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Little is known about the relationship between baseline systolic blood pressure (SBP) and subsequent clinical events in patients with different lesion patterns on diffusion weighted imaging (DWI). We analyzed the Acute Non-disabling Cerebrovascular Events (CHANCE) trial dataset. Patients were categorized into negative DW imaging (no detectable lesions), lacunar infarction (single lesion ≤15 mm) and non-lacunar infarction (single lesion15 mm or multiple lesions) based on lesion patterns on DWI. The primary outcome was recurrent stroke within 90 days. Cox proportional hazards models were used to assess the association between SBP levels and stroke outcomes in patients with different lesion patterns. A total of 1089 patients were analyzed. We found 258 cases (23.7%) with negative DW imaging, 392 (36.0%) with lacunar infarction and 439 (40.3%) with non-lacunar infarction. Patients with non-lacunar infarction had the highest incidence of stroke at 90-day (P .001). In non-lacunar infarction group, compared with SBP 160 mmHg, patients with SBP ≥ 160 mmHg had significantly higher risk of 90-day recurrent stroke (20.3% vs. 10.7%; adjusted hazard ratio 1.81, 95% confidence interval 1.09-3.00). No significant association was found between SBP and clinical outcomes in patients with negative DWI and lacunar stroke groups. The result at 1 year was similar as at 90-day. Therefore, non-lacunar infarction, the most common lesion pattern in CHANCE study, had the highest risk of recurrent stroke and combined vascular events both in 90 days and 1 year. High baseline SBP was significantly associated with increased risk of short- and long-term recurrent strokes in patients with non-lacunar infarction.

To summarize the predictive value of MRI for H3 K27M-mutant in midline gliomas using meta-analysis.Systematic electronic searches of the PubMed, Embase, ISI Web of Science, and Cochrane Library up to Jun 31, 2021, were conducted by two experienced neuroradiologists with the keywords of "MRI," "Glioma," and "H3 K27M." The hierarchical summary receiver-operating characteristic (HSROC) model was used to calculate the pooled sensitivity, specificity, positive likelihood ratio (LR +), negative likelihood ratio (LR -), and diagnostic odds ratio (DOR). Coupled forest plots were used to evaluate the heterogeneity of the included studies.Of seven original studies with a total of 593 patients, 240 glioma patients were included, with 45.5-70.6% H3 K27M-mutant gliomas. Using MRI, a pooled sensitivity of 0.78 (95% CI, 0.66-0.87), specificity of 0.85 (95% CI, 0.76-0.91), LR + of 5.07 (95% CI, 3.19-8.08), LR - of 0.26 (95% CI, 0.16-0.42), and DOR of 19.80 (95% CI, 9.28-42.28) were achieved for H3 K27M-mutant prediction. Significant heterogeneity was observed among the studies in terms of sensitivity (Q = 16.83, df = 7, p = 0.02; IThis meta-analysis demonstrated a clinical value of MRI to predict H3 K27M-mutant in midline gliomas with a pooled sensitivity of 0.78 and specificity of 0.85.

BackgroundReperfusion therapy is the most effective treatment for acute ischaemic stroke (AIS) but remains underutilised in China. There is an urgent need to develop tailored strategies to increase adherence to intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) within the guideline-recommended time window for eligible patients.AimsThis study aims to investigate the efficacy of a comprehensive quality improvement intervention on adherence to guideline-recommended reperfusion therapy for patients with AIS in China.DesignThe Improve Acute Reperfusion Treatment Quality for Stroke in China (IMPROVE Stroke Care in China) trial is designed as a stepped wedge cluster randomised trial within 51 hospitals. We developed the comprehensive intervention ‘STEP’ (Strategies, Toolkit, Exploration, Paradigm) to promote the reconstruction of workflow in stroke centres and shorten in-hospital delay of reperfusion treatment for patients with AIS. The participating hospitals (clusters) were randomised to three groups (cohorts) for different predefined steps to intervention implementation. The primary outcome was the adherent rate of IVT or EVT for eligible patients within the time window. The sample size was estimated to be 7644, and was determined by the number of cases to be enrolled in five study periods to detect a relative increase of 30% (from 19% to 25%) with 90% power and intraclass correlation coefficient of 0.03. All efficacy analyses will be conducted based on the intention-to-treat principle. The primary outcome will be analysed using a mixed-effects logistic regression with a random effect for the cluster (hospital), and a fixed effect for the strategy and period.ConclusionsIf the efficacy is well established, this targeted comprehensive intervention STEP will inform national strategies to increase adherence to guideline-recommended performance on reperfusion therapy.Trial registration numberclinicaltrials.gov Identifier:NCT003578107

Background and purpose: We performed a systemic review and meta-analysis to elucidate the effectiveness and safety of dual antiplatelet (DAPT) therapy with P2Y12 inhibitors (clopidogrel/ticagrelor) and aspirin versus aspirin monotherapy in patients with mild ischemic stroke or high-risk transient ischemic attack. Methods: Following Preferred Reported Items for Systematic Review and Meta-Analysis standards for meta-analyses, Medline, Embase, Cochrane Central Register of Controlled Trials, and the Cochrane Library were searched for randomized controlled trials that included patients with a diagnosis of an acute mild ischemic stroke or high-risk transient ischemic attack, intervention of DAPT therapy with clopidogrel/ticagrelor and aspirin versus aspirin alone from January 2012 to July 2020. The outcomes included subsequent stroke, all-cause mortality, cardiovascular death, hemorrhage (mild, moderate, or severe), and myocardial infarction. A DerSimonian-Laird random-effects model was used to estimate pooled risk ratio (RR) and corresponding 95% CI in R package meta. We assessed the heterogeneity of data across studies with use of the Cochran Q statistic and I 2 test. Results: Four eligible trials involving 21 493 participants were included in the meta-analysis. DAPT therapy started within 24 hours of symptom onset reduced the risk of stroke recurrence by 24% (RR, 0.76 [95% CI, 0.68–0.83], I 2 =0%) but was not associated with a change in all-cause mortality (RR, 1.30 [95% CI, 0.90–1.89], I 2 =0%), cardiovascular death (RR, 1.34 [95% CI, 0.56–3.17], I 2 =0%), mild bleeding (RR, 1.25 [95% CI, 0.37–4.29], I 2 =94%), or myocardial infarction (RR, 1.45 [95% CI, 0.62–3.39], I 2 =0%). However, DAPT was associated with an increased risk of severe or moderate bleeding (RR, 2.17 [95% CI, 1.16–4.08], I 2 =41%); further sensitivity tests found that the association was limited to trials with DAPT treatment duration over 21 days (RR, 2.86 [95% CI, 1.75–4.67], I 2 =0%) or ticagrelor (RR, 2.17 [95% CI, 1.16–4.08], I 2 =37%) but not within 21 days or clopidogrel. Conclusions: In patients with noncardioembolic mild stroke or high-risk transient ischemic attack, DAPT with aspirin and clopidogrel/ticagrelor is more effective than aspirin alone for recurrent stroke prevention with a small absolute increase in the risk of severe or moderate bleeding.

