Low-Density Lipoprotein Cholesterol, Cardiovascular Disease Risk, and Mortality in China.

Importance: Limited evidence supports the association between low-density lipoprotein cholesterol (LDL-C) and mortality across different atherosclerotic cardiovascular disease (ASCVD) risk stratifications. Objective: To explore the associations between LDL-C levels and mortality and to identify the optimal ranges of LDL-C with the lowest risk of mortality in populations with diverse ASCVD risk profiles. Design, Setting, and Participants: The ChinaHEART project is a prospective cohort study that recruited residents aged 35 to 75 years from 31 provinces in mainland China between November 2014 and December 2022. Participants were categorized into low-risk, primary prevention, and secondary prevention cohorts on the basis of their medical history and ASCVD risk. Data analysis was performed from December 2022 to October 2023. Main Outcomes and Measures: The primary end point was all-cause mortality, and secondary end points included cause-specific mortality. Mortality data were collected from the National Mortality Surveillance System and Vital Registration. The association between LDL-C levels and mortality was assessed by using Cox proportional hazard regression models with various adjusted variables. Results: A total of 4 379 252 individuals were recruited, and 3 789 025 (2 271 699 women [60.0%]; mean [SD] age, 56.1 [10.0] years) were included in the current study. The median (IQR) LDL-C concentration was 93.1 (70.9-117.3) mg/dL overall at baseline. During a median (IQR) follow-up of 4.6 (3.1-5.8) years, 92 888 deaths were recorded, including 38 627 cardiovascular deaths. The association between LDL-C concentration and all-cause or cardiovascular disease (CVD) mortality was U-shaped in both the low-risk cohort (2 838 354 participants) and the primary prevention cohort (829 567 participants), whereas it was J-shaped in the secondary prevention cohort (121 104 participants). The LDL-C levels corresponding to the lowest CVD mortality were 117.8 mg/dL in the low-risk group, 106.0 mg/dL in the primary prevention cohort, and 55.8 mg/dL in the secondary prevention cohort. The LDL-C concentration associated with the lowest all-cause mortality (90.9 mg/dL vs 117.0 mg/dL) and CVD mortality (87 mg/dL vs 114.6 mg/dL) were both lower in individuals with diabetes than in individuals without diabetes in the overall cohort. Conclusions and Relevance: This study found that the association between LDL-C and mortality varied among different ASCVD risk cohorts, suggesting that stricter lipid control targets may be needed for individuals with higher ASCVD risk and those with diabetes.

Association of the triglyceride-glucose index with all-cause and cause-specific mortality: a population-based cohort study of 3.5 million adults in China.

Background: The triglyceride-glucose (TyG) index has been recognized as a crucial risk factor for cardiovascular diseases. However, the association between the TyG index and mortality in the general population remains elusive. Methods: Participants were enrolled from the China Health Evaluation And risk Reduction through nationwide Teamwork (ChinaHEART), a nationwide prospective cohort study. The outcomes of interest were all-cause, cardiovascular, and cancer mortality. Restricted cubic splines and Cox regression models were used to assess the associations between the TyG index and outcomes. Findings: In total, 3,524,459 participants with a median follow-up of 4.6 (IQR, 3.1-5.8) years were included. The associations of the TyG index with all-cause and cardiovascular mortality were reverse L-shaped, with cut-off values of 9.75 for all-cause mortality and 9.85 for cardiovascular mortality. For each 1-unit increase in the TyG index, when below the cut-off values, the TyG index was not significantly associated with all-cause mortality (HR = 1.02, 95% CI: 1.00-1.03) and was only modestly associated with cardiovascular mortality (HR = 1.09, 95% CI: 1.06-1.11). Conversely, when the cut-off values were exceeded, the HRs (95% CI) were 2.10 (1.94-2.29) for all-cause mortality and 1.99 (1.72-2.30) for cardiovascular mortality. However, the association between the TyG index and cancer mortality was linearly negative (HR = 0.97, 95% CI: 0.94-0.99). Interpretation: The associations of the TyG index with all-cause and cardiovascular mortality displayed reverse L-shaped patterns, while an elevated TyG index showed a slight negative association with cancer mortality. We suggest that <9.75 could be the optimal TyG index cut-off value among the Chinese general population. Individuals at high risk of mortality might benefit from proper management of a high TyG index. Funding: The National High Level Hospital Clinical Research Funding (2023-GSP-ZD-2, 2023-GSP-RC-01), the Ministry of Finance of China and National Health Commission of China.

