: Controversial findings have been reported in the literature regarding the impact of the absence of standard modifiable cardiovascular risk factors (SMuRFs) on long-term mortality risk in patients with acute coronary syndrome (ACS). While the prognostic additive value of SMuRFs has been well described, the prognostic role of prior cardiovascular disease (CVD) by sex is less well-known in patients with and without SMuRFs., Methods: EPICOR and EPICOR Asia are prospective, observational registries conducted between 2010 and 2014, which enrolled ACS patients in 28 countries across Europe, Latin America, and Asia. Association between SMuRFs (diabetes, dyslipidaemia, hypertension, and smoking) and 2-year postdischarge mortality was evaluated using adjusted Cox models stratified by geographical region., Results: Among 23,489 patients, the mean age was 60.9 ± 11.9 years, 24.3% were women, 4,582 (20.1%) presented without SMuRFs, and 16,055 (69.5%) without prior CVD. Patients with SMuRFs had a higher crude 2-year postdischarge mortality (HR 1.86; 95% CI, 1.56-2.22; P < .001), compared to those without SMuRFs. After adjustment for potential confounding, the association between SMuRFs and 2-year mortality risk was substantially attenuated (HR 1.17, 95% CI 0.98-1.41; P = .087), regardless of the type of ACS. The risk conferred by prior CVD was added to the underlying risk of SMuRFs to provide risk-specific phenotypes (eg, women with SMuRFs and with prior CVD were at higher risk of dying than women without SMuRFs and without CVD; HR 1.67, 95% CI 1.34-2.06)., Conclusions: In this large-scale international ACS cohort the absence of SMuRFs was not associated with a lower adjusted 2-year postdischarge mortality risk. Patients with both SMuRFs and prior CVD had a higher mortality irrespective of their sex., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Lipid management with a low-density lipoprotein cholesterol (LDL-C) goal of < 1.4 mmol/L is recommended for patients with acute coronary syndrome (ACS) and diabetes mellitus (DM) due to a high risk for adverse cardiovascular events. This study evaluated the lipid-lowering treatment (LLT) pattern and the LDL-C goal attainment rate in this special population., Methods: DM patients were screened from the observational Dyslipidemia International Study II-China study which assessed LDL-C goal attainment in Chinese ACS patients. The baseline characteristics between the LLT and no pre-LLT groups were compared. The proportions of patients obtaining LDL-C goal at admission and at 6-months, the difference from the goal, and the pattern of the LLT regimen were analyzed., Results: Totally 252 eligible patients were included, with 28.6% taking LLT at admission. Patients in the LLT group were older, had a lower percentage of myocardial infarction, and had decreased levels of LDL-C and total cholesterol compared to those in the no pre-LLT group at baseline. The overall LDL-C goal attainment rate was 7.5% at admission and increased to 30.2% at 6 months. The mean difference between the actual LDL-C value and LDL-C goal value dropped from 1.27 mmol/L at baseline to 0.80 mmol/L at 6 months. At 6 months, 91.4% of the patients received statin monotherapy, and only 6.9% received a combination of statin and ezetimibe. The atorvastatin-equivalent daily statin dosage was moderate during the study period., Conclusion: The low rate of lipid goal attainment observed was in line with the outcomes of other DYSIS-China studies., (© 2023. The Author(s).)

Background: Acute coronary syndrome (ACS) is the most time-sensitive acute cardiac event that requires rapid dispatching and response. The medical priority dispatch system (MPDS), one of the most extensively used types of emergency dispatch systems, is hypothesized to provide better-quality prehospital emergency treatment. However, few studies have revealed the impact of MPDS use on the process of ACS care., Objective: This study aimed to investigate whether the use of MPDS was associated with higher prehospital diagnosis accuracy and shorter prehospital delay for patients with ACS transferred by an emergency medical service (EMS), using a national database in China., Methods: This retrospective analysis was based on an integrated database of China's MPDS and hospital registry. From January 1, 2016, to December 31, 2020, EMS-treated ACS cases were divided into before MPDS and after MPDS groups in accordance with the MPDS launch time at each EMS center. The primary outcomes included diagnosis consistency between hospital admission and discharge, and prehospital delay. Multivariable logistic regression and propensity score-matching analysis were performed to compare outcomes between the 2 groups for total ACS and subtypes., Results: A total of 9806 ACS cases (3561 before MPDS and 6245 after MPDS) treated by 43 EMS centers were included. The overall diagnosis consistency of the after MPDS group (Cohen κ=0.918, P<.001) was higher than that of the before MPDS group (Cohen κ=0.889, P<.001). After the use of the MPDS, the call-to-EMS arrival time was shortened in the matched ACS cases (20.0 vs 16.0 min, P<.001; adjusted difference: -1.67, 95% CI -2.33 to -1.02; P<.001) and in the subtype of ST-elevation myocardial infarction (adjusted difference: -3.81, 95% CI -4.63 to -2.98, P<.001), while the EMS arrival-to-door time (20.0 vs 20.0 min, P=.31) was not significantly different in all ACS cases and subtypes., Conclusions: The optimized use of MPDS in China was associated with increased diagnosis consistency and a reduced call-to-EMS arrival time among EMS-treated patients with ACS. An emergency medical dispatch system should be designed specifically to fit into different prehospital modes in the EMS system on a regional basis., (©Xuejie Dong, Fang Ding, Shuduo Zhou, Junxiong Ma, Na Li, Mailikezhati Maimaitiming, Yawei Xu, Zhigang Guo, Shaobin Jia, Chunjie Li, Suxin Luo, Huiping Bian, Gesang Luobu, Zuyi Yuan, Hong Shi, Zhi-jie Zheng, Yinzi Jin, Yong Huo. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 23.11.2022.)

Background: The evidence for the comparative effectiveness and safety of ticagrelor versus clopidogrel in older patients with acute coronary syndrome (ACS) is limited, especially in the acute phase of ACS. This study aimed to compare the in-hospital outcomes of ticagrelor versus clopidogrel in older patients with ACS., Methods: Hospitalised ACS patients aged ≥75 years who were recruited to the Improving Care for Cardiovascular Disease in China-ACS project between November 2014 and December 2019 and received aspirin and P2Y12 receptor inhibitors within 24 h after first medical contact were included. The primary outcomes were in-hospital major adverse cardiovascular events (MACE) and major bleeding. Multivariable Cox regression was performed to evaluate the comparative effectiveness and safety of ticagrelor and clopidogrel. Inverse probability of treatment weighting (IPTW) and propensity score matching analyses were performed to evaluate the robustness of the results., Results: Of 18,244 ACS patients, 18.5% received ticagrelor. Multivariable-adjusted analysis revealed comparable risks of in-hospital MACE between patients receiving ticagrelor and clopidogrel (hazard ratio [HR] 1.12, 95% confidence interval [CI] 0.92-1.35). However, ticagrelor use was associated with 45% higher risk of in-hospital major bleeding compared with clopidogrel use (HR 1.45, 95% CI 1.09-1.91). Similar results were found in the IPTW analysis., Conclusions: ACS patients aged ≥75 years receiving ticagrelor during the acute phase had similar risk of in-hospital MACE, but higher risk of in-hospital major bleeding compared with those receiving clopidogrel. More evidence is needed to guide the use of P2Y12 receptor inhibitors during hospitalisation in older patients with ACS., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Short-term exposure to ambient air pollution has been linked with daily hospitalization and mortality from acute coronary syndrome (ACS); however, the associations of subdaily (hourly) levels of criteria air pollutants with the onset of ACS and its subtypes have rarely been evaluated., Methods: We conducted a time-stratified case-crossover study among 1 292 880 patients with ACS from 2239 hospitals in 318 Chinese cities between January 1, 2015, and September 30, 2020. Hourly concentrations of fine particulate matter (PM 2.5 ), coarse particulate matter (PM 2.5-10 ), nitrogen dioxide (NO 2 ), sulfur dioxide (SO 2 ), carbon monoxide (CO), and ozone (O 3 ) were collected. Hourly onset data of ACS and its subtypes, including ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, and unstable angina, were also obtained. Conditional logistic regressions combined with polynomial distributed lag models were applied., Results: Acute exposures to PM 2.5 , NO 2 , SO 2 , and CO were each associated with the onset of ACS and its subtypes. These associations were strongest in the concurrent hour of exposure and were attenuated thereafter, with the weakest effects observed after 15 to 29 hours. There were no apparent thresholds in the concentration-response curves. An interquartile range increase in concentrations of PM 2.5 (36.0 μg/m 3 ), NO 2 (29.0 µg/m 3 ), SO 2 (9.0 µg/m 3 ), and CO (0.6 mg/m 3 ) over the 0 to 24 hours before onset was significantly associated with 1.32%, 3.89%, 0.67%, and 1.55% higher risks of ACS onset, respectively. For a given pollutant, the associations were comparable in magnitude across different subtypes of ACS. NO 2 showed the strongest associations with all 3 subtypes, followed by PM 2.5 , CO, and SO 2 . Greater magnitude of associations was observed among patients older than 65 years and in the cold season. Null associations of exposure to either PM 2.5-10 or O 3 with ACS onset were observed., Conclusions: The results suggest that transient exposure to the air pollutants PM 2.5 , NO 2 , SO 2 , or CO, but not PM 2.5-10 or O 3 , may trigger the onset of ACS, even at concentrations below the World Health Organization air quality guidelines.