Background and purposeCurrent randomised controlled trials (RCTs) showed an uncertain benefit of haemostatic therapy on preventing haematoma expansion and improving the outcome in patients with intracerebral haemorrhage (ICH). This meta-analysis aims to systematically evaluate the effect of haemostatic agents on the prevention of haemorrhage growth in patients with high-risk spontaneous ICH predicted by CT signs in RCTs.MethodsA comprehensive search of PubMed, EMBASE and Cochrane library from 1 January 2005 to 30 June 2021 was conducted. RCTs that compared haemostatic agents with placebo for the treatment of spontaneous patients with ICH with high-risk haemorrhage growth were included. The primary endpoint was haematoma expansion at 24 hours. Other major endpoints of interest included 90-day functional outcome and mortality.ResultsThe meta-analysis included four RCTs that randomised 2666 patients with ICH with high-risk haemorrhage growth. Haemostatic therapy reduced the rate of haematoma expansion at a marginally statistically significant level when compared with placebo (OR 0.84; 95% CI 0.70 to 1.00; p=0.051). Subgroup analysis for patients with black hole sign on CT revealed a significant reduction of haematoma expansion with haemostatic therapy (OR 0.61; 95% CI 0.39 to 0.94; p=0.03). However, both the primary analysis and subgroup analyses showed that haemostatic therapy could not reduce the rate of poor functional outcome (modified Rankin Scale >3) or death.ConclusionsHaemostatic therapy showed a marginally significant benefit in reducing early haematoma expansion in patients with high-risk spontaneous ICH predicted by markers on CT scan. However, no significant improvement in functional outcome or reduction of mortality was observed.

ObjectiveGastrointestinal (GI) bleeding in patients who had a stroke is strongly associated with a higher risk of death and loss of independence. However, it is unknown whether GI bleeding increases risk for recurrence of stroke. In this study, we assess the potential relationship between GI bleeding and stroke recurrence in patients within 12 months of an acute ischaemic stroke (AIS), using the China National Stroke Registry (CNSR).MethodsThis study included 22 216 patients who had an ischaemic stroke included in the CNSR from 2007 to 2008. We analysed baseline patient characteristics, GI bleeding and outcomes of patients who had an AIS, specifically stroke recurrence at 3, 6 and 12 months. We used multivariable logistic regression to evaluate a possible association between GI bleeding and stroke recurrence.ResultsOf the 12 415 patients included in our study, 12.3%, 15.5% and 17.7% had a stroke recurrence at 3, 6 and 12 months, respectively. GI bleeding was an independent stroke recurrence risk factor in patients after ischaemic stroke at 3 months (adjusted OR 1.481, 95% CI 1.118 to 1.962), 6 months (adjusted OR 1.448, 95% CI 1.106 to 1.896) and 12 months (adjusted OR 1.350; 95% CI 1.034 to 1.763).ConclusionGI bleeding was associated with the increased risk of stroke recurrence after an AIS.

Background Prior studies have shown an increased risk of ischemic stroke (IS) after myocardial infarction (MI); however, there are limited studies concerning the characteristics, in‐hospital mortality, and complications of patients with IS with a medical history of MI. We hypothesized that patients with IS with a medical history of MI may experience more severe strokes and have a higher risk of in‐hospital mortality and complications than patients with IS without a medical history of MI. Methods and Results Consecutive in‐hospital data were extracted from the China Stroke Center Alliance database from August 2015 to July 2019. Patient characteristics, hospital tests, in‐hospital mortality, and complications were analyzed and compared in patients with IS with or without a history of MI. Of 893 429 patients with IS, we identified 81 646 (9.1%) patients with a history of MI (MI group). Compared with patients with IS without MI, MI group patients were older, had a lower prevalence of current smoking, had a higher prevalence of a relative medical history, and took more medications before admission. Compared with the group with IS without MI, the MI group had a higher National Institute of Health Stroke Scale score after onset (4.0 versus 3.0; Hodges‐Lehmann estimator, 22.5) and a higher proportion of severe strokes (National Institute of Health Stroke Scale score ≥15) (7.1% versus 4.4%; absolute standardized difference=11.6%). In the fully adjusted models, the risk of in‐hospital mortality was higher in the MI group (odds ratio [OR], 1.74; 95% CI, 1.57–1.92; P P P P P P P P Conclusions Patients with IS with a medical history of MI have an increased risk of severe stroke, in‐hospital mortality, and complications. Studies exploring the underlying mechanisms are needed to improve and tailor stroke treatment strategies.

AimSpontaneous subarachnoid haemorrhage (SAH) caused by ruptured cerebral aneurysm is a severe subtype of haemorrhagic stroke. Although the incidence of SAH is relatively low among all cerebrovascular diseases, the mortality is the highest. The critical management of SAH is challenging. We provide this evidence-based guideline to present current and comprehensive recommendations for the diagnosis and treatment of non-trauma SAH.MethodsA formal literature search of MEDLINE (1 January 1990–30 June 2019) was performed. Data were synthesised with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The Chinese Stroke Association’s levels of evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by Chinese Stroke Association’s Stroke Fellow Committees. It is intended that this guideline be fully updated every 3 years.ResultsEvidence-based guidelines are presented for the care of patients presenting with non-trauma SAH. The focus of the guideline was subdivided into transfer and systems of care, diagnosis flowchart, aetiology and differentiation, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, management of vasospasm and delayed cerebral ischaemia, management of hydrocephalus, management of seizures and management of medical complications.ConclusionsThe guideline offers a framework for SAH management. Early professional and aggressive care of SAH might help dramatically.

Our study aimed to explore changes in health-related quality of life (HRQoL) during blood pressure control and blood lipid-lowering therapies. We conducted a 2 × 2 factorial-designed randomized controlled trial in 180 clinical centers in China. At baseline, participants were randomly assigned to an amlodipine + amiloride/hydrochlorothiazide group or an amlodipine + telmisartan group for the blood pressure control treatment and to a statin group or a routine intervention group for the blood lipid-lowering treatment. The allocation ratio was 1:1 for both treatments. Follow-up lasted for 4 years. HRQoL was assessed using the EuroQol five dimensions three levels (EQ-5D-3L) questionnaire every year. Of 13,542 hypertensive patients enrolled in the clinical trial, 9885 were eligible for the analysis. The problems for all dimensions of the EQ-5D-3L descriptive system were slight at baseline and were well preserved in the follow-up period. The EuroQol visual analog scale (EQ VAS) score and the EQ-5D-3L index improved over time (Ptrend

Background and Purpose— Emergency medical services (EMSs) are critical for early treatment of patients with ischemic stroke, yet data on EMS utilization and its association with timely treatment in China are still limited. Methods— We examined data from the Chinese Stroke Center Alliance for patients with ischemic stroke from June 2015 to June 2018. Absolute standardized difference was used for covariates’ balance assessments. We used multivariable logistic models with the generalized estimating equations to account for intrahospital clustering in identifying demographic and clinical factors associated with EMS use as well as in evaluating the association of EMS use with timely treatment. Results— Of the 560 447 patients with ischemic stroke analyzed, only 69 841 (12.5%) were transported by EMS. Multivariable-adjusted results indicated that those with younger age, lower levels of education, less insurance coverage, lower income, lower stroke severity, hypertension, diabetes mellitus, and peripheral vascular disease were less likely to use EMS. However, a history of cardiovascular diseases was associated with increased EMS usage. Compared with self-transport, EMS transport was associated with significantly shorter onset-to-door time, door-to-needle time (if prenotification was sent), earlier arrival (adjusted odds ratio [95% CIs] were 2.07 [1.95–2.20] for onset-to-door time ≤2 hours, 2.32 [2.18–2.47] for onset-to-door time ≤3.5 hours), and more rapid treatment (2.96 [2.88–3.05] for IV-tPA [intravenous recombinant tissue-type plasminogen activator] in eligible patients, 1.70 [1.62–1.77] for treatment with IV-tPA by 3 hours if onset-to-door time ≤2 hours, and 1.76 [1.70–1.83] for treatment with IV-tPA by 4.5 hours if onset-to-door time ≤3.5 hours). Conclusions— Although EMS transportation is associated with substantial reductions in prehospital delay and improved likelihood of early arrival and timely treatment, rate of utilization is currently low among Chinese patients with ischemic stroke. Developing an efficient EMS system and promoting culture-adapted education efforts are necessary for improving EMS activation.