Predicting the risk of 1-year mortality among patients hospitalized for acute heart failure in China.

BACKGROUND: We aimed to develop and validate a model to predict 1-year mortality risk among patients hospitalized for acute heart failure (AHF), build a risk score and interpret its application in clinical decision making. METHODS: By using data from China Patient-Centred Evaluative Assessment of Cardiac Events Prospective Heart Failure Study, which prospectively enrolled patients hospitalized for AHF in 52 hospitals across 20 provinces, we used multivariate Cox proportional hazard model to develop and validate a model to predict 1-year mortality. RESULTS: There were 4,875 patients included in the study, 857 (17.58%) of them died within 1-year following discharge of index hospitalization. A total of 13 predictors were selected to establish the prediction model, including age, medical history of chronic obstructive pulmonary disease and hypertension, systolic blood pressure, Kansas City Cardiomyopathy Questionnaire-12 score, angiotensin converting enzyme inhibitor or angiotensin receptor blocker at discharge, discharge symptom, N-terminal pro-brain natriuretic peptide, high-sensitivity troponin T, serum creatine, albumin, blood urea nitrogen, and highly sensitive C-reactive protein. The model showed a high performance on discrimination (C-index was 0.759 [95% confidence interval: 0.739, 0.778] in development cohort and 0.761 [95% confidence interval: 0.731, 0.791] in validation cohort), accuracy, calibration, and outperformed than several existed risk scores. A point-based risk score was built to stratify low- (0-12), intermediate- (13-16), and high-risk group (≥17) among patients. CONCLUSIONS: A prediction model using readily available predictors was developed and internal validated to predict 1-year mortality risk among patients hospitalized for AHF. It may serve as a useful tool for individual risk stratification and informing decision making to improve clinical care.

Association of cumulative health status with subsequent mortality in patients with acute heart failure.

OBJECTIVE: We aim to examine the association between long-term cumulative health status and subsequent mortality among patients with acute heart failure (HF). METHODS: Based on a national prospective cohort study of patients hospitalized for HF, we measured health status by Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 at 4 time points, i.e. admission, 1-,6- and 12-month after discharge. Cumulative health status was interpreted by cumulative KCCQ-12 score and cumulative times of good health status. Outcomes included subsequent all-cause and cardiovascular mortality. Multivariable Cox proportional hazard models were performed to examine the association between cumulative health status and subsequent mortality. RESULTS: Totally, 2328 patients (36.7% women and median age 66 [IQR: 56-75] years) were included, the median follow-up was 4.34 (IQR: 3.93-4.96) years. Compared with Quartile 4, the lowest Quartile 1 had the highest HR for all-cause mortality (2.96; 95% CI: 2.26-3.87), followed by Quartile 2 (1.79; 95% CI: 1.37-2.34) and Quartile 3 (1.62; 95% CI: 1.23-2.12). Patients with 0-time of good health status had the highest risk of all-cause mortality (HR: 2.41, 95% CI: 1.69-3.46) compared with patients with 4-times of good health status. Similar associations persisted for cardiovascular mortality. CONCLUSIONS: A greater burden of cumulative health status indicated worse survival among patients hospitalized for HF. Repeated KCCQ measurements could be helpful to monitor long-term health status and identify patients vulnerable to death. Clinical Trial Registration: www.clinicaltrials.gov (NCT02878811).

Effects of Cumulative Cognitive Function Within 1 Year of Discharge on Subsequent Mortality Among Patients Hospitalized for Acute Heart Failure: A Nationwide Prospective Cohort Study.

