Association of Cardiovascular Health With Risk of Incident Depression and Anxiety.

OBJECTIVE: To investigate the association between cardiovascular health (CVH), defined by the American Heart Association's Life's Essential 8 (LE8) score, and incident depression and anxiety. DESIGN: A prospective cohort study using data from UK Biobank. SETTING: Participants were enrolled from March 2006 to October 2010. PARTICIPANTS: Participants without cardiovascular diseases and common mental disorders at baseline and having complete data on metrics of LE8 were included. MEASUREMENTS: CVH was assessed by LE8 score including eight components. The overall CVH was categorized as low (LE8 score <50), moderate (50≤ LE8 score <80), and high (LE8 score ≥80). RESULTS: We included 115,855 participants (mean age: 55.7 years; female: 52.6%). During a median follow-up of 12.4 years, 3,194 (2.8%) and 4,005 (3.5%) participants had incident depression and anxiety, respectively. Compared with participants having low CVH, those having moderate and high CVH had 37% (HR = 0.63, 95% CI: 0.57-0.70) and 52% (HR = 0.48, 95% CI: 0.41-0.55) lower risk of incident depression. Similarly, moderate and high CVH were related to a lower risk of incident anxiety (HR = 0.81, 95% CI: 0.73-0.89 and HR = 0.68, 95% CI: 0.60-0.78). Restricted cubic spline showed that LE8 score was inversely related to incident depression and anxiety in a linear manner, and the risk of incident depression and anxiety decreased by 17% (HR = 0.83, 95% CI: 0.80-0.85) and 10% (HR = 0.90, 95% CI: 0.88-0.92) for 10-point increment in LE8 score, respectively. CONCLUSIONS: Higher CVH, evaluated by LE8 score, is strongly associated with a lower risk of incident depression and anxiety, suggesting the significance of optimizing CVH by adopting LE8.

Time in target range of systolic blood pressure and cognitive outcomes in patients with hypertension.

BACKGROUND: Blood pressure (BP) is a dynamic measure that fluctuates over time. However, conventional BP control indicators may not adequately reflect the variability of BP during a period of time. METHODS: We performed a secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT), which compared systolic blood pressure (SBP) targets of <120 mmHg (intensive) and <140 mmHg (standard) among patients with hypertension and high cardiac risks. The target ranges were defined as 110 to 130 mmHg in intensive treatment arm and 120 to 140 mmHg in standard treatment arm, respectively. Time in target range (TTR) was calculated based on SBP measurements recorded during the first 3-month follow-up using linear interpolation method. The Fine-Gray competing risk regression models were used to evaluate the association between TTR and cognitive outcomes. RESULTS: A total of 7965 patients with the mean (SD) age of 68.0 (9.2) years were included, and 35% were female. Patients with higher TTR were younger, more likely to be male and take <3 BP-lowering agents. Compared to the last quartile, the first quartile of TTR was significantly associated with a higher risk of probable dementia (HR: 1.74; 95% CI: 1.22-2.46; p = 0.002) and the composite of probable dementia or mild cognitive impairment (HR: 1.26; 95% CI: 1.03-1.55; p = 0.025). The risk of probable dementia and the composite outcome increased with per quartile decrease of TTR (HR: 1.18; 95% CI: 1.06-1.30; p = 0.002 and HR: 1.07; 95% CI: 1.00-1.14; p = 0.036). Sensitivity analyses showed similar results after adjusting mean SBP during the first 3-month follow-up. CONCLUSIONS: In this secondary analysis of SPRINT data, TTR was independently associated with probable dementia among patients with hypertension, suggesting that TTR could be used as a practical metric of BP control to evaluate the risk of dementia in older adults. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Identifier: NCT01206062.

The effects of motivational interviewing on hypertension management: A systematic review and meta-analysis.