Background: It is unclear the impact of the COVID-19 pandemic on the health care and outcomes for in-hospital patients with acute ischemic stroke (AIS). We aimed to evaluate the influence of COVID-19 on the quality of care for in-hospital patients with AIS. Methods: This is an observational registry study between November 23rd, 2019 and March 22nd, 2020. 408 hospital from 29 provinces in China were enrolled from Chinese Stroke Center Alliance (CSCA). Patients with AIS were extracted with demographic, clinical and previous history information. We focus on the time period before and after January 23rd, 2020, when the public health interventions were carried out in China. The primary outcome was adherence to 11 performance measures, with co-primary outcomes of a composite of percentage of performance measures adhered to. Secondary outcomes included were time measures and in-hospital outcomes. Results: 42056 patients with AIS was enrolled (mean age 66.5±12.1, male 61.3%). The overall in-hospital patients decreased slightly from 14323 to 14204 before the COVID-19 outbreak and went down sharply by 31.4% and 61.1% after the outbreak and the public conducted interventions in China. A remarkable reduction was shown in patients with NIHSS score ≤ 3 from 57.7% to 55.7% after the outbreak (p Conclusions: The admission number of patients with AIS declined significantly after the COVID-19 outbreak, but the quality of care and outcomes kept stable. Hospitals should admit AIS patients to the fullest extent of ability and provide tailored treatment strategies under the premise of no the cross-infection of COVID-19.

Background and Purpose: A variety of definitions for minor stroke have been proposed. We aimed to compare the clinical characteristics and outcomes of minor stroke defined as the National Institutes of Health Stroke Scale (NIHSS) score ≤5 versus ≤3. Methods: We retrieved acute ischemic stroke patients with NIHSS score ≤5 in the CSCA study (China Stroke Center Alliance) between August 2015 and 2019. In-hospital clinical outcomes including all-cause mortality, stroke, and myocardial infarction were compared between the NIHSS score ≤5 and NIHSS score ≤3 groups using absolute standardized differences (ASD). Results: A total of 1 006 798 patients were registered in the CSCA program from 1476 hospitals, 472 352 patients had NIHSS score ≤5, of whom 356 314 patients had NIHSS score ≤3. The in-hospital composite events of death, myocardial infarction, or recurrent stroke were not significantly different between the NIHSS score ≤5 and NIHSS score ≤3 groups (5.6% [26 346/472 352] versus 5.2% [18 682/356 314]; ASD, 1.8). The in-hospital all-cause mortality (0.1% [443/472 352] versus 0.1% [255/356 314]; ASD, Conclusions: Our large-scale study identified that minor stroke using NIHSS scores ≤5 and ≤3 as the definition was comparable with each other regarding in-hospital all-cause mortality, recurrent stroke, and hemorrhagic stroke. This observation may be useful for future comparison studies and clinical trial design.

Background and purposeGuidelines recommend dysphagia screening to identify those at high risk of pneumonia. However, little is known about the prevalence and predictors of dysphagia screening and pneumonia among patients with acute ischaemic stroke in China.MethodsUsing data from the Chinese Stroke Center Alliance, which is a multicentre, prospective, consecutive patient enrolment programme, univariate and multivariate analyses were conducted to identify patient and hospital characteristics associated with dysphagia screening and pneumonia during acute hospitalisation.ResultsOf 790 811 patients admitted to 1476 hospitals, 622 718 (78.7%) underwent dysphagia screening, and 64 398 (8.1%) developed pneumonia. Patients in stroke units were more likely to be screened for dysphagia than those not in stroke units (OR 1.50; 95% CI 1.48 to 1.52), while patients with a past history of stroke were less likely to be screened (OR 0.87; 95% CI 0.86 to 0.88). Dysphagia screening (OR 1.46; 95% CI 1.30 to 1.65), dysphagia (OR 7.31; 95% CI 7.15 to 7.46), and admission to stroke units (OR 1.17; 95% CI 1.14 to 1.19) were significantly associated with a greater risk of pneumonia.ConclusionsDysphagia was a critical factor in the development of pneumonia. Nearly one in five patients with acute ischaemic stroke in the Chinese Stroke Center Alliance were not screened for dysphagia. Pneumonia prevention during acute hospitalisation is dependent not only on dysphagia screening but also on the effectiveness of subsequent dysphagia management interventions. Further studies are needed to elucidate the relationship between dysphagia screening, stroke unit care and pneumonia in patients with acute ischaemic stroke.

BackgroundsEmbolic stroke is one of the main mechanisms of ischaemic stroke. Even if treated with recommended antithrombotic agents, stroke recurrence remains high. The Shuxuetong injection, a purified extract of traditional Chinese medicine widely used for thrombus diseases in clinical practice in China, could be a promising agent to prevent stroke recurrence.AimsTo describe the design of the Shuxuetong injection for prevention of recurrence in acute ischaemic stroke with embolism mechanisms.DesignThe Shuxuetong for Prevention of recurrence in Acute Cerebrovascular events with Embolism (SPACE) trial is a multicentre, randomised, double-blind, placebo-controlled, parallel-group, superiority trial to evaluate the efficacy and safety of Shuxuetong injection in reducing recurrence or silent new ischaemic lesions on patients with acute embolic stroke within 10 days. An estimated 2416 patients with embolic stroke within 72 hours of symptom onset from 80 hospitals will be randomly assigned to one of two groups receiving Shuxuetong injection or placebo injection for 10 days. The primary endpoint is symptomatic or asymptomatic new cerebral infarction within 10 days after randomisation.ConclusionThe SPACE Trial will provide valuable evidence for the efficacy and safety of Shuxuetong injection for the prevention of stroke recurrence in patients with imaging-defined embolic stroke.Clinical trial registrationNCT03090113.

Background and aimObesity paradox has aroused increasing concern in recent years. However, impact of obesity on outcomes in intracerebral haemorrhage (ICH) remains unclear. This study aimed to evaluate association of body mass index (BMI) with in-hospital mortality, complications and discharge disposition in ICH.MethodsData were from 85 705 ICH enrolled in the China Stroke Center Alliance study. Patients were divided into four groups: underweight, normal weight, overweight and obese according to Asian-Pacific criteria. The primary outcome was in-hospital mortality. The secondary outcomes included non-routine discharge disposition and in-hospital complications. Discharge to graded II or III hospital, community hospital or rehabilitation facilities was considered non-routine disposition. Multivariable logistic regression analysed association of BMI with outcomes.Results82 789 patients with ICH were included in the final analysis. Underweight (OR=2.057, 95% CI 1.193 to 3.550) patients had higher odds of in-hospital mortality than those with normal weight after adjusting for covariates, but no significant difference was observed for patients who were overweight or obese. No significant association was found between BMI and non-disposition. Underweight was associated with increased odds of several complications, including pneumonia (OR 1.343, 95% CI 1.138 to 1.584), poor swallow function (OR 1.351, 95% CI 1.122 to 1.628) and urinary tract infection (OR 1.532, 95% CI 1.064 to 2.204). Moreover, obese patients had higher odds of haematoma expansion (OR 1.326, 95% CI 1.168 to 1.504), deep vein thrombosis (OR 1.506, 95% CI 1.165 to 1.947) and gastrointestinal bleeding (OR 1.257, 95% CI 1.027 to 1.539).ConclusionsIn patients with ICH, being underweight was associated with increased in-hospital mortality. Being underweight and obese can both increased risk of in-hospital complications compared with having normal weight.