BACKGROUND: To examine the association between cumulative cognitive function and subsequent mortality among patients hospitalized for acute heart failure (AHF). METHODS: Based on a prospective cohort of patients hospitalized for AHF, cognitive function was measured using Mini-Cog test at admission, 1- and 12-month following discharge. Cumulative cognitive function was interpreted by cumulative Mini-Cog score and cumulative times of cognitive impairment. Outcomes included subsequent all-cause and cardiovascular mortality. RESULTS: 1 454 patients hospitalized for AHF with median follow-up of 4.76 (interquartile range [IQR]: 4.18-5.07) years were included. Tertile 1 of cumulative Mini-Cog score had the highest risk of all-cause (hazard ratio [HR]: 1.52, 95% confidence interval [CI]: 1.14-2.03) and cardiovascular mortality (HR: 1.40, 95% CI: 1.02-1.93) compared with Tertile 3; patients with ≥2 times of cognitive impairment had the highest risk of all-cause (HR: 1.34, 95% CI: 1.03-1.73) and cardiovascular mortality (HR: 1.25, 95% CI: 0.93-1.67) compared with patients without any cognitive impairment. Cumulative Mini-Cog score provided the highest incremental prognostic ability in predicting all-cause (C-statistics: 0.64, 95% CI: 0.61-0.66) and cardiovascular mortality (C-statistics: 0.63, 95% CI: 0.60-0.67) risk on the basis of Get With The Guidelines-Heart Failure score. CONCLUSIONS: Poor cumulative cognitive function was associated with increased risk of subsequent mortality and provided incremental prognostic ability for the outcomes among patients with AHF. Longitudinal assessment and monitoring of cognitive function among patients with AHF would be of great importance in identifying patients at greater risk of self-care absence for optimizing personal disease management in clinical practice.

Associations of cumulative depressive symptoms within 1-year of discharge with subsequent mortality among patients hospitalized for acute heart failure: Findings from The China PEACE Prospective Heart Failure Study.

BACKGROUND: To examine the associations between cumulative depressive symptoms and subsequent mortality among patients hospitalized for acute hear failure (AHF). METHODS: By using data from a prospective cohort study of patients with HF, depressive symptoms were measured by using Patient Health Questionnaire-2 (PHQ-2) at admission, 1-and 12-month after discharge. Cumulative depressive symptoms were interpreted by cumulative PHQ-2 score and cumulative times of depressive symptoms. Outcomes included subsequent 3-year all-cause and cardiovascular mortality. RESULTS: We included 2347 patients with the median follow-up of 4.4 (interquartile range [IQR]: 4.0-5.0) years. Tertile 3 of cumulative PHQ-2 score had the highest risk of all-cause (hazard ratio [HR]: 1.47, 95 % confidence interval [CI]: 1.21-1.78) and cardiovascular mortality (HR: 1.51, 95 % CI: 1.21-1.89) compared with Tertile 1; patients with≥2 times of depressive symptoms had the highest risk of all-cause (HR: 1.62, 95 % CI: 1.31-2.00) and cardiovascular mortality (HR: 1.60, 95 % CI: 1.25-2.05) compared with patients without any depressive symptom. Cumulative PHQ-2 score provided the highest level of incremental prognostic ability in predicting the risk of all-cause (C-statistics: 0.64, 95 % CI: 0.62-0.66) and cardiovascular mortality (C-statistics: 0.65, 95 % CI: 0.62-0.67) on the basis of Get With The Guidelines-Heart Failure score. CONCLUSION: Cumulative depressive symptoms were associated with the increased risk of subsequent mortality and provided incremental prognostic ability for the outcomes among patients with HF. Repeated depressive symptom measurements could be helpful to monitor long-term depressive symptoms, identify targeted patients and perform psychological interventions and social support to improve clinical outcomes among patients with AHF.

Long-Term Cumulative High-Sensitivity C-Reactive Protein and Mortality Among Patients With Acute Heart Failure.

