Effect of Intensive Personalized "5As+5Rs" Intervention on Smoking Cessation in Hospitalized Acute Coronary Syndrome Patients Not Ready to Quit Immediately: A Randomized Controlled Trial.

Introduction: The acute coronary syndrome (ACS) patients who are not ready to quit smoking immediately have an extremely low rate of cessation. This study aims to investigate the efficacy of intensive personalized '5As+5Rs'intervention (IPANR intervention) on smoking cessation in this population. Methods: A parallel-group randomized controlled trial was carried out, which compared IPANR intervention with routine 5Rs (control) at Fu Xing Hospital, Capital Medical University, Bei Jing, China. Three hundred and twenty hospitalized ACS smokers who were not ready to quit were randomly distributed to IPANR intervention group comprising three individual counseling during hospitalization and 15 intensive follow-up sessions (weekly during months 1, 2, 3, and monthly thereafter until month 6) or 5Rs group in a 1:1 fashion by 8 cardiologists who were blinded to the allocation sequence. Primary end point was carbon monoxide-confirmed continuous abstinence rate (CAR) through week 9 to week 12. Secondary outcome included abstinence rate at 24 weeks. Results: Overall, 97.5% (312/320) participants completed the trial. An intention-to-treat analysis showed statistically significant advantage of IPANR compared with control group at 4 weeks CAR (27.5% vs. 17.5%, RR = 1.571, 95% CI = 1.032-2.392, p = 0.032, number needed to treat (NNT) = 10), and abstinence rate at 24 weeks (23.8% vs.15.0%, RR 1.583, 95% CI = 0.998-2.512, p = 0.048, NNT: 11.36). At 24 weeks, cigarettes smoked per day by the patients who failed to quit were significant lower in IPANR group than 5Rs group (13.21 ± 8.23 vs. 17.45 ± 10.71; p < 0.001). Conclusions: The IPANR initiated during hospitalization, is a feasible and effective approach for smoking cessation in ACS patients not ready to quit immediately. Implications: Smoking has a major impact on acute stages of ACS for recurrent ischemic events and long-term outcomes. However, there are few evidence-based treatments for smokers who are not ready to quit. This study described a cessation intervention initiated during hospitalization and included 15 intensive follow-up aimed at enabling ACS smokers who were not ready to quit immediately to deliver adequate motivational and behavior change counseling. Given its effectiveness demonstrated in this prospective study, this intervention in hospitalized ACS smokers might have the potential to substantially improve the cessation rate of ACS patients who are not ready to quit smoking immediately.

Long-Term Persistence of Newly Initiated Warfarin Therapy in Chinese Patients With Nonvalvular Atrial Fibrillation.

BACKGROUND: Despite its therapeutic efficacy, warfarin is extremely underused in Chinese patients with nonvalvular atrial fibrillation (AF). Whether the nonpersistence of warfarin treatment contributes to its underuse is not known. The aims of this study were to determine nonpersistence rates of newly started warfarin treatment in Chinese patients with nonvalvular AF and to identify the factors associated with discontinuation of the treatment. METHODS AND RESULTS: We identified 1461 patients with nonvalvular AF enrolled in the Chinese Atrial Fibrillation Registry (CAFR) who newly started on warfarin therapy in the period between August 1, 2011, and June 30, 2014. During a follow-up of 426±232 days, 22.1% of patients discontinued warfarin within 3 months, 44.4% within 1 year, and 57.6% within 2 years of initiation of therapy. Patients with no or partial insurance coverage had a higher likelihood to discontinue warfarin than those with full insurance coverage (adjusted hazard ratio 1.65, 95% confidence interval [1.03-2.64]; P=0.038 and 1.66 [1.13-2.42]; P=0.009, respectively). Paroxysmal AF (1.56 [1.28-1.92]; P<0.0001), no prior stroke/transient ischemic attack/thromboembolism (1.60 [1.24-2.05]; P=0.0003), and no dyslipidemia (1.34 [1.06-1.70]; P=0.016) were also found to be independent predictors for nonpersistence of warfarin therapy. CONCLUSIONS: Nonpersistence of warfarin treatment becomes a serious problem for stroke prevention in Chinese patients with nonvalvular AF. Our findings can be used to identify patients who require closer attention or to develop better management strategy for oral anticoagulation therapy.

Validity of the Global Registry of Acute Coronary Events risk score in prediction of acute myocardial infarction mortality in hospitalised Chinese patients aged 80 and over.