Background: Little is known about healthcare quality and patient outcomes of ischemic cerebrovascular diseases between urban and rural areas in China during the past decade. Methods: We used a two-stage random sampling method to create a nationally representative sample of patients in China hospitalized for ischemic stroke (IS)/ Transient ischemic attack (TIA) in 2005, 2010, and 2015. Firstly, we used simple random sampling to obtain a list of participating hospitals in 2 urban and 3 rural strata. Secondly, we obtained medical records at each hospital on clinical profiles, tests, treatments and outcomes using a systematic sampling approach. We weighted our findings to explore rural-urban disparities from 2005 to 2015. Results: A total of 30 827 patients were sampled from 189 hospitals with 14 418 (46.8%) from urban and 16 409 (53.2%) from rural. We observed a decreased disparity between urban and rural in eligible patients receiving antiplatelet and anticoagulant for atrial fibrillation (AF) (both P trend trend trend trend Conclusion: Although urban-rural disparities in evidence-based treatments for IS/TIA patients have largely been eliminated, substantial gaps in quality of care persist in both settings.

Background and Purpose: China has made an impressive achievement in both the scale of coverage and the speed of expansion of its health insurance system, yet data regarding health insurance-related disparities in managements patents and in-hospital outcomes for ischemic stroke/transient ischemic attack (IS/TIA) are still limited. Methods: We used a two-stage random sampling method to create a nationally representative sample of patients in China hospitalized with IS/TIA in 2005, 2010, and 2015. Health insurance was limited in Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI), New Rural Cooperative Medical Scheme (NRCMS), and self-payment. We used three composite measures to summarize the treatment and management for assessment tests, in-hospital treatments, and medication at discharge. In-hospital outcomes, including death, discharge against medical advice (DAMA), and a composite outcome of death or DAMA, were assessed. Results: Of the 23,389 analyzed patients, the percentage of self-payment patients decreased from 56.3% in 2005 to 9.4% in 2015. Composite measures showed no significant difference between insurance status for in-hospital treatments and medication at discharge, except for assessment tests. Compared to UEBMI, other insurance groups had a higher risk of DAMA and in-hospital mortality or DAMA. Nevertheless, the discrepancies become smaller from 2005 to 2015 (P for interaction < 0.0001) (Figure 1). Conclusions: Health insurance-related disparities exist in management patterns and in-hospital outcomes for ischemic cerebrovascular disease, nevertheless, the discrepancies become improved to some degree from 2005 to 2010.

BackgroundIn June 2015, the Chinese Stroke Association (CSA) initiated the Chinese Stroke Center Alliance (CSCA) to establish the national hospital-based stroke care quality assessment and improvement platform. This article outlines its objectives, operational structure, patient population, quality improvement (QI) intervention tools, data elements, data collection methodology and current patient and hospital data.MethodsThe CSCA is a national, hospital-based, multicentre, voluntary, multifaceted intervention and continuous QI initiative. This multifaceted intervention includes stroke centre development, written care protocols, workshops and a monitoring/feedback system of evidence-based performance measures. The data coordinating centre of the CSCA resides at the China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital.ResultsAs of July 2017, 1576 hospitals in China have contributed detailed clinical information to serve as a benchmark for the stroke care quality of 433 264 patients with acute stroke/transient ischaemic attacks (TIA), including 352 572 (81.38%) acute ischaemic stroke, 30 362 (7.01%) TIA, 42 080 (9.71%) spontaneous intracranial haemorrhage, 5505 (1.27%) subarachnoid haemorrhage and 2745 (0.63%) not specified stroke.ConclusionThe CSCA programme is designed to establish a continuous national stroke registry and help healthcare providers develop stroke centres and treat patients in a consistent manner in accordance with accepted national guidelines and, ultimately, improve patient outcomes. It supports the CSA mission to reduce stroke burden in China.

Background and Purpose— The aim of the study was to investigate the utility of iodine contrast agent leakage (the iodine sign) analyzed by Gemstone spectral imaging in early hematoma formation compared with that of the spot sign for predicting early hematoma expansion (HE) and poor functional outcomes. Methods— From 2014 to 2017, 91 patients with spontaneous intracerebral hemorrhage who underwent spectral computed tomography angiography within 6 hours of spontaneous intracerebral hemorrhage onset were prospectively included in our study. We defined a positive iodine sign as tiny enhancing foci within the hematoma on Gemstone spectral imaging and an iodine concentration inside the foci of >7.82 (100 µg/mL). Univariate and multivariate logistical regression analyses were performed to assess risk factors for HE, and the predictive value of HE was analyzed. Results— Positive spot and iodine signs were present in 38.5% (35/91) and 57.1% (52/91) of the patients, respectively. Using multivariate analysis, the iodine sign independently predicted HE (odds ratio, 53.67; 95% CI, 11.88–242.42; P 2 =29.97; P Conclusions— The iodine sign is a reliable and sensitive marker for predicting HE and poor functional outcomes. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02625948.

Objective Prior data suggest paternal or sibling stroke was associated with increased risk of offspring stroke. Whether family history of cardiovascular disease (FHc) predicts risk of stroke recurrence remains unclear, we aim to determine this issue on patients with ischemic stroke (IS) or transient ischemic attack (TIA). Materials and Methods This is a post hoc analysis based on the Third China National Stroke Registry III. IS/TIA patients with data of FHc status were included. FHc was defined as family history of coronary heart disease (CHD) or stroke among first-degree relatives (include parents, children, and siblings (same parents)). Cox proportional hazards regression models were performed to assess the association between FHc and recurrent events at 1 year follow-up. Results Totally 14,208 patients with verified FHc status were included, 4,454 (31.3%) were female and the median (IQR) age was 62.0 (54.0, 70.0) years. Of these, 294 (2.1%), 726 (5.1%) and 1936 (13.6%) had family history of both CHD and stroke, family history of CHD, and family history of stroke only, respectively. Using multivariable Cox models adjusted for age, sex, and vascular risk factors, we found that patients with FHc experienced higher risk of stroke recurrence (HR=1.151, 95%CI=1.000-1.324) and combined vascular events (HR=1.186, 95%CI=1.036-1.358) at 1 year compared with those without FHc. In sensitivity analysis on patients who received primary secondary prevention treatment of antiplatelet and statins, the association persisted. Conclusions FHc is associated with increased risk of stroke recurrence even under primary secondary prevention treatment.