Background Elevated hsCRP (high-sensitivity C-reactive protein) level is associated with worse prognosis among patients hospitalized for heart failure. However, the prognostic value of the long-term cumulative hsCRP remains unknown. Methods and Results We consecutively enrolled patients hospitalized for heart failure and collected their hsCRP data at admission and 1 and 12 months after discharge. Long-term cumulative hsCRP was evaluated using 2 approaches, cumulative hsCRP level quartiles and cumulative times of high hsCRP levels. Patients were classified into 4 groups by cumulative hsCRP level quartiles and cumulative times of high hsCRP levels (0- to 3-times: number of times that hsCRP levels were higher than cutoff values at admission or 1 or 12 months), respectively. Multivariable Cox models were used to assess the association of mortality with cumulative hsCRP. A total of 1281 patients were included; the median age was 64 (interquartile range, 54-73) years, and 35.4% were women. Over a 4.8-year (interquartile range, 4.2-5.1) follow-up, 374 (29.2%) patients died. Elevated long-term cumulative hsCRP level was related to higher mortality. Specifically, taking the quartile 1 as the reference, the hazard ratios (HRs) were 1.29 (95% CI, 0.92-1.81) for quartile 2, 1.62 (95% CI, 1.16-2.25) for quartile 3, and 2.38 (95% CI, 1.75-3.23) for quartile 4. Similarly, compared with the patients with 0-times (hsCRP level lower than the cutoff values in all 3 time points) of high hsCRP level, the HRs were 1.36 for 1-time (hsCRP level higher than the cutoff value in one of the 3 time points) (95% CI, 0.92-2.01), 1.95 for 2-times (hsCRP levels higher than the cutoff values in 2 of the 3 time points) (95% CI, 1.34-2.82), and 2.80 for 3-times (hsCRP levels higher than the cutoff values in the 3 time points) (95% CI, 1.97-4.00). Conclusions Increasing long-term cumulative hsCRP level was associated with worse outcomes in patients hospitalized for acute heart failure. Repeated hsCRP measurements could assist physicians in identifying patients with a high risk of death. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02878811.

Individual Trajectories of Health Status During the First Year of Discharge From Hospitalization for Heart Failure and Their Associations With Death in the Following Years.

Background Improving health status is one of the major goals in the management of heart failure (HF). However, little is known about the long-term individual trajectories of health status in patients with acute HF after discharge. Methods and Results We enrolled 2328 patients hospitalized for HF from 51 hospitals prospectively and measured their health status via the Kansas City Cardiomyopathy Questionnaire-12 at admission and 1, 6, and 12 months after discharge, respectively. The median age of the patients included was 66 years, and 63.3% were men. Six patterns of Kansas City Cardiomyopathy Questionnaire-12 trajectories were identified by a latent class trajectory model: persistently good (34.0%), rapidly improving (35.5%), slowly improving (10.4%), moderately regressing (7.4%), severely regressing (7.5%), and persistently poor (5.3%). Advanced age, decompensated chronic HF, HF with mildly reduced ejection fraction, HF with preserved ejection fraction, depression symptoms, cognitive impairment, and each additional HF rehospitalization within 1 year of discharge were associated with unfavorable health status (moderately regressing, severely regressing, and persistently poor) (P<0.05). Compared with the pattern of persistently good, slowly improving (hazard ratio [HR], 1.50 [95% CI, 1.06-2.12]), moderately regressing (HR, 1.92 [1.43-2.58]), severely regressing (HR, 2.26 [1.54-3.31]), and persistently poor (HR, 2.34 [1.55-3.53]) were associated with increased risks of all-cause death. Conclusions One-fifth of 1-year survivors after hospitalization for HF experienced unfavorable health status trajectories and had a substantially increased risk of death during the following years. Our findings help inform the understanding of disease progression from a patient perception perspective and its relationship with long-term survival. Registration URL: https://www.clinicaltrials.gov; unique identifier: NCT02878811.

Age-Related Trends in the Predictive Value of Carotid Intima-Media Thickness for Cardiovascular Death: A Prospective Population-Based Cohort Study.

Background The age-related trends in the predictive ability of carotid intima-media thickness (CIMT) for cardiovascular risk remain unclear. We aimed to identify the age-related trends in the predictive value of CIMT for cardiovascular death. Methods and Results In a prospective cohort of adults aged 35 to 75 years without history of cardiovascular disease who were enrolled between 2014 and 2020, we measured CIMT at baseline and collected the vital status and cause of death. We divided the study population into 4 age groups (35-44, 45-54, 55-64, and 65-75 years). Competing risk models were fitted to estimate the associations between CIMT and cardiovascular death. The added values of CIMT in prediction were assessed by the differences of the Harrell's concordance index and the net reclassification improvement index. We included 369 478 adults and followed them for a median of 4.7 years. A total of 4723 (1.28%) cardiovascular deaths occurred. After adjusting for the traditional risk factors, the hazard ratios for CIMTmean per SD decreased with age, from 1.27 (95% CI, 1.17-1.37) in the 35 to 44 years age group to 1.14 (95% CI, 1.10-1.19) in the 65 to 75 years age group (P for interaction <0.01). Meanwhile, the net reclassification improvement indexes for CIMTmean were attenuated with age, from 22.60% (95% CI, 15.56%-29.64%) in the 35 to 44 years age group to 7.00% (95% CI, -6.82% to 20.83%) in the 65 to 75 years age group. Similar results were found for maximum CIMT in all age groups. Conclusions CIMT may improve cardiovascular risk prediction in the young and middle-aged populations, rather than those aged ≥55 years.