AIM: To detect the validity of the Global Registry of Acute Coronary Events (GRACE) risk score in predicting acute myocardial infarction (AMI) mortality of Chinese inpatients aged 80 and over. METHOD: Hospital mortality was defined as all-cause death rate of patients during hospitalisation. Using GRACE risk score to predict death risk, both discrimination (C statistic) and calibration (the predicted vs observed mortality based on the population with predicted risks) were evaluated. RESULTS: Three hundred eighty-six patients presenting with ST segment elevation AMI (STEMI) and non-STEMI were enrolled. The GRACE risk score ranged between 151 and 297, and the mortality was 23.3%. The overall discriminatory capacity of the GRACE model was high (C statistic 0.767, CI: 0.712-0.822). There was a high correlation (R(2) = 0.833) between the predicted and observed hospitalised AMI mortality. CONCLUSION: The GRACE score is a useful risk prediction model for hospital mortality of Chinese AMI patients aged 80 and over.

Validity of the GRACE score for 6-month death or reinfarction after presentation with acute myocardial infarction in patients 80 years of age and older.

INTRODUCTION AND OBJECTIVE: The Global Registry of Acute Coronary Events (GRACE) risk score provides a prediction of the probability of death and myocardial infarction within 6 months after acute coronary syndrome. Our aim was to detect the validity of the GRACE risk score in predicting 6-month death or reinfarction in Chinese acute myocardial infarction (AMI) inpatients 80 years of age and older between 2003 and 2012. METHODS: Using the GRACE risk score to predict the combined endpoints of all-cause death or reinfarction within 6 months of AMI, we evaluated its discrimination and calibration by the C-statistic and the Hosmer-Lemeshow test, respectively. RESULTS: In total, 370 patients presenting with ST segment elevation myocardial infarction (STEMI) and non-STEMI were included. The GRACE risk score ranged between 181 and 325; death or reinfarction within 6 months of AMI was 49.2%. The GRACE model showed good discrimination overall (C-statistic 0.708, 95% confidence interval: 0.655-0.760, P<0.001) and in patients with non-STEMI (C-statistic 0.756, 95% confidence interval: 0.690-0.823, P<0.001). However, the discriminatory capacity was lower in patients with STEMI (C-statistic 0.645, P=0.001). The calibration was optimal overall (Hosmer-Lemeshow, P=0.398) and in the subgroups (STEMI, P=0.098; non-STEMI, P=0.822). There was a high correlation (R=0.926) between the predicted and the observed 6-month death or reinfarction after AMI. CONCLUSION: The GRACE score is accurate for determination of 6-month death or reinfarction in Chinese AMI inpatients 80 years of age and older; however, the discrimination and calibration performs less well in patients with STEMI.

[A 5-year follow up study on smoking and current smoking cessation status in patients with acute myocardial infarction from a hospital in Xicheng district, Beijing].

OBJECTIVE: To explore the smoking and smoking cessation status in patients with acute myocardial infarction. METHODS: 456 hospitalized patients with acute myocardial infarction in Xicheng district were recorded in CCU ward between October 2003 and October 2008. Personal data and smoking status were collected. The smoking cessation status after discharge was investigated by telephone. RESULTS: (1) Patients who smoked were still male-dominated (96.3%). The average smoking rate in male patients was 55.9%, and even as high as 87.5% in patients at 29 - 50 years of age. (2) The average age in patients who smoked and with acute myocardial infarction was 58.0 ± 12.3 years old, 16 years advanced the age compared to the groups who never smoked or after stopped smoking. (3) The successful smoking cessation rate in patients with acute myocardial infarction after discharge was 42.5%, and 29 - 50 years old group having the highest rate of successful cessation, while the lowest rate seen in 51 - 65 years old group. (4) The failure rate of smoking cessation was 40.9% with the main reasons as: radical habit on smoking, withdrawal symptoms, stress in work and peer influence etc. The 51 - 65 year-old group was mainly suffered from habitual factors and withdrawal symptoms. CONCLUSION: The smoking rate and smoking cessation failure rate in adult patients with acute myocardial infarction in Xicheng district in Beijing remained high. The onset age of acute myocardial infarction was significantly in advance among patients who smoked. To actively advocate on smoking cessation was still vital for reducing the occurrence of acute myocardial infarction and to improve the prognosis in patients with myocardial infarction.

[Effects of tissue factor pathway inhibitor-1 on no-reflow in a rabbit model].