Background: Many patients with acute coronary syndrome have concurrent metabolic risk factors that affect risk of major adverse cardiovascular events (MACE). We aimed to assess the effects of the PCSK9 inhibitor alirocumab compared with placebo on MACE according to baseline metabolic risk factors., Methods: We performed a post-hoc analysis of the ODYSSEY OUTCOMES trial, which was a multicentre, double-blind, randomised controlled trial done in 1315 hospitals and outpatient clinics in 57 countries. Patients aged 40 years or older with recent acute coronary syndrome (ie, in the past 1-12 months) and elevated concentrations of atherogenic lipoproteins, despite high-intensity or maximum-tolerated statin treatment, were eligible for enrolment. Between Nov 2, 2012, and Feb 9, 2017, patients were randomly assigned (1:1) to 75 mg alirocumab by subcutaneous injection every 2 weeks or matching placebo, beginning 1-12 months after acute coronary syndrome and were followed up for a median of 2·8 years (IQR 2·3-3·4). Patients and investigators were masked to group assignment and treatment dose adjustment. The primary outcome was a composite of death from coronary artery disease, non-fatal myocardial infarction, fatal or non-fatal ischaemic stroke, or unstable angina requiring hospital admission. Analysis of MACE according to an ordinal number of metabolic risk factors was done post hoc. Metabolic risk factors were defined as blood pressure of at least 130/85 mm Hg or treatment with antihypertensive medication, triglyceride concentration of at least 150 mg/dL, HDL cholesterol concentration less than 40 mg/dL for men and 50 mg/dL women, fasting plasma glucose concentration of at least 100 mg/dL or treatment with glucose-lowering medication, and BMI of at least 30 kg/m 2 . Risk of MACE and effect of alirocumab were assessed according to the number of metabolic risk factors. ODYSSEY OUTCOMES is registered with ClinicalTrials.gov, number NCT01663402., Findings: Of 18 924 patients, 3882 (41%) of 9462 in the alirocumab group and 3859 (41%) of 9462 in the placebo group had three or more metabolic risk factors. In the placebo group, MACE incidence increased monotonically with each metabolic risk factor from 7·8% (no risk factors) to 19·6% (five risk factors; HR 1·18, 95% CI 1·13-1·24 per metabolic risk factor). Alirocumab decreased relative risk of MACE consistently across categories defined by the number of metabolic risk factors (p interaction =0·77), but absolute risk reduction (aRR) increased with the number of metabolic risk factors (no risk factors aRR 0·7%, -1·81 to 3·29 vs five risk factors aRR 3·9%, -1·45 to 9·25; p interaction <0·001). Similarly, when patients with diabetes were excluded, the incidence of MACE in the placebo group increased from 7·7% in patients with no metabolic risk factors to 14·6% in those with five metabolic risk factors and aRR with alirocumab increased from 0·91% in patients with no metabolic risk factors to 3·82% in those with five factors. Alirocumab was well tolerated in all subgroups defined by the presence of metabolic risk factors., Interpretation: Accumulation of metabolic risk factors was associated with higher risk of MACE in patients with recent acute coronary syndrome. Alirocumab reduced MACE consistently, but aRR increased with number of metabolic risk factors., Funding: Sanofi and Regeneron Pharmaceuticals., Competing Interests: Declaration of interests PO reports research grants or speaker and consulting honoraria (or both) from Amgen, AstraZeneca, Edwards, Getinge, Novartis, Promedica, Promedcs, Sanofi, and Servier. PGS reports grants, personal fees, and non-financial support from Sanofi; grants and personal fees from Amarin, Servier and Bayer; personal fees from Amgen, AstraZeneca, BMS, Boehringer Ingelheim, Idorsia, Pfizer, and Novartis; and has patent use of alirocumab to reduce risk after ACS (royalties to Sanofi) pending. YP and MSc are employees of Sanofi. DLB reports grants from Sanofi, Regeneron Pharmaceuticals, Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, The Medicines Company, Forest Laboratories/AstraZeneca, Ischemix, Amgen, Lilly, Chiesi, Ironwood, Abbott, Idorsia, Synaptic, Fractyl, Afimmune, Ferring Pharmaceuticals, Lexicon, Contego Medical, Owkin, HLS Therapeutics, 89Bio, and Garmin; is a Board Director at Boston Scientific and Boston VA Research Institute; receives unfunded research collaboration from Merck, FlowCo, and Takeda; is a site co-investigator for Svelte, CSI, Boston Scientific, Philips, St Jude Medical (Abbott), and Biotronik; is on the Advisory Board for Medscape Cardiology and Regado Biosciences; receives a grant from Roche and Pfizer; is a Deputy Editor for Clinical Cardiology; is a Chair at VA; receives grants from and is on the Scientific Advisory Board at Cardax, PLx Pharma, PhaseBio, Novo Nordisk, Cereno Scientific, CellProthera, MyoKardia/BMS, Janssen, Novartis, and NirvaMed; receives personal fees from Duke Clinical Research Institute, Mayo Clinic, Population Health Research Institute, Belvoir Publications, Slack Publications, WebMD, Elsevier, HMP Global, Harvard Clinical Research Institute (Baim Institute for Clinical Research), Journal of the American College of Cardiology, Cleveland Clinic, Mount Sinai School of Medicine, TobeSoft, Bayer, Medtelligence/ReachMD, CSL Behring, MJH Life Sciences, Level Ex, K2P, and the Canadian Medical and Surgical Knowledge Translation Research Group; reports personal fees and non-financial support from, and is a Senior Associate Editor, Chair, and Trustee at American College of Cardiology; reports personal fees and non-financial support from the Society of Cardiovascular Patient Care; non-financial support from American Heart Association; and grants, personal fees, and editorial support services from Boehringer Ingelheim. VAB reports grant support from Sanofi, Regeneron Pharmaceuticals, Astra Zeneca, DalCor, Esperion, and Novartis; consulting fees from Pfizer; honoraria from Medscape; and fees for participating on a Data Safety Monitoring Board or Advisory Board from the National Institutes of Health. RD reports research grants from Sanofi, DalCor Pharmaceuticals, Population Health Research Institute, Duke Clinical Research Institute, the TIMI group, Amgen, Cirius, Montreal Health Innovations Coordinating Center, and Lepetit, and personal fees, as a member of the Executive Steering Committee, from Amgen and Cirius. SGG reports research grant support (eg, steering committee or data and safety monitoring committee) or speaker and consulting honoraria (or both), from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, CSL Behring, Daiichi-Sankyo/American Regent, Eli Lilly, Esperion, Ferring Pharmaceuticals, GlaxoSmithKline, HLS Therapeutics, JAMP Pharma, Janssen/Johnson and Johnson, Merck, Novartis, Novo Nordisk A/C, Pendopharm, Pfizer, Regeneron, Sanofi, Servier, Valeo Pharma; and salary support or honoraria from the Heart and Stroke Foundation of Ontario/University of Toronto (Polo) Chair, Canadian Heart Research Centre and MD Primer, Canadian VIGOUR Centre, Cleveland Clinic Coordinating Centre for Clinical Research, Duke Clinical Research Institute, New York University Clinical Coordinating Centre, and PERFUSE Research Institute. YH reports speaker or consulting honoraria from Pfizer, Bayer, Novartis, AstraZeneca, and Sanofi. JWJ reports research grants from the Netherlands Heart Foundation, the Interuniversity Cardiology Institute of the Netherlands, and the European Commission Seventh Framework Programme, and research support from Amgen, Astellas, AstraZeneca, Daiichi- Sankyo, Lilly, Merck-Schering-Plough, Pfizer, Roche, and Sanofi. YK reports payment or honoraria for lectures, presentations, speaker's bureaus, manuscript writing or educational events from Sanofi, Pfizer, Servier, Amgen, Berlin-Chemie, Bayer, Recordati, AstraZeneca, MSD, Takeda, Boeringer Ingelheim, and KRKA; support for attending meetings or travel (or both) from Sanofi-Aventis, Pfizer, Servier, Berlin-Chemie, Bayer, AstraZeneca, and Takeda; and participation on a Data Safety Monitoring Board or Advisory Board for MSD, Servier, AstraZeneca, Sanofi. RP is an employee of Regeneron Pharmaceuticals. MSz reports serving as a consultant or on advisory boards (or both) for CiVi, Resverlogix, Baxter, Esperion, Sanofi, and Regeneron Pharmaceuticals. HDW reports receiving grant support paid to the institution and fees for serving on a steering committee for the ODYSSEY OUTCOMES trial (evaluation of cardiovascular outcomes after an acute coronary syndrome during treatment with alirocumab) from Sanofi-Aventis and Regeneron Pharmaceuticals, for the ACCELERATE study (a study of evacetrapib in high-risk vascular disease) from Eli Lilly, for the STRENGTH trial (outcomes study to assess statin residual risk reduction with EpaNova in high CV risk patients with hypertriglyceridemia) from Omthera Pharmaceuticals, for the SPIRE trial (the evaluation of bococizumab [PF-04950615; RN 316] in reducing the occurrence of major cardiovascular events in high risk subjects) from Pfizer USA, for the HEART-FID study (randomised placebo-controlled trial of FCM as treatment for heart failure with iron deficiency) from American Regent; for the CAMELLIA-TIMI study (a study to evaluate the effect of long-term treatment with BELVIQ [Lorcaserin HC] on the incidence of major adverse cardiovascular events and conversion to type 2 diabetes mellitus in patients with overweight and obesity and with cardiovascular disease or multiple cardiovascular risk factors) from Eisai, for the dal-GenE study (effect of dalcetrapib vs placebo on CV risk in a genetically defined population with a recent ACS) from DalCor Pharma UK, for the AEGIS-II study from CSL Behring, for the SCORED trial (effect of sotagliflozin on cardiovascular and renal events in patients with type 2 diabetes and moderate renal impairment who are at cardiovascular risk) and the SOLOIST-WHF trial (effect of sotagliflozin on cardiovascular events in patients with type 2 diabetes post worsening heart failure) from Sanofi-Aventis Australia, and for the CLEAR Outcomes Study (evaluation of major cardiovascular events in patients with, or at high risk for, cardiovascular disease who are statin intolerant treated with bempedoic acid [ETC-1002] or placebo) from esperion therapeutics. HDW was on the Advisory Boards for Acetelion, Sirtex, and Genentech, and received lecture fees from AstraZeneca. GGS reports research grants to the University of Colorado from Resverlogix, Sanofi, The Medicines Company, and Roche, and is coinventor of pending US patent 62/806,313 (Methods for reducing cardiovascular risk) assigned in full to the University of Colorado. TC declares no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Importance: Despite advances in the treatment of ST-segment elevation myocardial infarction (STEMI), little is known about how this evolving knowledge is applied in current clinical practice in China., Objective: To evaluate hospital performance and temporal trends in the management of STEMI., Design, Setting, and Participants: This study used data from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project, a nationwide quality improvement registry, in collaboration with the American Heart Association and the Chinese Society of Cardiology. Participants included patients with STEMI admitted to 143 tertiary hospitals across China from November 2014 to July 2019, and data were analyzed from November 2020 to December 2021., Main Outcomes and Measures: Levels, hospital-level variations, and trends for utilization rates of the 9 management strategies with Class I recommendations in Chinese and US guidelines., Results: A total of 57 560 hospitalizations with STEMI were included. Overall, 20.0% of patients received all the care according to the 9 guideline-recommended strategies. The performance rate of quality measures was low for reperfusion therapy (61.0%, 35 115/57 560 patients), β-blocker at discharge (68.3%, 37 750/55 285 patients), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge (55.1%, 2524/4578 patients), and smoking cessation counseling (36.5%, 9586/26 265 patients) among those who were eligible. Of 25 563 patients who underwent primary percutaneous coronary intervention (PCI), 66.8% underwent this procedure within 90 minutes of hospital arrival. Of 1128 patients who underwent fibrinolysis therapy, 253 (22.4%) underwent this treatment within 30 minutes of hospital arrival. Measures with high performance rates included receipt of dual antiplatelet therapy within 24 hours (95.5%, 54 263/56 848 patients) and at discharge (91.8%, 51 452/56 019 patients) and receipt of statin at discharge (93.0%, 52 214/56 141 patients) for those eligible. There was significant variation between hospitals in all-or-none score (ranging from 0 to 61.9%) and performance of individual measures. The quality of care improved during the study period, especially for reperfusion therapy, primary PCI within the first 90 minutes of hospital arrival, and smoking cessation counseling., Conclusions and Relevance: The quality of care for patients hospitalized with STEMI does not meet guideline-recommended strategies in China, with only 1 in 5 patients receiving all the care according to the 9 guideline-recommended strategies. Large disparities in the quality of care exist across hospitals.