Long-term cumulative high-sensitivity cardiac troponin T and mortality among patients with acute heart failure.

AIMS: This study aimed to evaluate the cumulative high-sensitivity cardiac troponin T (hs-cTNT) from admission to 12 months after discharge and its association with mortality after 12 months among patients with acute heart failure (HF). METHODS: We used data from the China Patient-Centered Evaluative Assessment of Cardiac Events Prospective Heart Failure Study (China PEACE 5p-HF Study), which enrolled patients hospitalized primarily for HF from 52 hospitals between 2016 and 2018. We included patients who survived within 12 months and had hs-cTNT data at admission (within 48 h of admission) and 1 and 12 months after discharge. To evaluate the long-term cumulative hs-cTNT, we calculated cumulative hs-cTNT levels and cumulative times of high hs-cTNT level. Patients were divided into groups according to the quartiles of cumulative hs-cTNT levels (Quartiles 1-4) and cumulative times of high hs-cTNT levels (0-3 times). Multivariable Cox models were constructed to examine the association of cumulative hs-cTNT with mortality during the follow-up period. RESULTS: We included 1137 patients with a median age of 64 [interquartile range (IQR), 54-73] years; 406 (35.7%) were female. The median cumulative hs-cTNT level was 150 (IQR, 91-241) ng/L*month. Based on the cumulative times of high hs-cTNT levels, 404 (35.5%) patients were with zero time, 203 (17.9%) with one time, 174 (15.3%) with two times, and 356 (31.3%) with three times. During a median follow-up of 4.76 (IQR, 4.25-5.07) years, 303 (26.6%) all-cause deaths occurred. The increasing cumulative hs-cTNT level and cumulative times of high hs-cTNT level were independently associated with excess all-cause mortality. Compared with Quartile 1 group, Quartile 4 had the highest hazard ratio (HR) of all-cause mortality [4.14; 95% confidence interval (CI): 2.51-6.85], followed by Quartile 3 (HR: 3.35; 95% CI: 2.05-5.48) and Quartile 2 (HR: 2.47; 95% CI: 1.49-4.08) groups. Similarly, taking the patients with zero time of high hs-cTNT level as the reference, the HRs were 1.60 (95% CI: 1.05-2.45), 2.61 (95% CI: 1.76-3.87), and 2.86 (95% CI: 1.98-4.14) in patients who had one, two, and three times of high hs-cTNT level, respectively. CONCLUSIONS: Elevated cumulative hs-cTNT from admission to 12 months after discharge was independently associated with mortality after 12 months among patients with acute HF. Repeated measurements of hs-cTNT after discharge may help monitor the cardiac damage and identify patients with high risk of death.

Long-Term Trajectories of High-Sensitivity C-Reactive Protein Level Among Patients with Acute Heart Failure.