Background The impact of estimated glomerular filtration rate ( eGFR ) on clinical short‐term outcomes after stroke thrombolysis with tissue plasminogen activator remains controversial. Methods and Results We analyzed 18 320 ischemic stroke patients who received intravenous tissue plasminogen activator at participating hospitals in the Chinese Stroke Center Alliance between June 2015 and November 2017. Multivariate logistic regression models were used to evaluate associations between eGFR (2 ) and in‐hospital mortality and symptomatic intracerebral hemorrhage, adjusting for patient and hospital characteristics and the hospital clustering effect. Of the 18 320 patients receiving tissue plasminogen activator, 601 (3.3%) had an eGFR eGFR 45 to 59, 3679 (20.1%) had an eGFR 60 to 89, and 13 415 (73.2%) had an eGFR ≥90. As compared with eGFR ≥90, eGFR values CI , 2.18–5.91), 45 to 59 (4.0% versus 0.9%, adjusted odds ratio, 2.00; 95% CI , 1.18–3.38), and 60 to 89 (2.5% versus 0.9%, adjusted odds ratio, 1.67; 95% CI , 1.20–2.34) were independently associated with increased odds of in‐hospital mortality. However, there was no statistically significant association between eGFR and symptomatic intracerebral hemorrhage. Conclusions eGFR was associated with an increased risk of in‐hospital mortality in acute ischemic stroke patients after treatment with tissue plasminogen activator. eGFR is an important predictor of poststroke short‐term death but not of symptomatic intracerebral hemorrhage.

Using data from the Blood Pressure and Clinical Outcome in TIA or Ischemic Stroke (BOSS) study, we aim to test the applicability and feasibility of stroke secondary prevention recommendations from the 2017 American College of Cardiology/American Heart Association guideline. Patients were categorized based on their blood pressure (BP) status at 3 months. The nonhypertension group was defined as those without a diagnosis of hypertension. The other patients were further divided into three subgroups according to office BP measured at 3-month visit (BP

Background and Purpose— We aim to compare the risk of 1-year ischemic stroke recurrence and death for atrial fibrillation diagnosed after stroke (AFDAS), atrial fibrillation known before stroke (KAF), and sinus rhythm (SR). Methods— From June 2012 to January 2013, 19 604 patients with acute ischemic stroke were admitted to 219 urban hospitals in the China National Stroke Registry II. Based on heart rhythm assessed during admission, we classified patients as AFDAS, KAF, or SR. We explored the relationship between heart rhythm groups and 1-year ischemic stroke recurrence or death by using Cox regression adjusted for multiple covariates. Considering that death is a competing risk for stroke recurrence, we used the competing risks analysis of Fine and Gray and subdistribution Cox proportional hazards to test the association between heart rhythm and 1-year outcomes. Results— Among 19 604 ischemic stroke patients, 17 727 had SR, 495 AFDAS, and 1382 KAF. At 1 year, 54 (10.9%) patients with AFDAS, 182 (13.2%) with KAF, and 1008 (5.7%) with SR had recurrent ischemic strokes ( P P Conclusions— This study showed that AFDAS had similar risk of 1-year ischemic stroke recurrence and mortality when compared with KAF and higher risk when compared with SR. The potential risk of AFDAS should be given more emphasis, and appropriate treatment is needed to achieve reduction in the incidence of stroke recurrence and mortality.

BackgroundIn 2009, China launched ambitious healthcare reform plans to provide affordable and equitable basic healthcare for all patients, including the substantial number of patients who had a stroke. However, little is known about the pattern of evidence-based stroke care and outcomes across hospitals, regions and time during the last decade.AimsThe Patient-centered Retrospective Observation of Guideline-Recommended Execution for Stroke Sufferers in China (China PROGRESS) Study aims to use findings from a representative sample of Chinese hospitals over the last decade to improve future stroke care for patients hospitalised with ischaemic stroke (IS) or transient ischaemic attack (TIA).DesignThe China PROGRESS Study will use a two-stage cluster sampling method to identify over 32000 patient records from 208 hospitals across the Eastern, Central and Western geographical regions in China. To assess the temporal trends in patient characteristics, treatment and outcomes, study investigators will select records from 2005, 2010 and 2015. A double data reading/entry system will be developed to conduct this assessment. A central coordinating centre will monitor case ascertainment, data abstraction and data management. Analyses will examine patient characteristics, testing patterns, in-hospital treatment and outcomes, and variations across regions and across time.ConclusionsThe China PROGRESS Study is the first nationally representative study that aims to better understand care quality and outcomes for patients with IS or TIA before and after the national healthcare reform in China. This initiative will translate findings into clinical practices that improve care quality for patients who had a stroke and policy recommendations that allow these changes to be implemented widely.Ethics approvalThis study has also been approved by the central institutional review board (IRB) at Beijing Tiantan Hospital.

Background and Objective: Pretreatment with statins has been shown in several studies to be associated with reduced infarct volume and improved functional outcomes after ischemic stroke, but limited data were available specific to atrial fibrillation (AF) related ischemic stroke. The present study investigated the impact of statin use before onset on both initial severity and in-hospital outcomes in ischemic stroke patients with AF. Method: All cases of first-ever ischemic stroke patients with AF were prospectively identified from China Stroke Center Alliances from June 2015 to November 2017. Moderate and severe stroke was defined as National Institutes of Health Stroke Scale score ≥16. In-hospital adverse outcomes included intracerebral hemorrhage, deep vein thrombosis or pulmonary embolism, and pneumonia. We used logistic regression model to estimate propensity score and then we performed inverse probability weighting to assess the association of pre-stroke statin use with moderate and severe stroke and in-hospital adverse outcomes. Results: Among the 18,076 patients included, 1589 (3.9 %) had previously been treated with statins. The risk of moderate and severe stroke was significantly lower in pre-stroke statin users than nonusers (15.3% vs. 18.7%; adjusted odd ratio: 0.85; 95% confidence interval: 0.81-0.90; p Conclusion: Use of statins before first-ever ischemic stroke in patients with AF was associated with reduced stroke severity at admission and decreased risk of adverse outcomes during hospitalization.

Background and Purpose: Emergency medical services (EMSs) is critical for the early treatment of ischemic stroke patients, yet data regarding EMSs utilization and its association with timely treatment are still limited in China. Methods: We examined the data from Chinese Stroke Center Alliance (CSCA) recording consecutive ischemic stroke patients from 2015 June to 2017 November. The absolute standardized difference was used for covariates balance assessments. We used multivariable logistic models to identify factors associated with EMSs usage and to evaluate the effect of EMSs on timely treatment. Results: Of the 326,534 analyzed ischemic patients, only 42,293 (13.0%) were transported by EMSs. Multivariable-adjusted results indicated that younger age, less education, non-urban employ medial insurance, lower income level, less stroke severity, smoking, history of stroke/transient ischemic attack, carotid stenosis, hypertension, diabetes and peripheral vascular disease were associated with decreased risk of EMSs usage. However, coronary heart disease or myocardial infarction, atrial fibrillation and heart failure were associated with increased risk of EMSs usage. Compared to self-transportation, EMS-transported patients were associated with significantly shorter onset-to-door time (Median (IQR): 210 (105-586) vs. 1020 (290-2250) minutes, P Conclusions: EMSs utilization is far from optimal among Chinse ischemic stroke patients. Nevertheless, use of EMSs transportation is associated with substantial reductions in prehospital delay and improved chance of timely treatment. Therefore, community education efforts are needed to improve EMSs activation.