Introduction and Objectives: Although several factors associated with sex differences in the management and outcomes after acute coronary syndrome (ACS) have been reported, little is known about the influence of socioeconomic factors on sex disparities. Our aim was to evaluate the influence of country wealth and income inequality on national sex differences in mortality after ACS., Methods: Sex differences in 2-year postdischarge mortality were evaluated in 23 489 ACS patients from the EPICOR and EPICOR Asia registries. Adjusted Cox regression models by country-based terciles of gross national income per capita and income inequality were used., Results: Women (24.3%) were older than men (65.5 vs 59.4 years, P <.001), had more comorbidities, were less often revascularized (63.6% vs 75.6%, P <.001) and received fewer guideline recommended therapies at discharge. Compared with men, a higher percentage of women died during follow-up (6.4% vs 4.9%, P <.001). The association between sex and mortality changed direction from hazard ratio (HR) 1.32 (95%CI, 1.17-1.49) in the univariate assessment to HR 0.76 (95%CI, 0.67-0.87) after adjustment for confounders. These differences were more evident with increasing country wealth (HR low-income countries = 0.85; 95%CI, 0.72-1.00; HR mid-income countries = 0.66; 95%CI, 0.50-0.87; HR high-income countries = 0.60; 95%CI, 0.40-0.90; trend test P = .115) and with decreasing income inequality (HR low-inequality index = 0.54; 95%CI, 0.36-0.81; HR intermediate-inequality index = 0.66; 95%CI, 0.50-0.88; HR high-inequality index = 0.87; 95%CI, 0.74-1.03; trend test P = .031)., Conclusions: Women with ACS living in high socioeconomic countries showed a lower postdischarge mortality risk compared with men. This risk was attenuated in countries with poorer socioeconomic background, where adjusted mortality rates were similar between women and men., (Copyright © 2021 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Background Medical staff represent critical stakeholders in the process of implementing a quality improvement (QI) program. Few studies, however, have examined factors that influence medical staff engagement and perception regarding QI programs. Methods and Results We conducted a nationally representative survey of a QI program in 6 cities in China. Quantitative data were analyzed using multilevel mixed-effects linear regression models, and qualitative data were analyzed using the framework method. The engagement of medical staff was significantly related to knowledge scores regarding the specific content of chest pain center accreditation (β=0.42; 95% CI, 0.27-0.57). Higher scores for inner motivation (odds ratio [OR], 1.79; 95% CI, 1.18-2.72) and resource support (OR, 1.52; 95% CI, 1.02-2.24) and lower scores for implementation barriers (OR, 0.81; 95% CI, 0.67-0.98) were associated with improved treatment behaviors among medical staff. Resource support (OR, 4.52; 95% CI, 2.99-6.84) and lower complexity (OR, 0.81; 95% CI, 0.65-1.00) had positive effects on medical staff satisfaction, and respondents with improved treatment behaviors were more satisfied with the QI program. Similar findings were found for factors that influenced medical staff's assessment of QI program sustainability. The qualitative analysis further confirmed and supplemented the findings of quantitative analysis. Conclusions Clarifying and addressing factors associated with medical staff's engagement and perception of QI programs will allow further improvements in quality of care for patients with acute coronary syndrome. These findings may also be applicable to other QI programs in China and other low- and middle-income countries. Registration URL: https://www.chictr.org.cn/; Unique identifier: Chi-CTR2100043319.

Objective: To evaluate the association between proton pump inhibitor (PPI) use and in-hospital gastrointestinal (GI) bleeding in patients with acute coronary syndrome (ACS) taking dual antiplatelet therapy (DAPT)., Patients and Methods: This study is based on the Improving Care for Cardiovascular Disease in China-ACS project, an ongoing collaborative registry and quality improvement project of the American Heart Association and the Chinese Society of Cardiology. A total of 25,567 patients with ACS taking DAPT from 172 hospitals from July 1, 2017, through December 31, 2018, were included. Multivariable Cox regression and propensity score-matched analyses were used to evaluate the association between PPI use and in-hospital GI bleeding., Results: Of these patients with ACS, 63.9% (n=16,332) were prescribed PPIs within 24 hours of admission. Patients using PPIs had a higher rate of GI bleeding compared with those not using PPIs (1.0% vs 0.5%; P<.001). In the multivariable Cox regression analysis, early PPI use was associated with a 58% higher risk of GI bleeding (hazard ratio, 1.58; 95% CI, 1.15 to 2.18; P=.005). Further propensity score matching attenuated the association but still showed that patients using PPIs had a higher rate of GI bleeding (0.8% vs 0.6%; P=.04)., Conclusion: In China, PPIs are widely used within 24 hours of admission in patients with ACS taking DAPT. An increased risk of GI bleeding is observed in inpatients with early PPI use. Randomized trials on early use of PPIs in patients with ACS receiving DAPT are warranted., Trial Registration: clinicaltrials.gov Identifier: NCT02306616., (Copyright © 2022. Published by Elsevier Inc.)

Background: Large-scale real-world data to evaluate the impact of chest pain centre (CPC) accreditation on acute coronary syndrome (ACS) emergency care in heavy-burden developing countries like China are rare., Methods: This study is a retrospective study based on data from the Hospital Quality Monitoring System (HQMS) database. This study included emergency patients admitted with ACS to hospitals that uploaded clinical data continuously to the database from 2013 to 2016. Propensity score matching was used to compare hospitals with and without CPC accreditation during this period. A longitudinal self-contrast comparison design with mixed-effects models was used to compare management of ACS before and after accreditation., Results: A total of 798 008 patients with ACS from 746 hospitals were included in the analysis. After matching admission date, hospital levels and types and adjusting for possible covariates, patients with ACS admitted to accredited CPCs had lower in-hospital mortality (OR=0.70, 95% CI 0.53 to 0.93), shorter length of stay (LOS; adjusted multiplicative effect=0.89, 95% CI 0.84 to 0.94) and more percutaneous coronary intervention (PCI) procedures (OR=3.53, 95% CI 2.20 to 5.66) than patients admitted in hospitals without applying for CPC accreditation. Furthermore, when compared with the 'before accreditation' group only in accredited CPCs, the in-hospital mortality and LOS decreased and the usage of PCI were increased in both 'accreditation' (for in-hospital mortality: OR=0.86, 95% CI 0.79 to 0.93; for LOS: 0.94, 95% CI 0.93 to 0.95; for PCI: OR=1.22, 95% CI 1.18 to 1.26) and 'after accreditation' groups (for in-hospital mortality: OR=0.90, 95% CI 0.84 to 0.97; for LOS: 0.89, 95% CI 0.89 to 0.90; for PCI: OR=1.36, 95% CI 1.33 to 1.39). The significant benefits of decreased in-hospital mortality, reduced LOS and increased PCI usage were also observed for patients with acute myocardial infarction., Conclusions: CPC accreditation is associated with better management and in-hospital clinical outcomes of patients with ACS. CPC establishment and accreditation should be promoted and implemented in countries with high levels of ACS., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Dyslipidemia International Study II (DYSIS II)-China was conducted to determine the low-density lipoprotein cholesterol (LDL-C) goal (<1.8 mmol/L) attainment rate in patients with post-acute coronary syndrome (ACS)., Hypothesis: Compliance with treatment guideline recommendations improves the LDL-C goal attainment rate in post-ACS patients., Methods: This multicenter prospective observational study conducted at 28 tertiary hospitals determined the LDL-C goal attainment rates at admission and 6-month follow-up in patients on lipid-lowering treatment (LLT) for ≥3 months and those not on LLT (LLT-naive or off LLT for ≥3 months) at admission. Predictors of goal attainment at 6 months were identified using multivariate logistic regression., Results: The LDL-C goal attainment rate at admission in 1102/1103 enrolled patients was 17.1%; it was 41.2% among 752 patients with available lipid results at 6 months. The distance to goal was 0.7 mmol/L at 6 months. Statin monotherapy was the most prescribed LLT. Only 7.7% of patients were receiving statin + ezetimibe and 8.4% of patients were receiving an atorvastatin-equivalent dose of ≥40 mg/day at 6 months. Being male (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.6) and undergoing percutaneous coronary intervention during index hospitalization (OR 1.5, 95% CI 1.1 to 2.1) were the independent predictors for LDL-C goal attainment., Conclusions: This real-world DYSIS II study in China reports a low LDL-C goal attainment rate in post-ACS patients even after 6 months of LLT. Lack of intensification of statin therapy and underutilization of combinations suggest gaps between real-world treatment practices and guideline recommendations., (© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Aims: Emerging evidence has linked cholesterol metabolism with platelet responsiveness. We sought to examine the dose-response relationship between low-density lipoprotein cholesterol (LDL-C) and major in-hospital bleeds in acute coronary syndrome (ACS) patients., Methods and Results: Among 42 378 ACS patients treated with percutaneous coronary intervention (PCI) enrolled in 240 hospitals in the Improving Care for Cardiovascular Disease in China-ACS project from 2014 to 2019, a total of 615 major bleeds, 218 ischaemic events, and 337 deaths were recorded. After controlling for baseline variables, a non-linear relationship was observed for major bleeds, with the higher risk at lower LDL-C levels. No dose-response relationship was identified for ischaemic events and mortality. A threshold value of LDL-C <70 mg/dL was associated with an increased risk for major bleeds (adjusted odds ratio: 1.49; 95% confidence interval: 1.21-1.84) in multivariable-adjusted logistic regression models and in propensity score-matched cohorts. The results were consistent in multiple sensitivity analyses. Among ticagrelor-treated patients, the LDL-C threshold for increased bleeding risk was observed at <88 mg/dL, whereas for clopidogrel-treated patients, the threshold was <54 mg/dL. Across a full spectrum of LDL-C levels, the treatment effect size associated with ticagrelor vs. clopidogrel on major bleeds favoured clopidogrel at lower LDL-C levels, but no difference at higher LDL-C levels., Conclusions: In a nationwide ACS registry, a non-linear association was identified between LDL-C levels and major in-hospital bleeds following PCI, with the higher risk at lower levels. As the potential for confounding may exist, further studies are warranted., Trial Registration: ClinicalTrials.gov Identifier: NCT02306616., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Background: Information is lacking on long-term management of patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m 2 )., Objectives: Our objectives were to describe antithrombotic management patterns and outcomes in patients with ACS with varying renal function from the EPICOR (long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients; NCT01171404) and EPICOR Asia (NCT01361386) studies., Methods: EPICOR and EPICOR Asia were prospective observational studies of patients who survived hospitalization for ACS and were enrolled at discharge in 28 countries across Europe, Latin America, and Asia. The studies were conducted from 2010 to 2013 and from 2011 to 2014, respectively. This analysis evaluated patient characteristics and oral antithrombotic management patterns and outcomes up to 2 years post-discharge according to admission eGFR: ≥ 90, 60-89, 30-59, or < 30 mL/min/1.73 m 2 ., Results: Among 22,380 patients with available data, eGFR < 60 mL/min/1.73 m 2 was observed in 16.7%. Patients with poorer renal function were older, were at greater cardiovascular risk, and had more prior cardiovascular disease and bleeding. Patients with CKD underwent fewer cardiovascular interventions and had more in-hospital cardiovascular and bleeding events. Dual antiplatelet therapy was less likely at discharge in patients with eGFR < 30 (82.3%) than in those with ≥ 90 (91.3%) mL/min/1.73 m 2 and declined more sharply during follow-up in patients with low eGFR (p < 0.0001). An adjusted proportional hazards model showed that patients with lower eGFR levels had a higher risk of cardiovascular events and bleeding., Conclusions: The presence of CKD in patients with ACS was associated with less aggressive cardiovascular management and an increased risk of cardiovascular events.

