Abstract
Background:
Limited data are available on the changes in the quality of care for ST elevation myocardial infarction (STEMI) during China's health system reform from 2009 to 2020. This study aimed to assess the changes in care processes and outcome for STEMI patients in Henan province of central China between 2011 and 2018.
Methods:
We compared the data from the Henan STEMI survey conducted in 2011–2012 (n = 1548, a cross-sectional study) and the Henan STEMI registry in 2016–2018 (n = 4748, a multicenter, prospective observational study). Changes in care processes and in-hospital mortality were determined. Process of care measures included reperfusion therapies, aspirin, P2Y12 antagonists, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins. Therapy use was analyzed among patients who were considered ideal candidates for treatment.
Results:
STEMI patients in 2016–2018 were younger (median age: 63.1 vs. 63.8 years) with a lower proportion of women (24.4% [1156/4748] vs. 28.2% [437/1548]) than in 2011–2012. The composite use rate for guideline-recommended treatments increased significantly from 2011 to 2018 (60.9% [5424/8901] vs. 82.7% [22,439/27,129], P <0.001). The proportion of patients treated by reperfusion within 12 h increased from 44.1% (546/1237) to 78.4% (2698/3440) (P <0.001) with a prolonged median onset-to-first medical contact time (from 144 min to 210 min, P <0.001). The use of antiplatelet agents, statins, and β-blockers increased significantly. The risk of in-hospital mortality significantly decreased over time (6.1% [95/1548] vs. 4.2% [198/4748], odds ratio [OR]: 0.67, 95% confidence interval [CI]: 0.50–0.88, P = 0.005) after adjustment.
Conclusions:
Gradual implementation of the guideline-recommended treatments in STEMI patients from 2011 to 2018 has been associated with decreased in-hospital mortality. However, gaps persist between clinical practice and guideline recommendation. Public awareness, reperfusion strategies, and construction of chest pain centers need to be further underscored in central China.
Keywords: ST elevation myocardial infarction, Management, Healthcare, Mortality
Introduction
Cardiovascular diseases, including ST elevation myocardial infarction (STEMI), remain the leading cause of death in China and worldwide.[1,2,3] Since 2009, mortality from cardiovascular diseases has been higher in rural China than in urban areas. Thrombolysis and primary percutaneous coronary intervention (PCI) have improved the prognosis of patients with STEMI.[4,5,6] However, there is a substantial gap between clinical practice and treatment guidelines in China. A retrospective study revealed that there was no change in early reperfusion rates or in-hospital mortality among STEMI patients between 2001 and 2011.[7]
In 2009, the Chinese government launched a national healthcare reform with the goal of providing affordable and equitable access to quality healthcare by 2020 for all of China's 1.3 billion citizens.[8] Out-of-pocket expenses as a percentage of health expenditures in China dropped dramatically from 60.13% in 2000 to 35.91% in 2016. Furthermore, health insurance coverage of the total population jumped from 22.1% in 2003 to 95.1% in 2013.
Henan is the most populated (94.4 million in 2015) and predominantly rural (55%) province in central China,[9] with a high burden of cardiovascular diseases.[2] Several quality improvement strategies for STEMI were implemented in Henan province of central China, beginning in 2013 as part of a national quality initiative. This initiative included the establishment and evaluation of chest pain centers (CPCs) with the goal of creating a regional cooperative treatment system and promoting the use of fibrin-specific thrombolytic agents.[10,11,12] However, there are limited data on changes in the quality of care for STEMI from 2011 to 2018. Therefore, we compared the data from the Henan STEMI survey conducted in 2011–2012 with the Henan STEMI registry data from 2016 to 2018 to assess changes in guideline-recommended treatments and in-hospital mortality between 2011 and 2018 in central China.
Methods
Ethical approval
The study was conducted in accordance with the Declaration of Helsinki (as revised in 2000). It was approved by the medical Ethics Committee of Henan Provincial People's Hospital with a waiver for informed consent (No. 2015[34]).