Objective: To compare the risk of 1-year ischemic stroke recurrence and death between atrial fibrillation (AF) diagnosed after stroke (AFDAS), AF known before stroke (KAF) and sinus rhythm (SR). Methods: From June 2012 to January 2013, 19 604 patients with acute ischemic stroke were admitted to 219 urban hospitals voluntarily participating in the China National Stroke Registry II. Based on heart rhythm assessed during admission, we classified patients as AFDAS, KAF, or SR. We explored the relationship between heart rhythm groups and 1-year ischemic stroke recurrence and death by using Cox regression adjusted for multiple covariates. Considering death is the competing risk of stroke recurrence, we used the competing-risks analysis of Fine and Gray to assess the association between heart rhythm and stroke recurrence. Results: Among 19604 ischemic stroke patients, 17727 had SR, 495 AFDAS, and 1382 KAF. At 1 year, 54 (10.9%) patients with AFDAS, 182 (13.2%) with KAF, and 1008 (5.7%) with SR had recurrent ischemic strokes (p< 0.0001). The mortality was 22.0% in patients with AFDAS , 22.1% in patients with KAF, and 7.0% in patients with SR (p< 0.0001). AFDAS-related ischemic stroke recurrence adjusted risk was higher than that of SR (hazard ratio 1.48 [95% confidence interval 1.19, 1.85]; p = 0.0005) but not different from that of KAF (hazard ratio 1.09 [95% confidence interval 0.85, 1.40]; p = 0.51). The adjusted risk of 1-year death for AFDAS was also higher than that of SR (hazard ratio 1.60 [95% confidence interval 1.29, 2.00]; p Conclusions: The higher 1-year ischemic stroke recurrence and mortality between AFDAS and SR together with the lack of difference between AFDAS and KAF suggest the similar potential risk of AFDAS.

Background and Purpose: Previous studies have reported the underuse of warfarin for ischemic stroke patients with atrial fibrillation (AF) in China. New oral anticoagulants (NOACs) have become an efficacious alternative to warfarin and been recommended by guidelines. We sought to explore the usage of NOAs and affecting factors in China. Methods: From June 2015 to November 2017, 511 036 patients with acute stroke/TIA were admitted to 1 624 hospitals voluntarily participating in the China Stroke Center Alliance (CSCA), an ongoing, national, hospital-based, multicenter, stroke care quality registry and improvement program. Multivariable logistic regression models using the generalized estimating equation method were used to identify patient/hospital factors independently associated with NOACs use during hospitalization. Results: Among 28 456 ischemic stroke patients with AF, only 798 (2.8%) received NOACs, 8 635 (30.3%) received traditional anticoagulants therapy, 18821 (66.1%) received antiplatelet drugs only. Among patients receiving traditional anticoagulants or NOACs, younger age, lower education level, lower income, rural basic medical insurance schemes, more severity, secondary hospital, Central or West China were associated with lower odds of receiving NOACs (Table 1). Conclusions: Ischemic stroke patients with AF are under treated with anticoagulant, especially with the usage of NOACs. Further efforts are needed to increase the prescription of NOACs and other anticoagulants.

Objectives: To determine the association of preceding therapeutic anticoagulation with stroke severity and in-hospital complications. Method: All acute ischemic stroke patients with known history of AF, who were included into CSCA, were divided into five groups: not receiving any antithrombotic therapy, only antiplatelet therapy, receiving subtherapeutic warfarin (international normalized ratio [INR] Results: Of 25 475 patients (mean [SD] age, 73.7 [10.6] years; 51.1% male), none were receiving NOACs, 438 (1.7%) were receiving therapeutic warfarin, 2 520 (9.9%) were receiving subtherapeutic warfarin, 5 847 (23.0%) were receiving antiplatelet therapy only, and 16 670 (65.4%) were not receiving any antithrombotic treatment before onset of stroke. Among 22 113 high-risk patients (prestroke CHA2DS2-VASc score ≥2), 19 546 (88.4%) were neither receiving warfarin nor NOACs before stroke. After adjusting for potential confounders, compared with no antithrombotic treatment, preceding use of therapeutic warfarin, untheraputic warfarin, or antiplatelet therapy only was associated with lower odds of moderate or severe stroke (adjusted odds ratio [95% CI], 0.71 [0.53-0.93], 0.88 [0.78-0.99], and 0.87 [0.80-0.96], respectively) and in-hospital complications (adjusted odds ratio [95% CI], 0.79 [0.62-1.00], 0.88 [0.79-0.98], and 0.99 [0.91-1.07], respectively). Conclusions: Among Chinese patients with acute ischemic stroke and known history of atrial fibrillation, therapeutic anticoagulation was associated not only with lower odds of moderate or severe stroke but also with lower odds of in-hospital complications.

We assessed the management and outcomes among hospitalized patients with coronary artery disease (CAD), stroke, peripheral artery disease (PAD), or with multiple (≥2) cardiovascular (CV) risk factors (multiple risk factors [MRFs]). We retrospectively studied 3732 hospitalized patients of either CV disease or ≥2 risk factors for atherothrombosis from October 2004 to January 2005. Outcomes included CV death, myocardial infarction (MI), stroke, and hospitalization for atherothrombotic events. About one-third had disease involving ≥1 vascular bed. Medication was more intense in patients with CAD than in others. The lowest use of statins and antiplatelet treatment was in the PAD-only group. Patients with PAD experienced a higher CV mortality (5.1%) than the patients with CAD (3.73%) or stroke (4.1%), P < .001. Cardiovascular death ranged from 1.2% for patients with MRFs, 2.8% for patients with 1-bed disease, 4.7% for patients with 2-bed disease to 6.4% for patients with 3-bed disease ( P for trend

Background: The annual incidence of stroke in China has increased more drastically in women; moreover, women who experience stroke are less likely to recover. Despite a few studies that have demonstrated gender differences in stroke care and outcomes, there has been limited research exploring insurance-related disparities in outcomes, particularly among female stroke patients. We examined the relationship between rural/urban insurance status on the 1-year clinical outcomes of stroke in women. Method: Cox proportional hazard model was employed to analysis the clinical outcome endpoints in our model. The logistic regression model was used to select significant risk factors. The generalized estimating equation model was applied to control the cluster effect of hospitals in order to obtain a more precise estimation. Results: Compared with women covered by the Urban Resident/Employee Basic Medical Insurance (URBMI/UEBMI), those covered by the New Rural Cooperative Medical Scheme (NRCMS) were younger, less likely to have vascular risk factors and stroke awareness or undergone treatment for hypertension and dyslipidemia, and more likely to have received early antithrombotics, antithrombotics at discharge, and lipid-lowering drugs (Table 1). One-year stroke recurrence and mortality was significantly higher in women covered by the NRCMS (Table 2). Significant differences in age, stroke risk factors, awareness and treatment, care process, and 1-year stroke recurrence and mortality were observed. Conclusion: Healthcare policymakers need to focus their attention on these disparities and take suitable steps to improve primary healthcare service in rural areas.

