Chenfei Rao

Efficacy of Long-Term β-Blocker Therapy for Secondary Prevention of Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery

Background— Conflicting results from recent observational studies have raised questions concerning the benefit of &bgr;-blockers for patients undergoing coronary artery bypass grafting (CABG). Furthermore, the efficacy of long-term &bgr;-blocker therapy in CABG patients after hospital discharge is uncertain. Methods and Results— The study included 5926 consecutive patients who underwent CABG and were discharged alive. The prevalence and consistency of &bgr;-blocker use were determined in patients with and without a history of myocardial infarction (MI). &bgr;-Blockers were always used in 1280 patients (50.9%) with and 1642 patients (48.1%) without previous MI after CABG. Compared with always users (n=2922, 49.3%), the risk of all-cause death was significantly higher among inconsistent &bgr;-blocker users (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.50–2.57), and never using &bgr;-blockers was associated with increased risk of both all-cause death (HR, 1.42; 95% CI, 1.01–2.00) and the composite of adverse cardiovascular events (HR, 1.29; 95% CI, 1.10–1.50). In the cohort without MI, the HR for all-cause death was 1.70 (95% CI, 1.17–2.48) in inconsistent users and 1.23 (95% CI, 0.76–1.99) in never users. In the MI cohort, mortality was higher for inconsistent users (HR, 2.14; 95% CI, 1.43–3.20) and for never users (HR, 1.59; 95% CI, 1.07–2.63). Consistent results were obtained in equivalent sensitivity analyses. Conclusions— In patients with or without previous MI undergoing CABG, the consistent use of &bgr;-blockers was associated with a lower risk of long-term mortality and adverse cardiovascular events. Strategies should be developed to understand and improve discharge prescription of &bgr;-blockers and long-term patient adherence.

Efficacy of Chronic -Blocker Therapy for Secondary Prevention on Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery

Background— Conflicting results from recent observational studies have raised questions concerning the benefit of &bgr;-blockers for patients undergoing coronary artery bypass grafting (CABG). Furthermore, the efficacy of long-term &bgr;-blocker therapy in CABG patients after hospital discharge is uncertain. Methods and Results— The study included 5926 consecutive patients who underwent CABG and were discharged alive. The prevalence and consistency of &bgr;-blocker use were determined in patients with and without a history of myocardial infarction (MI). &bgr;-Blockers were always used in 1280 patients (50.9%) with and 1642 patients (48.1%) without previous MI after CABG. Compared with always users (n=2922, 49.3%), the risk of all-cause death was significantly higher among inconsistent &bgr;-blocker users (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.50–2.57), and never using &bgr;-blockers was associated with increased risk of both all-cause death (HR, 1.42; 95% CI, 1.01–2.00) and the composite of adverse cardiovascular events (HR, 1.29; 95% CI, 1.10–1.50). In the cohort without MI, the HR for all-cause death was 1.70 (95% CI, 1.17–2.48) in inconsistent users and 1.23 (95% CI, 0.76–1.99) in never users. In the MI cohort, mortality was higher for inconsistent users (HR, 2.14; 95% CI, 1.43–3.20) and for never users (HR, 1.59; 95% CI, 1.07–2.63). Consistent results were obtained in equivalent sensitivity analyses. Conclusions— In patients with or without previous MI undergoing CABG, the consistent use of &bgr;-blockers was associated with a lower risk of long-term mortality and adverse cardiovascular events. Strategies should be developed to understand and improve discharge prescription of &bgr;-blockers and long-term patient adherence.

The Chinese Cardiac Surgery Registry: Design and Data Audit

BACKGROUND In light of the burgeoning volume and certain variation of in-hospital outcomes of cardiac operations in China, a large patient-level registry was needed. We generated the Chinese Cardiac Surgery Registry (CCSR) database in 2013 to benchmark, continuously monitor, and provide feedback of the quality of adult cardiac operations. We report on the design of this database and provide an overview of participating sites and quality of data. METHODS We established a network of participating sites with an adult cardiac surgery volume of more than 100 operations per year for continuous web-based registry of in-hospital and follow-up data of coronary artery bypass grafting (CABG) and valve operations. After a routine data quality audit, we report the performance and quality of care back to the participating sites. RESULTS In total, 87 centers participated and submitted 46,303 surgical procedures from January 2013 to December 2014. The timeliness rates of the short-list and in-hospital data submitted were 73.6% and 70.2%, respectively. The completeness and accuracy rates of the in-hospital data were 97.6% and 95.1%, respectively. We have provided 2 reports for each site and 1 national report regarding the performance of isolated CABG and valve operations. CONCLUSIONS The newly launched CCSR with a national representativeness network and good data quality has the potential to act as an important platform for monitoring and improving cardiac surgical care in mainland China, as well as facilitating research projects, establishing benchmarking standards, and identifying potential areas for quality improvements (ClinicalTrials.gov No. NCT02400125).