Objectives: To describe long-term antithrombotic management patterns (AMPs) in medically managed Asian patients with non-ST-segment myocardial infarction (NSTEMI) or unstable angina (UA)., Background: Current guidelines support an early invasive strategy in NSTEMI and UA patients, but many are medically managed, and data are limited on long-term AMPs in Asia., Methods: Data were analyzed from medically managed NSTEMI and UA patients included in the prospective, observational EPICOR Asia study (NCT01361386). Survivors to hospital discharge were enrolled (June 2011 to May 2012) from 8 countries/regions across Asia. Baseline characteristics and AMP use up to 2 years post-discharge were collected. Outcomes were major adverse cardiovascular events (MACE: myocardial infarction, ischemic stroke, and death) and bleeding., Results: Among 2289 medically managed patients, dual antiplatelet therapy (DAPT) use at discharge was greater in NSTEMI than in UA patients (81.8% vs 65.3%), and was significantly associated with male sex, positive cardiac markers, and prior cardiovascular medications (p < 0.0001). By 2 years, 57.9% and 42.6% of NSTEMI and UA patients, respectively, were on DAPT. On multivariable Cox regression analysis, risk of MACE at 2 years was most significantly associated with older age (HR [95% CI] 1.85 [1.36, 2.50]), diagnosis of NSTEMI vs UA (1.96 [1.47, 2.61]), and chronic renal failure (2.14 [1.34, 3.41]), all p ≤ 0.001. Risk of bleeding was most significantly associated with region (East Asia vs Southeast/South Asia) and diabetes., Conclusions: Approximately half of all patients were on DAPT at 2 years. MACE were more frequent in NSTEMI than UA patients during follow-up., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Background Long-term use of antiplatelet agents after acute coronary syndrome in diabetic patients is not well known. Here, we describe antiplatelet use and outcomes in such patients enrolled in the EPICOR Asia (Long-Term Follow-up of Antithrombotic Management Patterns in Acute Coronary Syndrome Patients in Asia) registry. Methods and Results EPICOR Asia is a prospective, observational study of 12 922 patients with acute coronary syndrome surviving to discharge, from 8 countries/regions in Asia. The present analysis included 3162 patients with diabetes mellitus (DM) and 9602 patients without DM. The impact of DM on use of antiplatelet agents and events (composite of death, myocardial infarction, and stroke, with or without any revascularization; individual components, and bleeding) was evaluated. Significant baseline differences were seen between patients with DM and patients without DM for age, sex, body mass index, cardiovascular history, angiographic findings, and use of percutaneous coronary intervention. At discharge, ≈90% of patients in each group received dual antiplatelet therapy. At 2-year follow-up, more patients with DM tended to still receive dual antiplatelet therapy (60% versus 56%). DM was associated with increased risk from ischemic but not major bleeding events. Independent predictors of the composite end point of death, myocardial infarction, and stroke in patients with DM were age ≥65 years and use of diuretics at discharge. Conclusions Antiplatelet agent use is broadly comparable in patients with DM and patients without DM, although patients with DM are more likely to be on dual antiplatelet therapy at 2 years. Patients with DM are at increased risk of ischemic events, suggesting an unmet need for improved antithrombotic treatment. Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT01361386.

Highlights: Over half of male acute coronary syndrome patients were smokers in China.Smoking was associated with higher risk of critical cardiac symptoms at admission.Only 35.3% of smoking patients received smoking cessation interventions in China., Background: Smoking cessation is recognized as an effective and cost-effective strategy for improving the prognosis of patients with coronary heart disease. Despite this, few studies have evaluated the smoking prevalence and provision of smoking cessation interventions among patients with acute coronary syndrome (ACS) in China., Objectives: To evaluate the smoking prevalence, clinical conditions and in-hospital outcomes associated with smoking, and the provision of smoking cessation interventions among ACS patients in China., Methods: This registry study was conducted using data from the Improving Care for Cardiovascular Disease in China project, a collaborative nationwide registry of the American Heart Association and the Chinese Society of Cardiology. Our study sample comprised 92,509 ACS inpatients admitted between November 2014 and December 2018. A web-based data collection platform was used to report required data., Results: Smoking prevalence among male and female ACS patients was 52.4% and 8.0%, respectively. Patients younger than 45 years had the highest smoking rate (men: 68.0%; women: 14.9%). Compared with non-smokers, smokers had an earlier onset age of ACS and a greater proportion of severe clinical manifestations at admission, including ST-elevation myocardial infarction (67.8% versus 54.8%; p < 0.001) and substantially elevated myocardial injury markers (86.1% versus 83.0%; p < 0.001). After multivariable adjustment, smoking was associated with higher risk of critical cardiac symptoms at admission (OR = 1.14, 95% CI: 1.08-1.20; p < 0.001) and had no direct association with in-hospital outcomes (OR = 0.93, 95% CI: 0.84-1.02; p = 0.107) of ACS patients. Of 37,336 smokers with ACS, only 35.3% received smoking cessation interventions before discharge. There was wide variation in provision of smoking cessation interventions across hospitals (0%-100%)., Conclusions: Smoking is highly prevalent among ACS patients in China. However, smoking cessation interventions are not widely adopted in clinical practice in China as part of formal treatment strategies for ACS patients, indicating an important target for quality improvement., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2020 The Author(s).)

Aims: Approximately half of cases of cardiovascular disease (CVD) worldwide occur in Asia, with acute coronary syndrome (ACS) a leading cause of mortality. Long-term ACS-related outcomes data in Asia are limited. This analysis examined 2-year ACS-related outcomes in patients enrolled in the EPICOR Asia study, and the association between patient characteristics and management on outcomes., Methods: EPICOR Asia is a multinational, prospective, primary data collection study of real-world management of Asian patients with ACS. Overall, 12,922 eligible adults (hospitalized for ACS within 48 h of symptom onset and who survived to discharge) were enrolled from 219 centers in eight Asian countries. Patients were followed up post-discharge for 2 years and clinical outcomes recorded., Results: Patients were of mean age 60 years and 76% were male. Diagnoses were STEMI (51.2%), NSTEMI (19.9%), and UA (28.9%). During follow-up, 5.2% of patients died; NSTEMI patients had the highest risk profile. Mortality rate (adjusted HR [95% CI]) was similar in NSTEMI (0.97 [0.81-1.17]) and lower in UA (0.52 [0.33-0.82]) vs STEMI. Similar trends (adjusted) were seen for the composite endpoint of death, myocardial infarction, or ischemic stroke, and bleeding rates did not differ significantly. For all three diagnoses, patients who were medically managed had a markedly elevated risk of both death and the composite endpoint., Conclusions: During 2-year follow-up, adjusted risks of mortality, the composite endpoint, and bleeding rates were similar in NSTEMI and STEMI patients. Outcomes risk was better for invasive management. Long-term management strategies in Asia need to be optimized., Competing Interests: Declaration of Competing Interest Yong Huo, Stephen W-L Lee, Jitendra PS Sawhney, Hyo-Soo Kim, Ángeles Alonso-Garcia, Jie Jiang, and Stephen Jan have nothing to disclose. Rungroj Krittayaphong has been a consultant or advisory board member for AstraZeneca and Boehringer Ingelheim. Stuart J Pocock receives research funds from AstraZeneca. Vo T Nhan has received research grants from AstraZeneca, Servier, Sanofi, and Boston Scientific, and has been a consultant or advisory board member for AstraZeneca, Pfizer, Sanofi, Boehringer Ingelheim, Servier, MSD, Abbott, Bayer, Novartis, Merck Serono, Biosensor, Biotronic, Boston Scientific, Terumo, and Medtronic. Chee Tang Chin has received research support from Eli Lilly and honoraria from Medtronic, and has been a consultant or advisory board member for AstraZeneca. Ana M Vega was a former employee of AstraZeneca and Nobuya Hayashi is a current employee of AstraZeneca. Tiong Kiam Ong has acted as a consultant or advisory board member for Sanofi-Aventis, Abbott Vascular, Boston Scientific, Boehringer Ingelheim, Novartis, and AstraZeneca., (Copyright © 2020. Published by Elsevier B.V.)