Background: Intravenous Thrombolysis with Recombinant Tissue Plasminogen Activator (rt-PA) availability at Chinese hospitals varies and may affect care quality for acute ischemic stroke patients. Limited research has shown whether there were differences in quality of care at China National Stroke Registry (CNSR II) hospitals based on rt-PA capability. Methods: For acute ischemic stroke patients admitted to CNSR II hospitals between 2012 and 2013, care quality at hospitals with or without Intravenous rt-PA capability was examined by evaluating conformity with performance and quality measures. The primary outcome was guideline-concordant care, defined as compliance with 10 predefined individual guideline-recommended performance metrics and composite score. A composite score was defined as the total number of interventions actually performed among eligible patients divided by the total number of recommended interventions among eligible patients. Propensity score matching was used to balance the baseline characteristics. We used cox model with shared frailty model and logistic regression with generalized estimating equation to compare the relationship between hospitals with rt-PA capability and hospitals without rt-PA on quality measures. Results: This study included 19604 acute ischemic stroke patients admitted to 219 CNSR II hospitals. Before matching, there were 7928 patients admitted to 86 (40.4%) hospitals with rt-PA capability and 11676 patients admitted to 133 (59.6%) hospitals without rt-PA capability. After matching, 7606 pairs of patients in rt-PA-capable hospitals and rt-PA-incapable hospitals were analyzed. Before matching, the composite score of guideline-concordant process of care was higher at hospitals with rt-PA capability than hospitals without rt-PA capability (74% versus 73%, P=0.0126). Hospitals with rt-PA capability were more likely to perform deep vein thrombosis prophylaxis within 48 hours of admission, dysphagia screening, assessment or receiving of rehabilitation, discharge antithrombotic, anticoagulation for atrial fibrillation and medications for lowering low-density lipoprotein (LDL) ≥100mg/dL. But hospitals with rt-PA capability were less likely to perform antithrombotic medication within 48 hours of admission and hypoglycemic therapy at discharge for patients with diabetes. After matching, differences of stroke care quality between hospitals with rt-PA capability and without rt-PA capability still exist after adjusting covariates. Conclusions: The CNSR II hospitals were associated with better performance in some of the hospitals but not all of them. The difference in conformity between rt-PA-capable hospitals and rt-PA-incapable hospitals was modest for performance measures of stroke care. However, more room for improvement still exists in key quality performance measures and further studies should be explored.

Introduction: A key element in modern stroke care is dedicated stroke units. However, it is unclear whether processes of acute ischemic stroke (AIS) care and outcomes are different between hospitals with and without stroke units in China. Methods: We analyzed the China National Stroke Registry II data from June 2012 to January 2013. Processes of care were examined by 13 individual national guideline-recommended indicators and composite score. Patients’ outcomes included all caused death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12month after discharge. Propensity score matching was used to balance the baseline characteristics. We used cox model with shared frailty model and logistic regression with generalized estimating equation to analysis the relationship between stroke units and clinical outcomes. Results: Among 19 604 AIS patients, there were 11050 (56.4%) patients in 121 hospitals with stroke units, and 8554 (43.6%) patients in 96 hospitals without stroke units. After matching, 8125 pairs of patients were analyzed. Totally, the composite score of processes was higher in hospitals with stroke units than that without(77% versus 74%, p Conclusions: Our study showed that processes of care of AIS were better in patients in hospitals with stroke units. However, patients in hospitals with stroke units didn’t performance differences in clinical outcomes after discharge.

Background: Guideline-concordant processes of care improve longitudinal outcomes in patients with acute stroke. Little is known whether there are different processes of acute ischemic stroke (AIS) care or outcomes between secondary and tertiary hospitals. Methods: We analyzed 19 604 AIS patients across 219 hospitals in China National Stroke Registry II from June 2012 to January 2013. The primary outcome was guideline-concordant care, defined as compliance with 13 guideline-recommended performance metrics and composite score. Propensity score matching was used to balance the baseline characteristics. We used cox model and logistic regression with generalized estimating equation to compare the relationship between secondary and tertiary hospitals on quality measures and all caused death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12month after discharge. Results: Among 19 604 AIS patients, 6 038 (30.8%) and 13 566 (69.2%) were admitted to 66 (30.1%) secondary and 153 (69.9%) tertiary hospitals separately. After matching, 5959 pairs of patients in secondary and tertiary were analyzed. The composite score was higher at tertiary hospitals than secondary hospitals (77% versus 74%, P Conclusions: In China, tertiary hospitals have better processes of AIS care and more favorable clinical outcomes than secondary hospitals. The quality of process of AIS care should be further increased to improve the patients’ clinical outcomes especially among secondary hospitals.

Introduction: Although urban and rural differences in care or outcomes are pervasive in many areas of medicine, little is known whether processes of acute ischemic stroke (AIS) care or outcomes are different between urban and rural patients in China. Methods: We analyzed China National Stroke Registry II data from June 2012 to January 2013. Urban and rural patients were classified by insurance types of urban basic medical insurance schemes and new rural cooperative medical schemes. Processes of care were examined by 13 individual national guideline-recommended indicators and composite score. Patients’ outcomes included all-cause death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12 month after discharge. Propensity score matching was used to balance the baseline characteristics. Cox model with shared frailty model and logistic regression with generalized estimating equation were employed to analyze the outcomes. Results: Among 19 604 AIS patients, there were 7747 (39.5%) rural and 10 021 (51.1%) urban patients. After matching, 5231 pairs of rural and urban subjects were analyzed. Totally, urban and rural patients had similar processes of care composite score (0.76±0.18 versus 0.77±0.18) (Figure 1). However, comparing to urban patients, rural patients had higher hazard of stroke recurrence and death at 3, 6 and 12 months, and higher odds of disability at 3 months (Table 1). Conclusions: Processes of care were similar between urban and rural patients with AIS. However, rural AIS patients had worse unfavorable clinical outcomes after discharge. Difference of stroke care after discharge should be further explored among rural and urban AIS patients.

Background: Physical Activity (PA) during leisure time has been inversely associated with Cardiovascular Disease (CVD) risk in Western populations. We aim to evaluate PA at work and leisure time in relation to Acute Myocardial Infarction (AMI) in Chinese. Methods: We conducted a hospital-based case-control study. Cases were first AMI (n=2909). Controls (n=2947) were matched to cases on age and sex. All the participants from 27 regions in China were enrolled between February 1999 and March 2003. Results: After adjustment for age and sex, the OR associated with heavy physical labour, compared with mainly sedentary was 1.44 (95% CI: 1.06 to 1.94), for walking, climbing, and lifting 1.00 (95% CI: 0.77 to 1.30) and for walking at one level 0.90 (95% CI: 0.75 to 1.07) (Global P value for multiple logistic regression, 0.0279, respectively). The ORs of leisure-time PA for strenuous exercise group compared with mainly sedentary group was 0.74 (95% CI: 0.61 to 0.90), and for mild and moderate exercise group 0.96 (95% CI: 0.85 to 1.08). People in the highest level (≥7 hours per week of leisure-time sport activity such as running, swimming) had an OR of 0.67 (95% CI: 0.55 to 0.82; P value=0.0001) compared with those in the lowest level (no leisure-time sport activity). Multivariate adjustment did not substantially alter the association. There was the interaction between leisure-time physical activity and related factors of AMI. People in the highest level of leisure-time physical activity consumed more cigarettes. Conclusions: Moderate work-related PA, such as walking, can reduce the risk of AMI and excessive heavy work-related PA increased the risk of AMI, compared mainly sedentary. Leisure-time physical activity was protective for AMI risk compared to sedentary lifestyles in a population in China.

Identification and treatment of hypertension in China remain suboptimal despite high prevalence of hypertension and increasing incidence of stroke and myocardial infarction.This study reported blood pressure levels, prevalence, awareness, treatment, and control rates of hypertension, in addition to drug treatments in China.This is a country-specific analysis of 45 108 individuals, average age 51.4 (standard deviation 9.6) (35-70) years, enrolled between 2005 and 2009, from 70 rural and 45 urban communities in 12 provinces.Among 18 915 (41.9% overall population) hypertensive participants, 7866 (41.6%) were aware, 6503 (34.4%) treated but only 1545 (8.2%) controlled. Prevalence of hypertension was higher, but awareness, treatment, and control were lower in rural than urban residents. Prevalence of hypertension was highest in eastern (44.3%), intermediate in central (39.3%), and lowest in western regions (37.0%). Awareness was higher in central (44.3%) and eastern (42.4%) but lower in western regions (37.0%). Similar patterns were observed in treatment rates, 37.7% central, 35.2% eastern, and 26.7% in western regions with control rates of 8.3% in eastern, 7.6% central, and 5.3% west regions. Of 4744 participants receiving documented treatments, 37.5% received traditional combination drugs alone, 55.4% western drugs alone and 7.1% combination of traditional combination drug in addition to western drugs.In China, hypertension is common, and while recent studies suggest some improvements, more than half of affected individuals were unaware that they had hypertension. Rates of control remain low. National programs effective in preventing and controlling hypertension in China are urgently needed.