OBJECTIVE: To investigate the role of plasma tissue factor (TF) and tissue factor pathway inhibitor-1 (TFPI-1) level and to observe the effect of extrinsic TFPI-1 on no-reflow (NR) in a rabbit model of ischemia/reperfusion. METHODS: Rabbits were randomized into four groups (n = 10 each): ischemic- reperfusion group (IR, subjected to 120 minutes of coronary artery occlusion and followed by 60 minutes of reperfusion); ischemic- reperfusion TFPI-1 group (100 ng/kg bolus and 1 ng x kg(-1) x min(-1) infusion during reperfusion); ischemic group (subjected to 180 minutes of coronary artery occlusion) and sham group. The NR area and ischemic area were determined by thioflavin S and Evan's blue staining in vivo. Plasma TF and TFPI-1 levels were measured before operation, before and at 120 minutes post coronary artery ligation, 10 and 60 minutes after reperfusion by ELISA. RESULTS: Plasma TF and TFPI-1 levels before and at 120 minutes post coronary artery ligation were similar among the four groups (all P > 0.05). At 10 and 60 minutes after reperfusion, the plasma TF levels in the IR group was significantly higher than those in ischemic group and sham group [10 minutes: (20.7 + or - 4.1) pg/ml vs. (13.9 + or - 2.2) pg/ml (P < 0.001), (20.7 + or - 4.1) pg/ml vs. (13.2 + or - 2.6) pg/ml (P < 0.001); 60 minutes: (15.8 + or - 2.6) pg/ml vs. (13.5 + or - 1.6) pg/ml (P < 0.05), (15.8 + or - 2.6) pg/ml vs. (12.1 + or - 0.7) pg/ml (P < 0.001)] while the plasma TFPI-1 levels were similar among IR, ischemic and sham groups at 10 minutes after reperfusion and at 60 minutes after reperfusion (all P > 0.05). TFPI-1 level [(9.7 + or - 1.6) ng/ml] was significantly lower in the IR group than in the ischemic group [(11.6 + or - 1.6) ng/ml, P < 0.05] and sham group [(10.1 + or - 1.3) ng/ml, P < 0.01]. TF mRNA expression in the NR area in IR group was significantly up-regulated compared to the ischemic group (P < 0.05) and sham group (P < 0.001) while TFPI-1 mRNA expression was similar between IR group and ischemic group (P > 0.05). NR severity in the ischemic-reperfusion TFPI-1 group was significantly attenuated compared to IR group (0.39 + or - 0.11 vs. 0.54 + or - 0.06, P < 0.01). CONCLUSION: Upregulated TF mRNA expression in the NR area and increased plasma TF level during reperfusion period, reduced plasma TFPI-1 level during reperfusion period as well as attenuated NR severity by extrinsic application of human rTFPI-1 in this model suggested an important role in the pathogenesis of the NR phenomenon.

[Development and validation of risk score model for acute myocardial infarction in China: prognostic value thereof for in hospital major adverse cardiac events and evaluation of revascularization].

OBJECTIVE: To develop a simple risk score model of in-hospital major adverse cardiac events (MACE) including all-cause mortality, new or recurrent myocardial infarction (MI), and evaluate the efficacy about revascularization on patients with different risk. METHODS: The basic characteristics, diagnosis, therapy, and in-hospital outcomes of 1512 ACS patients from Global Registry of Acute Coronary Events (GRACE) study of China were collected to develop a risk score model by multivariable stepwise logistic regression. The goodness-of-fit test and discriminative power of the final model were assessed respectively. The best cut-off value for the risk score was used to assess the impact of revascularization for ST-elevation MI (STEMI) and non-ST elevation acute coronary artery syndrome (NSTEACS) on in-hospital outcomes. RESULTS: (1) The following 6 independent risk factors accounted for about 92.5% of the prognostic information: age > or =80 years (4 points), SBP < or =90 mm Hg (6 points), DBP > or =90 mm Hg (2 points), Killip II (3 points), Killip III or IV (9 points), cardiac arrest during presentation (4 points), ST-segment elevation (3 points) or depression (5 points) or combination of elevation and depression (4 points) on electrocardiogram at presentation. (2) CHIEF risk model was excellent with Hosmer-Lemeshow goodness-of-fit test of 0.673 and c statistics of 0.776. (3)1301 ACS patients previously enrolled in GRACE study were divided into 2 groups with the best cut-off value of 5.5 points. The impact of revascularization on the in-hospital MACE of the higher risk subsets was stronger than that of the lower risk subsets both in STEMI [OR (95% CI) = 0.32 (0.11, 0.94), chi2 = 5.39, P = 0.02] and NSTEACS [OR (95% CI) = 0.32 (0.06, 0.94), chi2 =4.17, P = 0.04] population. However, both STEMI (61.7% vs. 78.3%, P = 0.000) and NSTEACS (42.0% vs 62.3%, P = 0.000) patients with the risk scores more than 5.5 points had lower revascularization rates. CONCLUSION: The risk score provides excellent ability to predict in-hospital death or (re) MI quantitatively and accurately. The patients undergoing revascularization with risk score greater than 5.5 have lower incidence rates of endpoint.