Background: Despite guideline recommendations, dual antiplatelet therapy (DAPT) is frequently used for longer than 1 year after an acute coronary syndrome (ACS) event. In Asia, information on antithrombotic management patterns (AMPs), including DAPT post discharge, is sparse. This analysis evaluated real-world AMPs up to 2 years post discharge for ACS., Hypothesis: There is wide variability in AMP use for ACS management in Asia., Methods: EPICOR Asia (NCT01361386) is a prospective observational study of patients discharged after hospitalization for an ACS in eight countries/regions in Asia, followed up for 2 years. Here, we describe AMPs used and present an exploratory analysis of characteristics and outcomes in patients who received DAPT for ≤12 months post discharge compared with >12 months., Results: Data were available for 12 922 patients; of 11 639 patients discharged on DAPT, 2364 (20.3%) received DAPT for ≤12 months and 9275 (79.7%) for >12 months, with approximately 60% still on DAPT at 2 years. Patients who received DAPT for >12 months were more likely to be younger, obese, lower Killip class, resident in India (vs China), and to have received invasive reperfusion. Clinical event rates during year 2 of follow-up were lower in patients with DAPT >12 vs ≤12 months, but no causal association can be implied in this non-randomized study., Conclusions: Most ACS patients remained on DAPT up to 1 year, in accordance with current guidelines, and over half remained on DAPT at 2 years post discharge. Patients not on DAPT at 12 months are a higher risk group requiring careful monitoring., (© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: Cardiovascular diseases account for approximately half of all deaths in Asia. The present analysis aimed to evaluate characteristics, antithrombotic management patterns (AMPs), and outcomes in patients with acute coronary syndrome (ACS) who underwent in-hospital percutaneous coronary intervention (PCI) and survived to hospital discharge, using data from the EPICOR Asia registry (NCT01361386)., Methods: Two-year post-discharge follow-up data were analyzed from 8757 ACS PCI patients from EPICOR Asia (218 centers, eight countries). Major adverse cardiovascular events (MACE; death, non-fatal myocardial infarction [MI], non-fatal ischemic stroke), PCI characteristics, and AMPs were recorded. For MACE, time - to - event was analyzed using Cox regression., Results: Primary PCI was performed in 62.0% of ST-segment elevation MI (STEMI), 38.7% of non-STEMI (NSTEMI), and 24.2% of unstable angina (UA) patients. At 12 months, 88.1% of patients were on dual antiplatelet therapy (DAPT), with no differences by index event. Most (61.5%) still received DAPT at 2 years. Two-year incidences of mortality, composite MACE, and bleeding were 3.6%, 6.2%, and 6.6%, respectively. Risk of death and MACE was increased with STEMI and NSTEMI vs. UA. Patients from East Asia showed lower mortality and more bleeding vs. Southeast Asia/India., Conclusions: Many patients in EPICOR Asia underwent PCI and received DAPT up to 2 years post-discharge. These real-world findings improve our understanding of AMP impact on outcomes in Asian patients with ACS undergoing PCI., Competing Interests: Declaration of competing interest S.Z., W.W., J.P.S.S., H.S.K., S.W.L.L., Y.H., J.Q., and J.G. declare no conflict of interest. R.K. reports having been a consultant or advisory board member for AstraZeneca and Boehringer Ingelheim (both modest). V.T.N. reports research grants from AstraZeneca, Servier, Sanofi, and Boston Scientific, and has been a consultant or advisory board member for AstraZeneca, Pfizer, Sanofi, Boehringer Ingelheim, Servier, MSD, Abbott, Bayer, Novartis, Merck Serono, Biosensor, Biotronic, Boston Scientific, Terumo, and Medtronic (all modest). T.K.O. reports having acted as a consultant or advisory board member for Sanofi-Aventis, Abbott Vascular, Boston Scientific, Boehringer Ingelheim, Novartis, and AstraZeneca (all modest). C.T.C. reports research support from Eli Lilly, honoraria from Medtronic, and has been a consultant or advisory board member for AstraZeneca (all modest). S.J.P. reports receiving research funds from AstraZeneca (modest)., (Copyright © 2020. Published by Elsevier B.V.)

Background: Long-term risk of post-discharge mortality associated with acute coronary syndrome remains a concern. The development of a model to reliably estimate two-year mortality risk from hospital discharge post-acute coronary syndrome will help guide treatment strategies., Methods: EPICOR (long-tErm follow uP of antithrombotic management patterns In acute CORonary syndrome patients, NCT01171404) and EPICOR Asia (EPICOR Asia, NCT01361386) are prospective observational studies of 23,489 patients hospitalized for an acute coronary syndrome event, who survived to discharge and were then followed up for two years. Patients were enrolled from 28 countries across Europe, Latin America and Asia. Risk scoring for two-year all-cause mortality risk was developed using identified predictive variables and forward stepwise Cox regression. Goodness-of-fit and discriminatory power was estimated., Results: Within two years of discharge 5.5% of patients died. We identified 17 independent mortality predictors: age, low ejection fraction, no coronary revascularization/thrombolysis, elevated serum creatinine, poor EQ-5D score, low haemoglobin, previous cardiac or chronic obstructive pulmonary disease, elevated blood glucose, on diuretics or an aldosterone inhibitor at discharge, male sex, low educational level, in-hospital cardiac complications, low body mass index, ST-segment elevation myocardial infarction diagnosis, and Killip class. Geographic variation in mortality risk was seen following adjustment for other predictive variables. The developed risk-scoring system provided excellent discrimination ( c -statistic=0.80, 95% confidence interval=0.79-0.82) with a steep gradient in two-year mortality risk: >25% (top decile) vs . ~1% (bottom quintile). A simplified risk model with 11 predictors gave only slightly weaker discrimination ( c -statistic=0.79, 95% confidence interval =0.78-0.81)., Conclusions: This risk score for two-year post-discharge mortality in acute coronary syndrome patients ( www.acsrisk.org ) can facilitate identification of high-risk patients and help guide tailored secondary prevention measures.

Background: Accumulating evidence has shown that type 2 diabetes (T2D) and coronary artery disease (CAD) may stem from a 'common soil'. The aim of our study was to examine the association between genetic predisposition to T2D and the risk of severe CAD among patients with acute coronary syndromes (ACS) undergoing angiography., Methods: The current case-control study included 1414 ACS patients with at least one major epicardial vessel stenosis > 50% enrolled in the ACS Genetic Study. The severity of CAD was quantified by the number of coronary arteries involved. Genetic risk score (GRS) was calculated using 41 common variants that robustly associated with increased risk of T2D in East Asians. Logistic regression models were used to estimate the association between GRS and the severity of CAD., Results: In the age-, sex- and BMI-adjusted model, each additional risk allele was associated with a 6% increased risk of multi-vessel disease (OR = 1.06, 95% CI 1.02-1.09). The OR was 1.43 (95% CI 1.08-1.89) for the risk of severe CAD when comparing the extreme tertiles of T2D-GRS. The association was not reduced after further adjustment for conventional cardiovascular risk factors. Additional adjustment for T2D status in our regression model attenuated the association by approximately one quarter. In subgroup analysis, the strengths of the associations between GRS and the severity of CAD were broadly similar in terms of baseline demographic information and disease characteristics., Conclusions: Our data indicated that genetic predisposition to T2D is associated with elevated risk of severe CAD. This association revealed a possible causal relationship and is partially mediated through diabetic status.

Background: The relationship between in-hospital coronary revascularization rate (CRR) and post-discharge mortality rates in survivors of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) at a system level is unclear., Objectives: The purpose of this study was to evaluate CRR and 2-year post-discharge mortality rate (2YMR) in NSTE-ACS., Methods: CRR and 2YMR were analyzed by hospital rate of CRR (in deciles), by country, and by world region in 11,931 patients with NSTE-ACS who survived to discharge and were enrolled in the EPICOR (long-tErm follow uP of antithrombotic management patterns In acute CORonary syndrome patients) and EPICOR Asia: twin multinational, observational, prospective cohort studies., Results: Significant differences in patient baseline characteristics, medical therapies, CRR, and 2YMR were found. Mean CRR ranged from 0.0% to 96.8% in the first and tenth decile, respectively (p < 0.001); from 12.3% in Romania to 92.4% in Slovenia (p < 0.001); and from 53.9% in South East Asia (SEAsia) to 90.4% in South Korea-Singapore-Hong Kong. 2YMR varied significantly between hospital deciles of CRR (3.6% in tenth decile vs. 9.2% in first decile; p < 0.001), countries (lowest 1.5% in Slovenia, highest 19.4% in Malaysia; p < 0.001), and regions (lowest 3.8% in South Korea-Singapore-Hong Kong, highest 11.7% in SEAsia; p < 0.001). Poisson regression models, adjusted for 15 mortality predictors, showed a significant inverse association between CRR and 2YMR for hospitals (r = -0.90; p < 0.001), countries (r = -0.65; p < 0.001), and regions (r = -0.87; p = 0.005)., Conclusions: Higher CRRs at the hospital, country, and world region levels are strongly associated with higher post-discharge survival, suggesting CRR as a marker of higher system quality., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Lowering low-density lipoprotein cholesterol (LDL-C) by statins is a key strategy for secondary prevention of acute coronary syndrome (ACS). However, few studies have examined prehospital statin use and admission LDL-C levels in ACS patients with history of myocardial infarction (MI) or revascularization. This study aimed to assess use of prehospital statins and LDL-C levels at admission in ACS patients with history of MI or revascularization., Methods: Improving Care for Cardiovascular Disease in China project was a nationwide registry, with 192 participating hospitals reporting details of clinical information of ACS patients from November 2014. By May 2018, 80,282 patients with ACS were included. LDL-C levels were obtained from the initial admission lipid testing., Results: Of the 80,282 ACS patients, 6,523 with a history of MI or revascularization were enrolled. Among them, 50.8% were receiving lipid-lowering therapy before hospitalization (statin monotherapy in 98.4%, combination in 1.2%). A total of 30.1% of patients had LDL-C < 70 mg/dL at admission. In patients receiving prehospital statins, 36.1% had LDL-C < 70 mg/dL compared to 24.0% without prehospital statins (P < .001). At discharge, 91.8% of patients were treated with statin monotherapy, 90.7% at moderate doses irrespective of prehospital statin use and LDL-C levels at admission., Conclusions: Among ACS patients with history of MI or revascularization, half were not being treated with statin therapy prior to admission, and most had not attained LDL-C < 70 mg/dL despite prehospital statin use. There is an important opportunity to provide intensive statin or combination lipid-lowering therapy to these very high risk patients., (Copyright © 2019. Published by Elsevier Inc.)

Background: This study aimed to examine hospital performance on evidence-based management strategies for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and variations across hospitals., Methods: Improving Care for Cardiovascular Disease in China (CCC)-ACS project is an ongoing registry and quality improvement project, with 150 tertiary hospitals recruited across China. We examined hospital performance on nine management strategies (Class I Recommendations with A Level of Evidence) based on established guidelines. We also evaluated the proportion of patients receiving defect-free care, which was defined as the care that included all the required management strategies for which the patient was eligible. The hospital-level variations in the performance were examined., Results: From 2014 to 2018, 28,170 NSTE-ACS patients were included. Overall, 16% of patients received defect-free care. Higher-performing metrics were statin at discharge (93%), cardiac troponin measurement (92%), dual antiplatelet therapy (DAPT) within 24 hours (90%), and DAPT at discharge (85%). These were followed by metrics of β-blocker at discharge (69%), angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) at discharge (59%), and risk stratification (56%). Lower-performing metrics were smoking cessation counseling (35%) and percutaneous coronary intervention (PCI) within recommended times (33%). The proportion of patients receiving defect-free care substantially varied across hospitals, ranging from 0% to 58% (Median (interquartile range):12% (7%-21%)). There were large variations across hospitals in performance on risk stratification, smoking cessation counseling, PCI within recommended times, ACEI/ARB at discharge and β-blocker at discharge., Conclusions: About one in six NSTE-ACS patients received defect-free care, and the performance varied across hospitals., (Copyright © 2019. Published by Elsevier Inc.)