Background: Inflammation contributes to the progression of heart failure (HF). However, long-term inflammatory trajectories and their associations with outcomes in patients with acute HF remain unclear. Methods: Data was obtained from the China Patient-Centered Evaluative Assessment of Cardiac Events Prospective Heart Failure Study, and high-sensitivity C-reactive protein (hsCRP) was used to reflect the inflammatory level. Only patients who survived over 12-month and had hsCRP data at admission, 1-, and 12-month after discharge were included. The latent class trajectory modeling was used to characterize hsCRP trajectories. Multivariable Cox regression models were used to explore the association between hsCRP trajectories and following mortality. Results: Totally, 1281 patients with a median 4.77 (interquartile range [IQR]: 4.24-5.07) years follow-up were included. The median age was 64 years (IQR: 54-73 years); 453 (35.4%) were female. Four distinct inflammatory trajectories were characterized: persistently low (n = 419, 32.7%), very high-marked decrease (n = 99, 7.7%), persistently high (n = 649, 50.7%), and persistently very high (n = 114, 8.9%). Compared with the persistently low trajectory, the all-cause mortality was increased in a graded pattern in the persistently high (hazard ratio [HR]: 1.59, 95% confidence interval [CI]: 1.23-2.07) and persistently very high (HR: 2.56, 95% CI: 1.83-3.70) trajectories; nevertheless, the mortality was not significantly increased in very high-marked decrease trajectory (HR: 0.94, 95% CI: 0.57-1.54). Conclusion: Four distinct inflammatory trajectories were identified among patients with acute HF who survived over 12-month. Patients with persistently high and very high trajectories had significantly higher mortality than those with the persistently low trajectory.

Hospital Variation of Spironolactone Use in Patients Hospitalized for Heart Failure in China-The China PEACE Retrospective Heart Failure Study.

Background Although aldosterone antagonists improve outcomes in select individuals with heart failure and reduced ejection fraction, studies in the United States have raised concerns about underuse and overuse. Variations in the prescription of aldosterone antagonist in China are unknown. Methods and Results In the multicenter, hospital-based, retrospective China PEACE (China Patient-Centered Evaluative Assessment of Cardiac Events) study, we identified a nationally representative cohort of admissions for heart failure in a nationally representative sample of Chinese hospitals in 2015. Patients were classified into 1 of 3 groups according to their eligibility for spironolactone-"ideal" (left ventricular ejection fraction <40% and without contraindications), "contraindicated" (a documented contraindication, irrespective of left ventricular ejection fraction), and "uncertain-benefit" (all others). We measured hospital variation of spironolactone prescriptions at discharge in the "ideal" and "contraindicated" group and calculated the median odds ratio (MOR), a measure of institution-level variation for 2 individuals with similar characteristics discharged at 2 randomly selected hospitals. Hospital characteristics associated with spironolactone use were identified using multivariable linear regression model. Among 1222 ideal patients from 97 hospitals, the median rate of spironolactone prescription was 78.6% (interquartile range [IQR], 42.8%-89.6% [range, 0%-100%], MOR, 3.4 [95% CI, 2.7-4.0]) at discharge. Among 900 contraindicated patients from 83 hospitals, the median rate of spironolactone prescription was 30.0% (IQR, 9.1%-50.0% [range, 0%-100%], MOR, 3.1 [95% CI, 2.4-3.9]) at discharge. Hospitals with independent departments of cardiology and located in Eastern China were associated with a 38.0% (95% CI, 18.7-57.3; P<0.001) and a 14.6% (95% CI, 2.3%-26.9%; P=0.020) higher rate of spironolactone use for ideal patients. Conclusions In this national study of hospitals in China, the use of spironolactone among ideal patients and the inappropriate use of spironolactone among patients with contraindications was substantial, with rates that varied markedly by institution. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02877914.

Impact of Non-cardiac Comorbidities on Long-Term Clinical Outcomes and Health Status After Acute Heart Failure in China.

Background: Individual non-cardiac comorbidities are prevalent in HF; however, few studies reported how the aggregate burden of non-cardiac comorbidities affects long-term outcomes, and it is unknown whether this burden is associated with changes in health status. Aims: To assess the association of the overall burden of non-cardiac comorbidities with clinical outcomes and quality of life (QoL) in patients hospitalized for heart failure (HF). Methods: We prospectively enrolled patients hospitalized for HF from 52 hospitals in China. Eight key non-cardiac comorbidities [diabetes, chronic renal disease, chronic obstructive pulmonary disease (COPD), anemia, stroke, cancer, peripheral arterial disease (PAD), and liver cirrhosis] were included, and patients were categorized into four groups: none, one, two, and three or more comorbidities. We fitted Cox proportional hazards models to assess the burden of comorbidities on 1-year death and rehospitalization. Results: Of the 4,866 patients, 25.3% had no non-cardiac comorbidity, 32.2% had one, 22.9% had two, and 19.6% had three or more in China. Compared with those without non-cardiac comorbidities, patients with three or more comorbidities had higher risks of 1-year all-cause death [heart rate, HR 1.89; 95% confidence interval (CI) 1.48-2.39] and all-rehospitalization (HR 1.35; 95%CI 1.15-1.58) after adjustment. Although all patients with HF experienced a longitudinal improvement in QoL in the 180 days after discharge, those with three or more non-cardiac comorbidities had an unadjusted 11.4 (95%CI -13.4 to -9.4) lower Kansas City Cardiomyopathy Questionnaire (KCCQ) scores than patients without comorbidities. This difference decreased to -6.4 (95%CI -8.6 to -4.2) after adjustment for covariates. Conclusion: Among patients hospitalized with HF in this study, a higher burden of non-cardiac comorbidities was significantly associated with worse health-related QoL (HRQoL), increased risks of death, and rehospitalization post-discharge. The findings highlight the need to address the management of comorbidities effectively in standardized HF care.