OBJECTIVE: This systematic review aimed to examine the effects of motivational interviewing-based interventions on hypertension management. METHODS: Six databases were searched from inception to 25 July, 2022 for randomized controlled trials involving adults diagnosed with hypertension and including motivational interviewing in the treatment interventions. RESULTS: In total, 11 studies with 2121 participants were included. Compared with no or minimal additional intervention, motivational interviewing-based intervention showed greater reduction in systolic blood pressure (MD: -6.56, 95 % CI: -10.51, -2.62, P = 0.001) and diastolic blood pressure (MD: -3.75, 95 % CI: -4.92, -2.58, P < 0.001). Compared with the lower intensity intervention, motivational interviewing-based intervention produced statistically significant effect on reducing systolic blood pressure (MD: -2.72, 95 % CI: -5.34, -0.10, P = 0.040); while there was no significant effect on reducing diastolic blood pressure (MD: -0.47, 95 % CI: -2.21, 1.28, P = 0.600). Four out of six studies demonstrated medication adherence significantly improved following motivational interviewing-based intervention. Two studies included self-efficacy and quality of life, and inconsistent findings were observed. CONCLUSION: Motivational interviewing could be effective in improving blood pressure control among patients with hypertension. Future studies with more rigorous study designs should be conducted to confirm the effects of motivational interviewing on medication adherence and psychological well-being. PRACTICE IMPLICATIONS: Motivational interviewing could be applied as a promising intervention strategy among patients with hypertension.

Progression of depressive symptoms after early exposure to famine: The China Health and Retirement Longitudinal Study.

BACKGROUND: The effect of early exposure to famine on progression of depressive symptoms has not been studied and the Chinese Famine offers a unique opportunity to explore this association with its long duration and widespread influence. OBJECTIVE: To investigate the longitudinal association of early famine exposure with subsequent depressive symptoms and whether there existed a critical exposure period. METHODS: Data from the China Health and Retirement Longitudinal Study (CHARLS) were analysed. Famine exposure was evaluated retrospectively in 2014 and severe famine exposure was defined as starvation to death of family members. Depressive symptoms were assessed prospectively from wave 1 (2011-2012) to wave 4 (2018) using the 10-item Center for Epidemiological Studies Depression Scale (CES-D). Linear mixed model and Cox proportional hazards model were applied to evaluate associations of famine exposure with progression or occurrence of depressive symptoms. RESULTS: A total of 7053 participants were included. Compared with no famine exposure, severe famine exposure was associated with a faster growth in CES-D score (0.169 point/year, 95 % CI 0.035 to 0.304, P = 0.013) and an elevated risk of occurrence of depressive symptoms (HR 1.360, 95 % CI 1.069 to 1.729, P = 0.012). Further analysis revealed that famine exposure during middle childhood was associated with a faster growth in CES-D score (0.404 point/year, 95 % CI 0.164 to 0.644, P = 0.001). LIMITATIONS: This is an observational study therefore causal relationship cannot be concluded. CONCLUSIONS: Early exposure to severe famine was associated with aggravation of depressive symptoms. Middle childhood might be a critical time window for depression prevention.

Systolic Blood Pressure and 1-Year Clinical Outcomes in Patients Hospitalized for Heart Failure.

Background: High systolic blood pressure (SBP) is an important risk factor for the progression of heart failure (HF); however, the association between SBP and prognosis among patients with established HF was uncertain. This study aimed to investigate the association between SBP and long-term clinical outcomes in patients hospitalized for HF. Methods: This study prospectively enrolled adult patients hospitalized for HF in 52 hospitals from 20 provinces in China. SBPs were measured in a stable condition judged by clinicians during hospitalization before discharge according to the standard research protocol. The primary outcomes included 1-year all-cause death and HF readmission. The multivariable Cox proportional hazards regression models were fitted to examine the association between SBP and clinical outcomes. Restricted cubic splines were used to examine the non-linear associations. Results: The 4,564 patients had a mean age of 65.3 ± 13.5 years and 37.9% were female. The average SBP was 123.2 ± 19.0 mmHg. One-year all-cause death and HF readmission were 16.9 and 32.7%, respectively. After adjustment, patients with SBP < 110 mmHg had a higher risk of all-cause death compared with those with SBP of 130-139 mmHg (HR 1.71; 95% CI: 1.32-2.20). Patients with SBP < 110 mmHg (HR 1.36; 95% CI: 1.14-1.64) and SBP ≥ 150 mmHg (HR 1.26; 95% CI: 1.01-1.58) had a higher risk of HF readmission, and the association between SBP and HF readmission followed a J-curve relationship with the nadir SBP around 130 mmHg. These associations were consistent regardless of age, sex, left ventricular ejection fraction, hypertension, coronary heart disease, and medications for HF. Conclusion: In patients hospitalized for HF, lower SBP in a stable phase during hospitalization portends an increased risk of 1-year death, and a J-curve association has been observed between SBP and 1-year HF readmission. These associations were consistent among clinically important subgroups.