Importance: Prior observational studies suggest that quality of care improvement (QCI) initiatives can improve the clinical outcomes of acute coronary syndrome (ACS). To our knowledge, this has never been demonstrated in a well-powered randomized clinical trial., Objective: To determine whether a clinical pathway-based, multifaceted QCI intervention could improve clinical outcomes among patients with ACS in resource-constrained hospitals in China., Design, Setting, Participants: This large, stepped-wedge cluster randomized clinical trial was conducted in nonpercutaneous coronary intervention hospitals across China and included all patients older than 18 years and with a final diagnosis of ACS who were recruited consecutively between October 2011 and December 2014. We excluded patients who died before or within 10 minutes of hospital arrival. We recruited 5768 and 0 eligible patients for the control and intervention groups, respectively, in step 1, 4326 and 1365 in step 2, 3278 and 3059 in step 3, 1419 and 4468 in step 4, and 0 and 5645 in step 5., Interventions: The intervention included establishing a QCI team, training clinical staff, implementing ACS clinical pathways, sequential site performance assessment and feedback, online technical support, and patient education. The usual care was the control that was compared., Main Outcomes and Measures: The primary outcome was the incidence of in-hospital major adverse cardiovascular events (MACE), comprising all-cause mortality, reinfarction/myocardial infarction, and nonfatal stroke. Secondary outcomes included 16 key performance indicators (KPIs) and the composite score developed from these KPIs., Results: Of 29 346 patients (17 639 men [61%]; mean [SD] age for control, 64.1 [11.6] years; mean [SD] age for intervention, 63.9 [11.7] years) who were recruited from 101 hospitals, 14 809 (50.5%) were in the control period and 14 537 (49.5%) were in the intervention period. There was no significant difference in the incidence of in-hospital MACE between the intervention and control periods after adjusting for cluster and time effects (3.9% vs 4.4%; odds ratio, 0.93; 95% CI, 0.75-1.15; P = .52). The intervention showed a significant improvement in the composite KPI score (mean [SD], 0.69 [0.22] vs 0.61 [0.23]; P < .01) and in 7 individual KPIs, including the early use of antiplatelet therapy and the use of appropriate secondary prevention medicines at discharge. No unexpected adverse events were reported., Conclusions and Relevance: Among resource-constrained Chinese hospitals, introducing a multifaceted QCI intervention had no significant effect on in-hospital MACE, although it improved a few of the care process indicators of evidence-based ACS management., Trial Registration: ClinicalTrials.gov identifier: NCT01398228.

Background: Coronary heart disease is a leading cause of mortality among women. Systematic evaluation of the quality of care and outcomes in women hospitalized for acute coronary syndrome (ACS), an acute manifestation of coronary heart disease, remains lacking in China., Methods: The CCC-ACS project (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) is an ongoing nationwide registry of the American Heart Association and the Chinese Society of Cardiology. Using data from the CCC-ACS project, we evaluated sex differences in acute management, medical therapies for secondary prevention, and in-hospital mortality in 82 196 patients admitted for ACS at 192 hospitals in China from 2014 to 2018., Results: Women with ACS were older than men (69.0 versus 61.1 years, P<0.001) and had more comorbidities. After multivariable adjustment, eligible women were less likely to receive evidence-based acute treatments for ACS than men, including early dual antiplatelet therapy, heparins during hospitalization, and reperfusion therapy for ST-segment-elevation myocardial infarction. With respect to strategies for secondary prevention, eligible women were less likely to receive dual antiplatelet therapy, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins at discharge, and smoking cessation and cardiac rehabilitation counseling during hospitalization. In-hospital mortality rate was higher in women than in men (2.60% versus 1.50%, P<0.001). The sex difference in in-hospital mortality was no longer observed in patients with ST-segment-elevation myocardial infarction (adjusted odds ratio, 1.18; 95% CI, 1.00 to 1.41; P=0.057) and non-ST-segment elevation ACS (adjusted odds ratio, 0.84; 95% CI, 0.66 to 1.06; P=0.147) after adjustment for clinical characteristics and acute treatments., Conclusions: Women hospitalized for ACS in China received acute treatments and strategies for secondary prevention less frequently than men. The observed sex differences in in-hospital mortality were mainly attributable to worse clinical profiles and fewer evidence-based acute treatments provided to women with ACS. Specially targeted quality improvement programs may be warranted to narrow sex-related disparities in quality of care and outcomes in patients with ACS., Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02306616.

Background: Guidelines have classified patients with acute coronary syndrome (ACS) and diabetes as a special population, with specific sections presented for the management of these patients considering their extremely high risk. However, in China up-to-date information is lacking regarding the burden of diabetes in patients with ACS and the potential impact of diabetes status on the in-hospital outcomes of these patients. This study aims to provide updated estimation for the burden of diabetes in patients with ACS in China and to evaluate whether diabetes is still associated with excess risks of early mortality and major adverse cardiovascular and cerebrovascular events (MACCE) for ACS patients., Methods: The Improving Care for Cardiovascular Disease in China-ACS Project was a collaborative study of the American Heart Association and the Chinese Society of Cardiology. A total of 63,450 inpatients with a definitive diagnosis of ACS were included. Prevalence of diabetes was evaluated in the overall study population and subgroups. Multivariate logistic regression was performed to examine the association between diabetes and in-hospital outcomes, and a propensity-score-matched analysis was further conducted., Results: Among these ACS patients, 23,880 (37.6%) had diabetes/possible diabetes. Both STEMI and NSTE-ACS patients had a high prevalence of diabetes/possible diabetes (36.8% versus 39.0%). The prevalence of diabetes/possible diabetes was higher in women (45.0% versus 35.2%, p < 0.001). Even in patients younger than 45 years, 26.9% had diabetes/possible diabetes. While receiving comparable treatments for ACS, diabetes/possible diabetes was associated with a twofold higher risk of all-cause death (adjusted odds ratio 2.04 [95% confidence interval 1.78-2.33]) and a 1.5-fold higher risk of MACCE (adjusted odds ratio 1.54 [95% confidence interval 1.39-1.72])., Conclusions: Diabetes was highly prevalent in patients with ACS in China. Considerable excess risks for early mortality and major adverse cardiovascular events were found in these patients. Trial registration NCT02306616. Registered December 3, 2014.

Background: Therapeutic variability not explained by patient clinical characteristics is a potential source of avoidable morbidity and mortality. We aimed to explore regional variability in the management and mortality of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS)., Methods and Results: 11,931 NSTE-ACS hospital survivors enrolled in two prospective registries: EPICOR [5625 patients, 555 hospitals, 20 countries in Europe (E) and Latin America (LA), September 2010-March 2011] and EPICOR Asia (6306 patients, 218 hospitals, 8 countries, June 2011-May 2012) were compared among eight pre-defined regions: Northern E (NE), Southern E (SE), Eastern E (EE); Latin America (LA); China (CN), India (IN), South-East Asia (SA), and South Korea, Hong Kong and Singapore (KS). Patient characteristics differed between regions: mean age (lowest 59 years, IN; highest 65.9 years, SE), diabetes (21.4% NE; 35.5% IN) and smoking (32% NE; 62% IN). Variations in dual antiplatelet therapy at discharge (lowest 83.1%, IN; highest 97.5%, SA), coronary angiography (53.9% SA; 90.6% KS), percutaneous coronary intervention (35.8% SA; 78.6% KS) and coronary artery bypass graft (0.7% KS; 5.7% NE) were observed. Unadjusted 2-year mortality ranged between 3.8% in KS and 11.7% in SE. Two-year, risk-adjusted mortality rates ranged between 5.1% (95% confidence interval 2.9-7.3%) in KS to 10.5% (8.3-12.7%) in LA., Conclusion: Wide regional variations in patient features, hospital care, coronary revascularization and post-discharge mortality are present among patients hospitalized for NSTE-ACS. Focused regional interventions to improve the quality of care for NSTE-ACS patients are still needed.

Objective: The aim of this study was to investigate statin description on discharge and the benefit on the long-term outcomes in acute coronary syndromes (ACS) patients with very low baseline LDL-cholesterol (LDL-c)., Methods: This is a post-hoc analysis of 3374 ACS patients who were discharged alive and had baseline LDL-c levels below 70 mg/dL (1.8 mmol/L). The propensity score of using statin was estimated with a multivariable Logistic model including patient's demography, social economic status, cardiovascular risk factors, subtype of the diagnosis, and treatments received during hospitalization and current LDL-c level. The risk of major adverse cardiovascular events (MACEs) was compared between patients received and not-received statin with Cox-regression models adjusting for the propensity score plus other factors. A sensitivity analysis was done in propensity score matched patients., Results: Compared with nonstatin group, the incidence of MACE at 12 months after discharge was lower in the statin group (11.1% vs 5.8%; P < 0.001). The propensity score plus other factors-adjusted hazard ratios for MACEs was significant (0.58; 95% CI: 0.39, 0.87). The effect showed a significant dose-response relationship (P for trend = 0.02). The results in analyses with propensity-score matched participants were in consistent with above findings. Analyses on total mortality in 12 months showed similar results., Conclusions: Among ACS survivors with a very low baseline LDL-c, low to moderate intensity statin therapy was associated significantly with lower risk of MACEs and total mortality at 12 months. The results suggested that ACS survivors should take statin regardless of the baseline of LDL-c., (© 2018 Wiley Periodicals, Inc.)

Background: The EPICOR Asia (long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients in Asia) study (NCT01361386) was an observational study of patients hospitalized for acute coronary syndromes (ACS) enrolled in 218 hospitals in eight countries/regions in Asia. This study examined costs, length of stay and the predictors of high costs during an ACS hospitalization., Methods and Results: Data for patients hospitalized for an ACS (n = 12,922) were collected on demographics, medical history, event characteristics, socioeconomic and insurance status at discharge. Patients were followed up at 6 weeks' post-hospitalization for an ACS event to assess associated treatment costs from a health sector perspective. Primary outcome was the incurring of costs in the highest quintile by country and index event diagnosis, and identification of associated predictors. Cost data were available for 10,819 patients. Mean length of stay was 10.1 days. The highest-cost countries were China, Singapore, and South Korea. Significant predictors of high-cost care were age, male sex, income, country, prior disease history, hospitalization in 3 months before index event, no dependency before index event, having an invasive procedure, hospital type and length of stay., Conclusions: Substantial variability exists in healthcare costs for hospitalized ACS patients across Asia. Of concern is the observation that the highest costs were reported in China, given the rapidly increasing numbers of procedures in recent years., Trial Registration: NCT01361386 .