Comparing Outcomes of Coronary Artery Bypass Grafting Among Large Teaching and Urban Hospitals in China and the United States

Background— Coronary artery disease is prevalent in China, with concomitant increases in the volume of coronary artery bypass grafting (CABG). The present study aims to compare CABG-related outcomes between China and the United States among large teaching and urban hospitals. Methods and Results— Observational analysis of patients aged ≥18 years, discharged from acute-care, large teaching and urban hospitals in China and the United States after hospitalization for an isolated CABG surgery. Data were obtained from the Chinese Cardiac Surgery Registry in China and the National Inpatient Sample in the United States. Analysis was stratified by 2 periods: 2007, 2008, and 2010; and 2011 to 2013 periods. The primary outcome was in-hospital mortality, and the secondary outcome was length of stay. The sample included 51 408 patients: 32 040 from 77 hospitals in the China-CABG group and 19 368 from 303 hospitals in the US-CABG group. In the 2007 to 2008, 2010 period and for all-age and aged ≥65 years, the China-CABG group had higher mortality than the US-CABG group (1.91% versus 1.58%, P=0.059; and 3.12% versus 2.20%, P=0.004) and significantly higher age-, sex-, and comorbidity-adjusted odds of death (odds ratio, 1.58; 95% confidential interval, 1.22–2.04; and odds ratio, 1.73; 95% confidential interval, 1.24–2.40). There were no significant mortality differences in the 2011 to 2013 period. For preoperative, postoperative, and total hospital stay, respectively, the median (interquartile range) length of stay across the entire study period between China-CABG and US-CABG groups were 9 (8) versus 1 (3), 9 (6) versus 6 (3), and 20 (12) versus 7 (5) days (all P<0.001). This difference did not change significantly over time. Conclusions— In 2011 to 2013, there was no significant difference in in-hospital mortality among patients who underwent an isolated CABG surgery in large teaching and urban hospitals in China and the United States. The longer length of stay in China may represent an opportunity for improvement.

Quality Measurement and Improvement Study of Surgical Coronary Revascularization: Medication Adherence (MISSION-2)

Background: Secondary preventive therapies play a key role in the prevention of adverse outcomes after coronary artery bypass grafting (CABG). However, medication adherence after CABG is often poor, and conventional interventions for improving adherence have limited success. With increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve adherence. Carefully designed trials are needed to provide reliable evidence for the use of these applications in patients after CABG. Methods: The Measurement and Improvement Studies of Surgical Coronary Revascularization: Medication Adherence (MISSION-2) study is a multicenter randomized controlled trial, aiming to randomize 1000 CABG patients to the intervention or control groups in a 1:1 ratio. We developed the multifaceted, patient-centered, smartphone-based Heart Health Application to encourage medication adherence in the intervention group through a health self-management program initiated during hospital admission for CABG. The application integrated daily scheduled reminders to take the discharge medications, cardiac educational materials, a dynamic dashboard to review cardiovascular risk factors and secondary prevention targets, and weekly questionnaires with interactive feedback. The primary outcome was secondary preventive medication adherence measured by the Chinese version of the 8-item Morisky Medication Adherence Scale at 6 months after randomization. Secondary outcomes included all-cause death, cardiovascular rehospitalization, and a composite of death, myocardial infarction, stroke, and repeat revascularization. Discussion: Findings will not only provide evidence regarding the feasibility and effectiveness of the described intervention for improving adherence to CABG secondary preventive therapies but also explore a model for outpatient health self-management that could be translated to various chronic diseases and widely disseminated across resource-limited settings. Trial Registration: https://clinicaltrials.gov(NCT02432469).