Multi-Biomarker Points and Outcomes in Patients Hospitalized for Heart Failure: Insights From the China PEACE Prospective Heart Failure Study.

Objective: To quantitatively characterize the pattern of systemic impairment reflected by conventional biomarkers and assess how it relates to clinical outcomes and quality of life among patients hospitalized for heart failure (HF). Methods: Patients hospitalized for HF from 52 hospitals in China were enrolled between 2016 and 2018. They were divided into developing and validating cohorts; the developing cohort was used for calculating the weights of biomarkers and constructing the multi-biomarker panel, while the validating one was used for evaluating the relationship between multi-biomarker points and outcomes. In total, five conventional biomarkers reflecting various pathophysiological processes were included in the panel: N-terminal pro-B type natriuretic peptide, high-sensitivity troponin T, hemoglobin, albumin, and creatinine. The weights of the biomarkers were defined based on their relationship with cardiovascular death, and each patient had a multi-biomarker point ranging from 0 to 12. The primary clinical outcome was cardiovascular death, and the other clinical outcomes included rehospitalization for HF, all-cause death, and all-cause rehospitalization in 1-year. The quality of life was measured using Kansas City Cardiovascular Questionnaire. Multi-variable Cox proportional hazard models were used to assess the risks of clinical outcomes, and generalized linear models were used to evaluate the quality of life. Results: In total, 4,693 patients hospitalized for HF were included in this analysis; the median (interquartile range, IQR) age was 67 (57-75) years old and 1,763 (37.6%) were female. The median multi-biomarker point was 5 (IQR, 2-6). There were 18.0% of patients in the low point group (<2), 29.4% in the mid-low point group (2-4), 27.8% in the mid-high point group (5-6), and 24.7% in the high point group (>6). Compared with those in the low point group, the patients in the high point group had a significantly excess risk of cardiovascular death (adjusted hazard ratio: 5.69, 95% CI, 3.33-9.70). Furthermore, patients with higher points were also more prone to worse quality of life. Conclusion: Systemic impairment reflected by abnormal conventional biomarker values was common amongst patients hospitalized for HF and had substantially cumulative adverse influence on clinical outcomes and quality of life.

Prognostic Value of Multiple Circulating Biomarkers for 2-Year Death in Acute Heart Failure With Preserved Ejection Fraction.

Background: Heart failure with preserved ejection fraction (HFpEF) is increasingly recognized as a major global public health burden and lacks effective risk stratification. We aimed to assess a multi-biomarker model in improving risk prediction in HFpEF. Methods: We analyzed 18 biomarkers from the main pathophysiological domains of HF in 380 patients hospitalized for HFpEF from a prospective cohort. The association between these biomarkers and 2-year risk of all-cause death was assessed by Cox proportional hazards model. Support vector machine (SVM), a supervised machine learning method, was used to develop a prediction model of 2-year all-cause and cardiovascular death using a combination of 18 biomarkers and clinical indicators. The improvement of this model was evaluated by c-statistics, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Results: The median age of patients was 71-years, and 50.5% were female. Multiple biomarkers independently predicted the 2-year risk of death in Cox regression model, including N-terminal pro B-type brain-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-TnT), growth differentiation factor-15 (GDF-15), tumor necrosis factor-α (TNFα), endoglin, and 3 biomarkers of extracellular matrix turnover [tissue inhibitor of metalloproteinases (TIMP)-1, matrix metalloproteinase (MMP)-2, and MMP-9) (FDR < 0.05). The SVM model effectively predicted the 2-year risk of all-cause death in patients with acute HFpEF in training set (AUC 0.834, 95% CI: 0.771-0.895) and validation set (AUC 0.798, 95% CI: 0.719-0.877). The NRI and IDI indicated that the SVM model significantly improved patient classification compared to the reference model in both sets (p < 0.05). Conclusions: Multiple circulating biomarkers coupled with an appropriate machine-learning method could effectively predict the risk of long-term mortality in patients with acute HFpEF. It is a promising strategy for improving risk stratification in HFpEF.

Characteristics, interventions and outcomes of patients with valvular heart disease hospitalised in China: a cross-sectional study.