Background: Elderly patients with acute coronary syndrome (ACS) are at high risk for ischemic and bleeding events. This study aimed to evaluate the clinical effectiveness and safety of dual loading antiplatelet therapy for patients 75 years and older undergoing percutaneous coronary intervention for ACS., Methods and Results: The Improving Care for Cardiovascular Disease in China-ACS project was a collaborative study of the American Heart Association and Chinese Society of Cardiology. A total of 5887 patients 75 years and older with ACS who had percutaneous coronary intervention and received dual antiplatelet therapy with aspirin and P2Y 12 inhibitors (clopidogrel or ticagrelor) between November 2014 and June 2017 were enrolled. The primary effectiveness and safety outcomes were in-hospital major adverse cardiovascular events and major bleeding. Hazard ratios (HRs) of in-hospital outcomes with different loading statuses of antiplatelet therapy were estimated using Cox proportional hazard models with multivariate adjustment. A propensity score-matched analysis was also conducted. Compared with patients receiving a dual nonloading dose, patients taking a dual loading dose had increased risks of both major adverse cardiovascular events (HR, 1.66, 95% confidence interval, 1.13-2.44; [ P =0.010]) and major bleeding (HR, 2.34, 95% confidence interval, 1.75-3.13; [ P <0.001]). Among 3284 propensity score-matched patients, a dual loading dose was associated with a 1.36-fold risk of major adverse cardiovascular events (HR, 1.36; 95% confidence interval, 0.88-2.11 [ P =0.168]) and a 2.08-fold risk of major bleeding (HR, 2.08; 95% confidence interval, 1.47-2.93 [ P <0.001])., Conclusions: A dual loading dose of antiplatelet therapy was associated with increased major bleeding risk but not with decreased major adverse cardiovascular events risk among patients 75 years and older undergoing percutaneous coronary intervention for ACS in China., Clinical Trial Registration: URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02306616., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Many patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) are medically managed without coronary revascularization. The reasons vary and may impact prognosis., Methods: EPICOR Asia (NCT01361386) is a prospective study of hospital survivors post-ACS enrolled in 218 hospitals from 8 countries/regions in Asia (06/2011-05/2012). All medically managed NSTE-ACS patients were classified into 3 groups: 1) no coronary angiography (CAG-); 2) non-significant coronary artery disease (CAD) on angiogram (CAG+ CAD-); and 3) significant CAD (CAG+ CAD+). We compared baseline differences between patients medically managed and patients undergoing revascularization, and also between the medically managed groups. Adverse events were reported and compared up to 2years., Results: Of 6163 NSTE-ACS patients, 2272 (37%) were medically managed, with 1339 (59%), 254 (11%), and 679 (30%) in the CAG-, CAG+ CAD-, and CAG+ CAD+ groups, respectively. There were marked differences in the proportion of medically managed patients among the 8 countries/regions (13-81%). Medically managed patients had higher mortality at 2years compared with revascularization (8.7% vs. 3.0%, p<0.001). Among medically managed patients, CAG- patients were older, more likely to have pre-existing cardiovascular disease, and had the highest 2-year mortality (10.5% vs. 4.3% [CAG+ CAD-] and 6.6% [CAG+ CAD+], p<0.001). Mortality differences persisted after adjusting for other patient risk factors., Conclusions: Medically managed NSTE-ACS patients are a heterogeneous group with different risk stratification and variable prognosis. Identification of reasons underlying different management strategies, and key factors adversely influencing long-term prognosis, may improve outcomes., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Early invasive strategies and antithrombotic treatments are key treatments of non-ST-segment-elevation acute coronary syndrome (NSTE-ACS). Few studies have examined the use of these strategies in patients with NSTE-ACS in China. This study aimed to assess the applications of invasive strategies and antithrombotic treatments in patients with NSTE-ACS and compare their outcomes., Methods and Results: A nationwide registry study, Improving CCC (Care for Cardiovascular Disease in China) ACS project, was launched in 2014 as a collaborative study of the American Heart Association and Chinese Society of Cardiology (CSC), with 142 participating hospitals reporting details of clinical management and outcomes of patients with NSTE-ACS. The use of invasive strategies and antithrombotic treatments was examined based on updated guidelines. Major adverse cardiovascular events were analyzed. A total of 9953 patients with NSTE-ACS were enrolled. Angiography was performed in 63.1% of these patients, and 58.2% underwent percutaneous coronary intervention (PCI). However, 40.6% of patients did not undergo early risk assessment, and very-high-risk patients had the lowest proportion of PCI (41.7%). PCI was performed within recommended times in 11.1% of very-high-risk patients and 26.3% of high risk patients. Those who underwent PCI within 2 hours had higher mortality in high-risk and very-high-risk patients who received PCI. Early dual antiplatelet treatment was given in 88.3% of patients., Conclusions: There are notable differences between guideline recommendations and the clinical management of patients with NSTE-ACS in China. The reasons for very-high-risk NSTE-ACS patients not undergoing PCI, and the optimal timing of PCI, require further clarification., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616., (© 2017 American Heart Association, Inc.)

Background: A sizeable gap exists between guideline recommendations for treatment of acute coronary syndrome (ACS) and application of these recommendations in clinical practice. The CCC-ACS project is a novel national quality enhancement registry designed to help medical care providers bridge this gap, thereby improving clinical outcomes for ACS patients in China., Methods and Results: The CCC-ACS project uses data collection, analysis, feedback, rapid-cycle improvement, and performance recognition to extend the use of evidence-based guidelines throughout the health care system and improve cardiovascular health. The project was launched in 2014, with 150 centers recruited representing the diversity of care for ACS patients in tertiary hospitals across China. Clinical information for patients with ACS is collected via a Web-based data collecting platform, including patients' demographics, medical history, symptoms on arrival, in-hospital treatment and procedures, in-hospital outcomes, and discharge medications for secondary prevention. Improvement in adherence to guideline recommendations is facilitated through monthly benchmarked hospital quality reports, recognition of hospital quality achievement, and regular webinars. As of April 16, 2016, a total of 35,616 ACS cases have been enrolled., Conclusions: The CCC-ACS is a national hospital-based quality improvement program, aiming to increase adherence to ACS guidelines in China and improve patient outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To estimate out-of-pocket costs and the incidence of catastrophic health expenditure in people admitted to hospital with acute coronary syndromes in Asia., Methods: Participants were enrolled between June 2011 and May 2012 into this observational study in China, India, Malaysia, Republic of Korea, Singapore, Thailand and Viet Nam. Sites were required to enrol a minimum of 10 consecutive participants who had been hospitalized for an acute coronary syndrome. Catastrophic health expenditure was defined as out-of-pocket costs of initial hospitalization > 30% of annual baseline household income, and it was assessed six weeks after discharge. We assessed associations between health expenditure and age, sex, diagnosis of the index coronary event and health insurance status of the participant, using logistic regression models., Findings: Of 12,922 participants, 9370 (73%) had complete data on expenditure. The mean out-of-pocket cost was 3237 United States dollars. Catastrophic health expenditure was reported by 66% (1984/3007) of those without insurance versus 52% (3296/6366) of those with health insurance (P < 0.05). The occurrence of catastrophic expenditure ranged from 80% (1055/1327) in uninsured and 56% (3212/5692) of insured participants in China, to 0% (0/41) in Malaysia., Conclusion: Large variation exists across Asia in catastrophic health expenditure resulting from hospitalization for acute coronary syndromes. While insurance offers some protection, substantial numbers of people with health insurance still incur financial catastrophe.

Aims: A reliable prediction tool is needed to identify acute coronary syndrome (ACS) patients with high mortality risk after their initial hospitalization., Methods: EPICOR (long-tErm follow uP of antithrombotic management patterns In acute CORonary syndrome patients: NCT01171404) is a prospective cohort study of 10,568 consecutive hospital survivors after an ACS event (4943 ST-segment elevation myocardial infarction (STEMI) and 5625 non-ST-elevation ACS (NSTE-ACS)). Of these cases, 65.1% underwent percutaneous coronary intervention (PCI) and 2.5% coronary artery bypass graft (CABG). Post-discharge mortality was recorded for up to two years. From over 50 potential predictor variables a new risk score for one-year mortality was developed using forward stepwise Cox regression, and examined for goodness-of-fit, discriminatory power, and external validation., Results: A total of 407 patients (3.9%) died within one year of discharge. We identified 12 highly significant independent predictors of mortality (in order of predictive strength): age, lower ejection fraction, poorer EQ-5D quality of life, elevated serum creatinine, in-hospital cardiac complications, chronic obstructive pulmonary disease, elevated blood glucose, male gender, no PCI/CABG after NSTE-ACS, low hemoglobin, peripheral artery disease, on diuretics at discharge. When combined into a new risk score excellent discrimination was achieved (c-statistic=0.81) and this was also validated on a large similar cohort (9907 patients) in Asia (c=0.78). For both STEMI and NSTE-ACS there was a steep gradient in one-year mortality ranging from 0.5% in the lowest quintile to 18.2% in the highest decile. NSTE-ACS contributes over twice as many high-risk patients as STEMI., Conclusions: Post-discharge mortality for ACS patients remains of concern. Our new user-friendly risk score available on www.acsrisk.org can readily identify who is at high risk., (© The European Society of Cardiology 2014.)

Background: In-hospital and postdischarge mortality for acute coronary syndromes (ACS) vary across Asia and remain generally poorer than globally. The relationship between real-life antithrombotic management patterns (AMPs) and ACS-related outcomes in Asia is unclear., Methods: EPICOR Asia (Long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients in Asia) (NCT01361386) is a prospective, multinational, observational study of patients discharged after hospitalization for an ACS, with 2-year follow-up. The aim is to describe short- and long-term (up to 2 years post-index event) AMPs in patients hospitalized for ACS and to record clinical outcomes, healthcare resource use, and self-reported health status. Pre- and in-hospital management, AMPs, and associated outcomes, with particular focus on ischemic and bleeding events, will be recorded during the 2-year follow up., Results: Between June 2011 and May 2012, 13 005 patients were enrolled. From these, 12 922 patients surviving an ACS (6616 with STEMI, 2570 with NSTEMI, and 3736 with UA) were eligible for inclusion from 219 hospitals across 8 countries and regions in Asia: China (n = 8214), Hong Kong (n = 177), India (n = 2468), Malaysia (n = 100), Singapore (n = 93), South Korea (n = 705), Thailand (n = 957), and Vietnam (n = 208)., Conclusions: EPICOR Asia will provide information regarding clinical management and AMPs for ACS patients in Asia. Impact of AMPs on clinical outcomes, healthcare resource use, and self-reported health status both during hospitalization and up to 2 years after discharge will also be described., (© 2015 Wiley Periodicals, Inc.)