Response to Letters Regarding Article, “Efficacy of Long-Term β-Blocker Therapy for Secondary Prevention of Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery”

Poullis states that the possible underlying pharmacokinetic mechanism might affect the efficacy of β-blockers. Actually, in our study, inconsistent users included those who had no β-blocker therapy early after the surgery but were prescribed with the medication because of frequent cardiovascular symptoms, including palpitation and angina pectoris.1 This could not be simply attributed to poor adherence and gives an explanation for the worse long-term outcomes for inconsistent users. The rate of elective coronary artery bypass grafting was 84% in the United Kingdom, 41% in the United States,2 and 98% in our study, showing great variance of patients’ characteristics across regions. Propensity score matching was performed as part of the additional sensitivity analyses to reduce the impact of treatment selection bias and potential confounding. Left internal mammary artery-to-left anterior descending artery graft was used in 95% of our patients, and was treated as a patient-level variable …

The China Patient-Centred Evaluative Assessment of Cardiac Events (China PEACE)-Prospective Study of 3-Vessel Disease: rationale and design

Introduction Complex coronary artery disease (left main and three-vessel disease) carries high risks of adverse events and cost burden. However, in China, little is known about which patients are directed toward which treatment strategies and what outcomes are being achieved. Methods and analysis Using the China PEACE (Patient-centered Evaluative Assessment of Cardiac Events) research network, this prospective study of three-Vessel Disease, the China PEACE-3VD study, has a plan to consecutively register over 4000 patients with a diagnosis of 3VD and/or left-main disease by elective coronary angiography at 24 large cardiovascular centres in China. We centrally conducted medical record abstraction and SYNTAX Score calculation for all registered patients. The sites invited patients to the prospective cohort, and conducted 1-year follow-up on major events, including cardiac events, symptoms, secondary prevention and quality of life. The estimated entire sample size of eligible patients of 4000 was determined based on both feasibility and consideration of adequate statistical precision for describing the treatment decisions, guidelines adherence and appropriateness of treatment for patients with complex coronary artery diseases. The study is designed to investigate patient, clinician and hospital factors associated with each treatment strategy (percutaneous coronary intervention, coronary artery bypass grafting or medical therapy) as well as appropriateness of treatment choice, current guideline compliance and patient-reported outcomes for patients with complex coronary artery disease in large cardiovascular centres in China, as a foundation for enhanced knowledge in the field and to assist quality improvement initiatives. Ethics and dissemination The study protocol was approved by the ethics committee at the China National Center for Cardiovascular Diseases. Findings will be shared with participating hospitals, policymakers and the academic community, to promote quality monitoring, quality improvement and the efficient allocation, and use of coronary revascularisation procedures in China. Trial registration number NCT01625312; Pre-results

Rationale and design of a randomized cluster trial to improve guideline-adherence of secondary preventive drugs prescription after coronary artery bypass grafting in China: Measurement and Improvement Studies of Surgical Coronary Revascularization: Secondary Prevention (MISSION-1) Study

OBJECTIVES The benefits of secondary preventive drugs after coronary artery bypass grafting have been thoroughly established. However, the prescription rates of these drugs are low at discharge in China. We sought to evaluate the effectiveness of continuous quality improvement with mobile-based interventions for clinicians on improving the guideline-adherence of secondary preventive drugs prescription. METHODS AND RESULTS The quality MISSION-1 study is a cluster-randomized controlled trial. We enrolled 60 hospitals with a bypass surgery volume of more than 30 a year and randomly assigned them into the intervention group or the control group in a 1:1 ratio using minimized random grouping. The intervention group undertakes a series of mobile-based interventions, while the control group maintains a routine practice pattern. All sites consecutively register patients who underwent isolated coronary artery bypass grafting and submit in-hospital data. We require supporting documents regarding prescription information at discharge to adjudicate the outcome measures. The estimated sample size of enrolled patients is 9,600. The primary outcome measure is the prescription rate of statins for eligible patients at discharge. The secondary outcome measures are β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and optimal medical therapy. MISSION-1 study is now recruiting patients. CONCLUSIONS The MISSION-1 study has the potential to identify the effectiveness of interventions on improving secondary prevention adherence at discharge after bypass surgery in China and further disseminate findings to other settings to improve the quality of care.