OBJECTIVES: Little is known about contemporary characteristics and management of valvular heart disease (VHD) in China. This study aimed to examine the clinical characteristics, aetiology and type of VHD, interventions and in-hospital outcomes of patients with VHD hospitalised in China. METHODS: We used a two-stage random sampling design to create a nationally representative sample of patients with VHD hospitalised in 2015 in China and included adult patients with mild, moderate or severe VHD. We abstracted data from medical records, including echocardiogram reports, on patient characteristics, aetiology, type and severity of VHD, interventions and in-hospital outcomes. We weighted our findings to estimate nationally representative hospitalisations. We performed multivariable logistic regression analysis to identify factors associated with valve intervention. RESULTS: In 2015, 38 841 patients with VHD were hospitalised in 188 randomly sampled hospitals, representing 662 384 inpatients with VHD in China. We sampled 9363 patients, mean age 68.7 years (95% CI 42.2 to 95.2) and 46.8% (95% CI 45.8% to 47.8%) male, with an echocardiogram. Degenerative origin was the predominant aetiology overall (33.3%, 95% CI 32.3% to 34.3%), while rheumatic origin was the most frequent aetiology among patients with VHD as the primary diagnosis (37.4%, 95% CI 35.9% to 38.8%). Rheumatic origin was also the most common aetiology among patients with moderate or severe VHD (27.3%, 95% CI 25.6% to 29.0% and 33.6%, 95% CI 31.9% to 35.2%, respectively). The most common VHD was mitral regurgitation (79.1%, 95% CI 78.2% to 79.9%), followed by tricuspid regurgitation (77.4%, 95% CI 76.5% to 78.2%). Among patients with a primary diagnosis of severe VHD who were admitted to facilities capable of valve intervention, 35.6% (95% CI 33.1% to 38.1%) underwent valve intervention during the hospitalisation. The likelihood of intervention decreased significantly among patients with higher operative risk. CONCLUSIONS: Among patients with VHD hospitalised in China, the predominant aetiology was degenerative in origin; among patients with moderate or severe VHD, rheumatic origin was the most common aetiology. Targeted strategies and policies should be promoted to address degenerative VHD. Patients with severe VHD may be undertreated, particularly those with high operative risk.

Health Status Predicts Short- and Long-Term Risk of Composite Clinical Outcomes in Acute Heart Failure.

OBJECTIVES: This study aims to examine the association between the Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 score and the 30-day and 1-year rates of composite events of cardiovascular death and heart failure (HF) rehospitalization in patients with acute HF. BACKGROUND: Few studies reported the prognostic effects of KCCQ in acute HF. METHODS: This study prospectively enrolled adult patients hospitalized for HF from 52 hospitals in China and collected the KCCQ-12 score within 48 hour of index admission. The study used multivariable Cox regression to examine the association between KCCQ-12 score and 30-day and 1-year composite events and was further stratified by new-onset HF and acutely decompensated chronic heart failure (ADCHF). Subgroup analyses were performed to explore the potential heterogeneity. The study evaluated the incremental prognostic value of KCCQ-12 score over N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and established risk scores by C-statistics, net reclassification improvement, and integrated discrimination improvement. RESULTS: Among 4,898 patients, 29.4% had new-onset HF. After adjustment, each 10-point decrease in the KCCQ-12 score was associated with a 13% increase in 30-day risk and a 7% increase in 1-year risk. The associations were consistent regardless of new-onset HF or ADCHF, age, sex, left ventricular ejection fraction, New York Heart Association functional class, NT-proBNP level, comorbidities, and renal function. Adding KCCQ-12 score to NT-proBNP and established risk scores significantly improved prognostic capabilities measured by C-statistics, net reclassification improvement, and integrated discrimination improvement. CONCLUSIONS: In acute HF, a poor KCCQ-12 score predicted short- and long-term risks of cardiovascular death and HF rehospitalization. KCCQ-12 could serve as a convenient tool for rapid initial risk stratification and provide additional prognostic value over NT-proBNP and established risk scores.

Systolic blood pressure at admission and long-term clinical outcomes in patients hospitalized for heart failure.