Background: Clinical outcomes and the effects of oral anticoagulants among patients with acute coronary syndrome (ACS) and either a history of or acute heart failure (HF) are largely unknown. We aimed to assess the relationship between prior HF or acute HF complicating an index ACS event and subsequent clinical outcomes and the efficacy and safety of apixaban compared with placebo in these populations., Methods: High-risk patients were randomly assigned post-ACS to apixaban 5.0 mg or placebo twice daily. Median follow-up was 8 (4-12) months. The primary outcome was cardiovascular death, myocardial infarction, or stroke. The main safety outcome was thrombolysis in myocardial infarction major bleeding., Results: Heart failure was reported in 2,995 patients (41%), either as prior HF (2,076 [28%]) or acute HF (2,028 [27%]). Patients with HF had a very high baseline risk and were more often managed medically. Heart failure was associated with a higher rate of the primary outcome (prior HF: adjusted hazard ratio [HR] 1.73, 95% CI 1.42-2.10, P < .0001, acute HF: adjusted HR 1.65, 95% CI 1.35-2.01, P < .0001) and cardiovascular death (prior HF: HR 2.54, 95% CI 1.82-3.54, acute HF: adjusted HR 2.52, 95% CI 1.82-3.50). Patients with acute HF also had significantly higher rates of thrombolysis in myocardial infarction major bleeding (prior HF: adjusted HR 1.22, 95% CI 0.65-2.27, P = .54, acute HF: adjusted HR 1.78, 95% CI 1.03-3.08, P = .04). There was no statistical evidence of a differential effect of apixaban on clinical events or bleeding in patients with or without prior HF; however, among patients with acute HF, there were numerically fewer events with apixaban than placebo (14.8 vs 19.3, HR 0.76, 95% CI 0.57-1.01, interaction P = .13), a trend that was not seen in patients with prior HF or no HF., Conclusions: In high-risk patients post-ACS, both prior and acute HFs are associated with an increased risk of subsequent clinical events. Apixaban did not significantly reduce clinical events and increased bleeding in patients with and without HF; however, there was a tendency toward fewer clinical events with apixaban in patients with acute HF., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Acute coronary syndromes (ACS) remain a leading cause of mortality and morbidity in the Asia-Pacific (APAC) region. International guidelines advocate invasive procedures in all but low-risk ACS patients; however, a high proportion of ACS patients in the APAC region receive solely medical management due to a combination of unique geographical, socioeconomic, and population-specific barriers. The APAC ACS Medical Management Working Group recently convened to discuss the ACS medical management landscape in the APAC region. Local and international ACS guidelines and the global and APAC clinical evidence-base for medical management of ACS were reviewed. Challenges in the provision of optimal care for these patients were identified and broadly categorized into issues related to (1) accessibility/systems of care, (2) risk stratification, (3) education, (4) optimization of pharmacotherapy, and (5) cost/affordability. While ACS guidelines clearly represent a valuable standard of care, the group concluded that these challenges can be best met by establishing cardiac networks and individual hospital models/clinical pathways taking into account local risk factors (including socioeconomic status), affordability and availability of pharmacotherapies/invasive facilities, and the nature of local healthcare systems. Potential solutions central to the optimization of ACS medical management in the APAC region are outlined with specific recommendations., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Guideline recommendations on the use of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes and in those undergoing percutaneous coronary intervention (PCI) have been formulated by both the ACC/AHA and the ESC. These recommendations are based primarily on large, phase III, randomized, controlled trials of the P2Y12 inhibitors clopidogrel, prasugrel, and ticagrelor. However, few East Asian patients have been included in the trials to assess the use of these agents, particularly the newer agents prasugrel and ticagrelor. Additionally, an increasing body of data suggests that East Asian patients have differing risk profiles for both thrombophilia and bleeding compared with white patients, and that a different 'therapeutic window' of on-treatment platelet reactivity might be appropriate in East Asian patients. Furthermore, a phenomenon referred to as the 'East Asian paradox' has been described, in which East Asian patients have a similar or even a lower rate of ischaemic events after PCI compared with white patients, despite a higher level of platelet reactivity during DAPT. Recognizing these concerns, the World Heart Federation has undertaken this evidence-based review and produced this expert consensus statement to determine the antiplatelet treatment strategies that are most appropriate for East Asian patients., (Copyright © 2014 World Heart Federation (Geneva). Published by Elsevier B.V. All rights reserved.)

Guideline recommendations on the use of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes and in those undergoing percutaneous coronary intervention (PCI) have been formulated by both the ACC/AHA and the ESC. These recommendations are based primarily on large, phase III, randomized, controlled trials of the P2Y12 inhibitors clopidogrel, prasugrel, and ticagrelor. However, few East Asian patients have been included in the trials to assess the use of these agents, particularly the newer agents prasugrel and ticagrelor. Additionally, an increasing body of data suggests that East Asian patients have differing risk profiles for both thrombophilia and bleeding compared with white patients, and that a different 'therapeutic window' of on-treatment platelet reactivity might be appropriate in East Asian patients. Furthermore, a phenomenon referred to as the 'East Asian paradox' has been described, in which East Asian patients have a similar or even a lower rate of ischaemic events after PCI compared with white patients, despite a higher level of platelet reactivity during DAPT. Recognizing these concerns, the World Heart Federation has undertaken this evidence-based review and produced this expert consensus statement to determine the antiplatelet treatment strategies that are most appropriate for East Asian patients.

Background: Current guidelines recommend intensive low-density lipoprotein (LDL) cholesterol lowering with statins, with a target of 70 mg/dL (1.81 mmol/L) LDL cholesterol for those with a very high risk of coronary artery events. However, there is no multicenter study assessing the effect of intensive lipid-lowering therapy with statins on acute coronary syndrome (ACS) in a Chinese population with low baseline LDL cholesterol levels., Methods and Results: Patients (n=1355) with ACS were treated with a moderate dose of statin (atorvastatin 10 mg/d, or equivalent dose of other statins, n=675) or with an intensive dose of statin (atorvastatin, 20 or 40 mg/d, or equivalent dose of other statins, n=680) for 2 years. The primary end points were cardiac death, non-fatal acute myocardial infarction (MI), revascularization, ischemic stroke and documented unstable angina or severe heart failure requiring emergency hospitalization. Baseline lipid levels were nearly identical in both groups with a mean LDL cholesterol level of 2.7 mmol/L (103 mg/dL). At 3 months, LDL cholesterol levels declined 20.2% in the moderate dose statin group and 26.6% in the intensive statin group, respectively (P<0.001). In a 2-year follow-up, a primary end point event occurred in 20 patients in the moderate dose statin group and in 28 patients in the intensive statin group. There was no significant between-group difference in the primary outcome (hazard ratio, 1.39; 95% confidence interval [CI], 0.78-2.46; P=0.245)., Conclusions: For ACS patients with a relatively low baseline LDL cholesterol level who received optimized current medication and interventional therapy, the incremental LDL cholesterol reduction of 6.4% achieved by double-dose statin did not bring significant clinical effectiveness., (Copyright © 2014. Published by Elsevier Ireland Ltd.)

Objective: To explore the current status on traditional Chinese medicine (TCM) use for hospitalized acute coronary syndrome patients in China's level 2 hospitals, and to explore associated factors of TCM use for these patients., Methods: This survey was performed in 102 level 2 hospitals from 15 provinces or autonomous region in China. Patients admitted to these hospitals with acute coronary syndrome during September 2011 to May 2012 were eligible for this study. Information on TCM use was obtained from their medical records. Chi-square test and logistic regression analysis were used to explore the related factors of TCM use in these patients., Results: We recruited 5 432 acute coronary syndrome patients in this study, TCM was applied to 3 503 patients (64.5%). Multivariable logistic regression showed that pre-hospital TCM use was positively related with in-hospital TCM use (OR = 2.08, P < 0.01) , while pre-hospital use of 4 medicines recommended by the guidelines(including aspirin/clopidogrel, β acceptor blocker, stain and angiotensin converting enzyme inhibitor/angiotensin converting enzyme receptor blocker ), being a smoker and diagnosis of myocardial infarction rather than unstable angina at hospital discharge were negatively related with in-hospital TCM use (the ORs were 0.58, 0.78 and 0.71, respectively, all P < 0.01). The TCM use varied significantly between regions. Taking southwest region as a reference, the ORs varied between 2.98-13.37 (all P < 0.01) in eastern China, south China, central China, north China, northwest and northeast regions., Conclusions: TCM is widely used in hospitalized acute coronary syndrome patients in China's resource-constrained level 2 hospitals. Pre-hospital TCM use is positively correlated with in-hospital TCM use for these patients.

Objective: To study the changes of adenosine diphosphate (ADP)-induced platelet aggregation rate, and evaluate the effects of Maixuekang Capsule (, MKC) on platelet aggregation rate and long-term prognosis of patients with acute coronary syndrome after percutaneous coronary intervention (PCI)., Methods: A total of 236 patients with acute coronary syndrome, who received successful PCI, were randomly assigned to a trial group (116 cases) and a control group (120 cases) according to random numbers; treatment allocation occurred when the participants met the inclusion criteria and signed the informed consent forms. In the trial group, the patients were treated with MKC combined with routine medication, and in the control group the patients were treated with routine medication. The therapeutic course for the two groups was 12 months and the follow-up was 12 months. The levels of ADP-induced platelet aggregation rate and serum high-sensitive C-reactive protein (hs-CRP) were determined before PCI, 12 h and 30 days after PCI. In the meantime, the incidence of cardio-/cerebrovascular events was recorded during the 12-month follow-up., Results: Compared with before PCI, the levels of ADP-induced platelet aggregation rate and serum hs-CRP were significantly higher at 12 h after PCI (P<0.05). They were significantly reduced after 30-day-treatment of MKC, showing statistical differences when compared with those in the control group (P<0.05). During the 12-month follow-up, the incidence of cardio-/cerebrovascular events was significantly lower in the trial group than in the control group (6.9% vs. 12.5%, P<0.01)., Conclusions: ADP-induced platelet aggregation function was significantly elevated after PCI. MKC improved the prognosis of patients with acute coronary syndrome, possibly through inhibiting the platelet aggregation, fighting against inflammation, and protecting the vascular endothelial function.

Background: Current guidelines recommended intensive low-density lipoprotein cholesterol lowering with statins, aiming at the target of 70 mg/dL (1.81 mmol/L) of low-density lipoprotein cholesterol for those with very high risk of coronary artery events. However, there is no multicenter study assessing the effect of intensive lipid lowering therapy with statins on acute coronary syndrome (ACS) in Chinese population., Methods: An open-label multicenter study is planned to evaluate whether intensive treatment with statins for 2 to 5 years results in more reduction of cardiovascular events in patients with ACS compared to the standard statin therapy. A total of 1,600 patients will be randomly assigned to receive intensive statin therapy (atorvastatin, 20 or 40 mg/d, or equivalent dose of other statins) or standard statin therapy (atorvastatin, 10 mg/d, or equivalent dose of other statins). Both groups will receive dietary counseling. Over the follow-up period, the primary outcome measure is the time to occurrence of cardiac death, nonfatal acute myocardial infarction, revascularization with either percutaneous coronary intervention or coronary-artery bypass grafting, documented unstable angina or severe heart failure requiring emergency hospitalization, and stroke. The planned duration for enrollment is between December 2006 and December 2009., Conclusions: The CHILLAS study will be the first multicenter study in a Chinese population using a patient-level analysis to compare the effects and safety of intensive statin therapy with that of standard-dose statin therapy, which may provide new evidence and therapeutic standards for the treatment of ACS.