Study population and data collection
The Henan STEMI survey was launched in 2012 with the aim of describing the treatment process and in-hospital mortality of patients with STEMI in Henan province from 2011 to 2012. A total of 1686 patients with STEMI from 17 hospitals in Henan province (8 tertiary hospitals and 9 secondary hospitals) from June 2011 to June 2012 were enrolled. Baseline data, reperfusion strategy, medications used, and in-hospital mortality were obtained using a uniform questionnaire. At least 10% of randomly selected questionnaires were monitored for accuracy against medical records.[13] The Henan STEMI registry was initiated in 2016, and the design of the registry has been described previously.[14] Briefly, it was a multicenter, prospective, and observational study that aimed to evaluate the characteristics, management, and outcomes of patients with STEMI as observed in routine clinical practice. The registry enrolled 5479 patients with STEMI in 66 (50 secondary and 16 tertiary) hospitals in Henan from September 2016 to August 2018. The 137 cases who did not meet the study criteria were excluded to obtain a study size of 5342 patients with STEMI. Clinical data were collected by trained investigators via a secure, password protected, web-based data collection platform. Besides real-time automatic logic and range check on the completeness and validity of the data, 53.8% of reported cases were monitored for accuracy against medical records for onsite quality control. The hospitals involved in the two studies are shown in Supplementary Table 1, http://links.lww.com/CM9/B554.
Patients with a primary diagnosis of STEMI who were admitted within 30 days of symptom onset were consecutively enrolled in each study. STEMI was diagnosed in accordance with the universal definition of myocardial infarction (MI) in patients who specifically displayed a persistent ST-segment elevation (≥0.1 mV at J points) in two or more contiguous leads or new onset of a left bundle branch block.[15]
For the main analysis of in-hospital treatments and outcomes, cases with prior reperfusion were excluded because of the potential influence of the doctor's treatment choice. Patients were excluded if they were discharged alive within the first 24 h after admission because there was insufficient time for treatment. Therefore, 138 patients in the Henan STEMI survey and 594 in the Henan STEMI registry were excluded [Figure 1]. Finally, 1548 and 4748 STEMI patients were enrolled from June 2011 to June 2012 and September 2016 to August 2018, respectively.
Figure 1.
Study population of STEMI patients. STEMI: ST elevation myocardial infarction.
Measurements of care processes and outcome
We evaluated the use of the following evidence-based treatments recommended by guidelines for STEMI: (1) reperfusion with thrombolysis or PCI within 12 h after onset; (2) aspirin within 24 h after admission; (3) P2Y12 antagonists within 24 h after admission; (4) beta-blockers during hospitalization; (5) angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) during hospitalization; and (6) statins during hospitalization.[4,5,6] Use rates of the treatments were calculated for patients who were considered ideal candidates for treatment. For each of the six treatments, the proportion of ideal patients who received that treatment was calculated. A composite use rate was determined by dividing the number of times that a hospital successfully delivered each treatment to an ideal patient by the total number of opportunities that the hospital had to deliver such therapies.[16] The primary outcome was in-hospital mortality, defined as all death during the hospitalization.
Statistical analysis
Categorical variables are presented as numbers and percentages that were compared using the chi-squared or Fisher exact tests. Continuous variables are presented as medians (interquartile range [IQR]); differences were compared using the Mann–Whitney U test. For missing data, we imputed sample medians. For comparison of in-hospital mortality, generalized linear mixed models were used to account for patients clustered within hospitals, after adjusting for age, sex, hospital class (secondary or tertiary), risk factors, or medical history (hypertension, diabetes, current smoker, previous coronary heart disease, and previous ischemic stroke), clinical characteristics (heart rate, systolic blood pressure, anterior MI, and cardiogenic shock), and patients who received all treatments described above.
Continuous variables (age, heart rate, and systolic blood pressure) were transformed into categorical variables according to clinically meaningful cut-off values [Table 1]. For the model, odds ratios (ORs) with 95% confidence intervals (CIs) were determined for data in the 2016–2018 registry vs. data in the 2011–2012 survey. Two-sided P-values <0.05 were considered statistically significant. Statistical analyses were performed with SAS 9.4 (SAS Institute Inc., Cary, NC, USA).
Table 1.
Baseline characteristics of patients with STEMI.