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.

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.

Are medical record front page data suitable for risk adjustment in hospital performance measurement? Development and validation of a risk model of in-hospital mortality after acute myocardial infarction.

OBJECTIVES: To develop a model of in-hospital mortality using medical record front page (MRFP) data and assess its validity in case-mix standardisation by comparison with a model developed using the complete medical record data. DESIGN: A nationally representative retrospective study. SETTING: Representative hospitals in China, covering 161 hospitals in modelling cohort and 156 hospitals in validation cohort. PARTICIPANTS: Representative patients admitted for acute myocardial infarction. 8370 patients in modelling cohort and 9704 patients in validation cohort. PRIMARY OUTCOME MEASURES: In-hospital mortality, which was defined explicitly as death that occurred during hospitalisation, and the hospital-level risk standardised mortality rate (RSMR). RESULTS: A total of 14 variables were included in the model predicting in-hospital mortality based on MRFP data, with the area under receiver operating characteristic curve of 0.78 among modelling cohort and 0.79 among validation cohort. The median of absolute difference between the hospital RSMR predicted by hierarchical generalised linear models established based on MRFP data and complete medical record data, which was built as 'reference model', was 0.08% (10th and 90th percentiles: -1.8% and 1.6%). In the regression model comparing the RSMR between two models, the slope and intercept of the regression equation is 0.90 and 0.007 in modelling cohort, while 0.85 and 0.010 in validation cohort, which indicated that the evaluation capability from two models were very similar. CONCLUSIONS: The models based on MRFP data showed good discrimination and calibration capability, as well as similar risk prediction effect in comparison with the model based on complete medical record data, which proved that MRFP data could be suitable for risk adjustment in hospital performance measurement.

Prognostic value of copeptin in patients with acute coronary syndrome: A systematic review and meta-analysis.

BACKGROUND: The aim of this study was to evaluate the value of copeptin in predicting mortality including both short-term and long-term mortality in patients with acute coronary syndrome (ACS). METHODS: Potential studies were searched and selected through PubMed, Embase and Cochrane databases up to December 2019. The predictive performance was evaluated by the pooled sensitivity and specificity, and summary receiver operating characteristic curves. Cochran's Q test and I2 index were used to assess between-study heterogeneity, and Deek's test and funnel plots were used to assess publication bias. RESULTS: Total six studies comprising 2269 patients were included in this meta-analysis. The area under the receiver operating characteristic curve of copeptin in predicting mortality in patients with ACS was 0.73 (95% CI: 0.69-0.77). The pooled sensitivity and specificity of copeptin were 0.77 (95% CI: 0.59-0.89) and 0.60 (95% CI: 0.47-0.71), respectively. Significant between-study heterogeneity was identified in both sensitivity (P = 0.01; I2 = 69.76%) and specificity (P<0.001; I2 = 97.32%) among the six included studies. The meta-regression analysis indicated that the number of study centers was significantly associated with the heterogeneity of sensitivity (P = 0.03), whereas the study design (P = 0.03) and duration of follow-up (P<0.001) were significantly associated with the heterogeneity of specificity. CONCLUSIONS: Copeptin has acceptable prognostic value for mortality in patients with ACS. Further studies based on multimarker strategy are needed to evaluate the prognostic value of copeptin for ACS in conjunction with other well-established biomarkers.