Background The safety and efficacy of everolimus-eluting stent (EES) versus zotarolimus-eluting stent (ZES) are controversial both in randomized controlled clinical trials (RCTs) and observational studies. The aim of this study was to assess the safety and efficacy of EES versus ZES. Methods Pubmed, Embase, Cochrane database and www.clinicaltrials.gov updated to Mar 2014 with safety [major adverse cardiac events (MACE)], all-cause mortality, non-fatal myocardial infarction (MI), stent thrombosis (ST) and efficacy [target vessel revascularization (TVR), target lesion revascularization (TLR), target vessel failure (TVF), target lesion failure (TLF)] endpoints and follow-up of ≥12months were identified. Results Data from 11,778 patients in 8 RCTs and 34,850 patients in 26 observational studies were included. In RCT studies, no evidence indicating that EES was safer or more efficacious than ZES. In observational studies, EES associated with a significantly lower risk for MACE (RR: 0.56, 95% CI: 0.46–0.69), ST (RR: 0.59, 95% CI: 0.45–0.78), TVR (RR: 0.61, 95% CI: 0.47–0.79), TLR (RR: 0.57, 95% CI: 0.38–0.83) and TLF (RR: 0.69, 95% CI: 0.50–0.93). The pooled data of RCTs and observational studies showed that compared to ZES, EES associated with a significant lower risk for MACE (RR: 0.65, 95% CI: 0.54–0.78), ST (RR: 0.66, 95% CI: 0.52–0.83), TVR (RR: 0.72, 95% CI: 0.58–0.89), TLR (RR: 0.63, 95% CI: 0.49–0.82) and TLF (RR: 078, 95% CI: 0.62–1.00). Conclusions In RCTs, EES and ZES showed comparable safety and efficacy, while in observational studies or pooled data, EES was safer and more efficacious than ZES.

Evidence shows that a sodium intake between 3 g per day and 6 g per day was associated with the lowest risk of death and cardiovascular events in global population. However, the optimal range of sodium intake for cardiovascular health in China is still controversial. We enrolled individuals from 115 urban and rural communities in 12 areas across China mainland. Trained local staff recorded baseline information from 43034 participants with interview-based questionnaires, and obtained morning fasting urine samples to estimated 24-hour sodium (used as a surrogate for intake). We examined the association between estimated urinary sodium excretion and the composite outcome of death and major cardiovascular events in Chinese population. The mean estimated sodium excretion was 5.84 g per day. With a median follow-up of 4.00 years, the composite outcome occurred in 916 (2.13%) participants, of which 597 (1.39%) died and 476 (1.11%) suffered from cardiovascular diseases. As compared with an estimated sodium excretion of 5.00 to 6.99 g per day (reference range), a higher estimated sodium excretion ( 8.00 g per day) was associated with an increased but not significant risk of the composite outcome (odds ratio, 1.15; 95% confidence interval [CI], 0.82 to 1.61), as well as that with an estimated sodium excretion below 4.00 g per day (odds ratio, 1.21; 95% CI, 0.93 to 1.58). We recorded similar trend in death, but major cardiovascular events had a different tendency. An estimated sodium intake between 4 g per day and 7 g per day was associated with a lower risk of death and cardiovascular events in China. The recommended daily intake of sodium is 1 g larger than that suggested by former study, because Asian people, especially Chinese, generally eat more salt than other countries, and the tolerance of sodium may be higher.

To evaluate and compare physical activity patterns of urban and rural dwellers in China, and study their relationship with obesity, hypertension and diabetes. We studied 46285 subjects aged from 35 to 70 years from baseline survey of the PURE study in China, of whom 22807 were urban dwellers and

Background and purposeThe clinical significance of carbon dioxide combining power (CO2CP) in ischaemic cerebrovascular disease is not well established, and the role of CO2CP in the prognosis of acute ischaemic stroke (AIS) or transient ischaemic attack (TIA) has not been reported. The objective of the study was to investigate the associations between CO2CP and clinical outcomes in patients with AIS or TIA.MethodsData were derived from the China National Stroke Registry III. Patients were classified into five groups by quintiles of CO2CP levels and three groups according to the normal range of CO2CP (23–29 mmol/L). Multivariable Cox and logistic regressions were adopted to explore the associations of CO2CP levels with all-cause death and poor functional outcomes (modified Rankin Scale (mRS) 3–6/2–6) at 3 months and 1 year.ResultsAmong 9531 patients included in the study, the median (IQR) CO2CP was 24.9 (23.0–27.0) mmol/L. After adjustment for potential confounders, patients in the first CO2CP quintile (21.1–23.3 mmol/L) had higher risk of all-cause death and poor functional outcomes (mRS score of 3–6/2–6) (HR or OR with 95% CI 2.37 (1.32 to 4.25), 1.49 (1.20 to 1.83) and 1.21 (1.03 to 1.42), respectively) compared with those in the fourth quintile. Similar results were found for outcomes at 1 year. Furthermore, all associations were also significant when CO2CP was 2CP of 23–29 mmol/L.ConclusionsDecreased CO2CP was associated with high risk of all-cause death and poor functional outcomes in patients with AIS or TIA.

BackgroundStudies show tranexamic acid can reduce the risk of death and early neurological deterioration after intracranial haemorrhage. We aimed to assess whether tranexamic acid reduces haematoma expansion and improves outcome in intracerebral haemorrhage patients susceptible to haemorrhage expansion.MethodsWe did a prospective, double-blind, randomised, placebo-controlled trial at 10 stroke centres in China. Acute supratentorial intracerebral haemorrhage patients were eligible if they had indication of haemorrhage expansion on admission imaging (eg, spot sign, black hole sign or blend sign), and were treatable within 8 hours of symptom onset. Patients were randomly assigned (1:1) to receive either tranexamic acid or a matching placebo. The primary outcome was intracerebral haematoma growth (>33% relative or >6 mL absolute) at 24 hours. Clinical outcomes were assessed at 90 days.ResultsOf the 171 included patients, 124 (72.5%) were male, and the mean age was 55.9±11.6 years. 89 patients received tranexamic acid and 82 received placebo. The primary outcome did not differ significantly between the groups: 36 (40.4%) patients in the tranexamic acid group and 34 (41.5%) patients in the placebo group had intracranial haemorrhage growth (OR 0.96, 95% CI 0.52 to 1.77, p=0.89). The proportion of death was lower in the tranexamic acid treatment group than placebo group (8.1% vs 10.0%), but there were no significant differences in secondary outcomes including absolute intracranial haemorrhage growth, death and dependency.ConclusionsAmong patients susceptible to haemorrhage expansion treated within 8 hours of stroke onset, tranexamic acid did not significantly prevent intracerebral haemorrhage growth. Larger studies are needed to assess safety and efficacy of tranexamic acid in intracerebral haemorrhage patients.