AIMS: The study sought to investigate the association between admission systolic blood pressure (SBP) and 1-year clinical outcomes in patients hospitalized for heart failure (HF) and in subgroups. METHODS: This study was based on the China Patient-centred Evaluative Assessment of Cardiac Events Prospective Heart Failure Study, which prospectively enrolled patients hospitalized for HF in 52 hospitals from 20 provinces in China between August 2016 and May 2018. Patients were divided into four groups according to the quartiles of SBP at admission. The multivariable Cox proportional hazards regression models were fitted to examine the association between admission SBP and all-cause death and HF readmission within 1 year after the index hospitalization. Restricted cubic splines were used to explore the non-linear association between SBP and the clinical outcomes. RESULTS: Among 4896 patients, those with lower admission SBP were younger, more likely to be male, have left ventricular ejection fraction <40%, and receive ß-blockers, aldosterone antagonists, and diuretics. After adjustment for potential confounders, lower admission SBP was significantly associated with higher all-cause death and there is no threshold, while we only observed such an association with HF readmission when admission SBP was lower than 120 mmHg. Compared with the 4th SBP quartile, patients in the 1st SBP quartile had higher risk of all-cause death (hazard ratio, 1.85; 95% confidence interval 1.48-2.33; P < 0.001) and HF readmission (hazard ratio, 1.40; 95% confidence interval 1.19-1.65, P < 0.001). These associations were consistent in most subgroups, such as age, sex, and left ventricular ejection fraction. CONCLUSIONS: In patients hospitalized for HF, lower admission SBP portends an increased risk of 1 year all-cause death and HF readmission, and these associations were consistent among subgroups.

The China Patient-centred Evaluative Assessment of Cardiac Events (PEACE) prospective heart failure study design.

INTRODUCTION: China faces the prospect of a large growth in the prevalence of heart failure (HF). However, there is limited knowledge about outcomes in patients after HF hospitalisations, including patient-reported outcomes (PROs). This paper is to present the study goal, methodology and data collection of the China Patient-centred Evaluative Assessment of Cardiac Events Prospective Heart Failure Study (China PEACE 5p-HF Study). METHODS AND ANALYSIS: The China PEACE 5p-HF Study, a prospective cohort study, will enrol 5000 patients with HF during 2016-2018 from 52 diverse hospitals throughout China and the follow-up period will be 12 months. Information on patients' medical history, in-hospital treatment and in-hospital outcomes are being abstracted from medical records. Details of patients' demographics, socioeconomic status, cardiovascular risk factors, access to healthcare services are being collected through comprehensive baseline interviews. Generic and disease-specific health status, depression, stress, anxiety and cognitive function are being administered using validated PRO instruments. Follow-up interviews will capture PROs and hospitalisation events at 1, 6 and 12 months follow-up. Standardised transthoracic echocardiograms and 6 min walk tests are being done in patients who enrolled in hospitals with these facilities at baseline and at 1 and 12 months after discharge. Collection of blood and urine samples are also being conducted at baseline, 1 and 12 months follow-up and stored for future analyses. ETHICS AND DISSEMINATION: The National Center for Cardiovascular Diseases/Fuwai Hospital ethics committee approved this study, and all collaborating hospitals received approval from their local ethics committee. Written informed consent will be obtained from all patients. Findings will be disseminated in future peer-reviewed papers and will help to support improvements in the quality of care for HF nationwide. TRIAL REGISTRATION NUMBER: NCT02878811.

Proportions and Risk Factors of Developing Multidrug Resistance Among Patients with Tuberculosis in China: A Population-Based Case-Control Study.

AIMS: Limited studies have been conducted to explore risk factors of developing multidrug-resistant tuberculosis (MDR-TB) in China. This study aimed to find the proportions and risk factors of developing MDR-TB in China among new patients and previously treated tuberculosis (TB) patients. METHODS: A population-based case-control study was conducted from March 2010 to December 2013 in five cities in China. Proportions and risk factors of developing MDR-TB were calculated and analyzed separately for new patients and previously treated patients. RESULTS: The proportion of MDR-TB was 3.9% among new patients and 25.3% among previously treated patients in our study population. The proportion of extensively drug resistant TB was 0.1% among new patients and 1.4% among previously treated patients in our study population. Multivariate analysis found that being registered as migrants (odds ratio [OR] = 6.08; 95% confidence interval [CI]: 1.75-21.09), having more than three affected lung fields (OR = 2.18; 95% CI: 1.20-2.94), having more than 8 months of initial treatment (OR = 2.15; 95% CI: 1.09-4.28), having more than three prior episodes of anti-TB treatment (OR = 3.10; 95% CI: 1.48-6.48), and experiencing failure or continued worsening from the last treatment (OR = 3.82; 95% CI: 1.86-7.85) were associated with developing MDR-TB in previously treated patients with TB. Univariate analysis showed that less than 30 years of living in the same location (p = 0.034) was a risk factor for new patients with MDR-TB. CONCLUSION: The surveillance of multidrug resistance among patients with previously treated TB who also possess these risk factors and the management of patients with MDR-TB should be reinforced.