| Characteristics | 2011–2012 (n = 1548) | 2016–2018 (n = 4748) | Statistics | P-value |
|---|---|---|---|---|
| Age | 63.8 (55.8–72.0) | 63.1 (52.8–71.0) | 2.84* | 0.004 |
| ≥75 years | 265 (17.1) | 798 (16.8) | 0.08† | 0.776 |
| Women | 437 (28.2) | 1156 (24.3) | 9.31† | 0.002 |
| Han Chinese | 1535 (99.2) | 4698 (98.9) | 0.54† | 0.464 |
| Farmer | 831 (53.7) | 3209 (67.6) | 98.16† | <0.001 |
| Secondary hospital | 723 (46.7) | 2283 (48.1) | 0.89† | 0.346 |
| Risk factors | ||||
| Hypertension | 726 (46.9) | 2091 (44.0) | – | 0.052 |
| Diabetes | 255 (16.5) | 823 (17.3) | 0.61† | 0.435 |
| Current smoker | 623 (40.2) | 1900 (40.0) | 0.03† | 0.873 |
| Medical history | ||||
| Ischemic stroke | 148 (9.6) | 582 (12.3) | 8.28† | 0.004 |
| Coronary heart disease | 124 (8.0) | 295 (6.2) | 6.07† | 0.014 |
| MI | 101 (6.5) | 246 (5.2) | 4.05† | 0.044 |
| PCI | 42 (2.7) | 152 (3.2) | 0.93† | 0.334 |
| Coronary artery bypass graft | 4 (0.3) | 6 (0.1) | 0.59† | 0.444 |
| Clinical characteristic | ||||
| Cardiogenic shock | 81 (5.2) | 278 (5.9) | 0.84† | 0.359 |
| Anterior MI | 855 (55.2) | 2673 (56.3) | 0.54† | 0.464 |
| Heart rate | ||||
| <50 beats/min | 41 (2.6) | 207 (4.4) | 9.03† | 0.003 |
| 50–109 beats/min | 1419 (91.7) | 4288 (90.3) | 2.53† | 0.112 |
| ≥110 beats/min | 88 (5.7) | 253 (5.3) | 0.29† | 0.591 |
| Systolic blood pressure | ||||
| <90 mmHg | 46 (3.0) | 205 (4.3) | 5.53† | 0.019 |
| 90–139 mmHg | 1010 (65.2) | 2842 (59.9) | 14.27† | <0.001 |
| ≥140 mmHg | 492 (31.8) | 1701 (35.8) | 8.41† | 0.004 |
| Length of stay (days) | 11.0 (8.0–15.0) | 10.8 (7.7–13.9) | 3.22* | 0.001 |
Data are presented as median (interquartile range) or n (%). *Z value. †Chi-squared value. MI: Myocardial infarction; PCI: Percutaneous coronary intervention; STEMI: ST elevation myocardial infarction; –: Not applicable.
Results
Baseline characteristics
Compared with STEMI patients in the 2011–2012 survey, patients in the 2016–2018 registry were younger and had a lower proportion of women, less prior MIs, and shorter hospital stays; however, the patients in the 2016–2018 registry had a higher prevalence of farmers, ischemic stroke, abnormal heart rate (<50 beats/min), and abnormal systolic blood pressure (<90 mmHg or ≥140 mmHg). There were no statistically significant differences in the incidence of cardiovascular risk factors (hypertension, diabetes, and smoking) and clinical characteristics (cardiogenic shock and anterior MI) between the two studies [Table 1].
Temporal changes in the processes of care
The composite use rate for guideline-recommended treatments increased significantly from 2011 to 2018 (60.9% [5424/8901] vs. 82.7% [22,439/27,129], P <0.001). Although the proportion of patients eligible for reperfusion decreased from 2011 to 2018, the proportion of patients treated with reperfusion within 12 h of hospital admission increased from 44.1% (546/1237) to 78.4% (2698/3440) (P <0.001), with a significant increase in the use of primary PCI. The use of fibrinolytic therapy remained stable; however, treatment with specific thrombolytic agents increased from 79.6% (347/436) to 94.9%(1186/1250). The increased use in primary PCI was accompanied by prolonged treatment delays. From 2011 to 2018, the median onset to first medical contact (FMC) time (pre-hospital delay) was significantly prolonged (144 min vs. 210 min, P <0.001). For in-hospital delay, the median FMC-to-fibrinolysis time was prolonged, whereas the median FMC-to-PCI time did not change. The rate of FMC-to-PCI time ≤90 min increased, whereas the rate of FMC-to-fibrinolysis ≤30 min decreased [Table 2, Figure 2, and Supplementary Table 2, http://links.lww.com/CM9/B555].
Table 2.
Reperfusion therapy and treatment delays among patients with STEMI.
| Characteristics | 2011–2012 | 2016–2018 | P-value |
|---|---|---|---|
| Reperfusion | |||
| STEMI eligible for reperfusion | 1237/1548 (79.9) | 3440/4748 (72.5) | <0.001 |
| Among eligible | |||
| Reperfused | 546/1237 (44.1) | 2698/3440 (78.4) | <0.001 |
| Fibrinolysis | 436/1237 (35.2) | 1250/3440 (36.3) | 0.493 |
| Primary PCI | 110/1237 (8.9) | 1448/3440 (42.1) | <0.001 |
| Specific thrombolytic agents | 347/436 (79.6) | 1186/1250 (94.9) | <0.001 |
| Treatment delays | |||
| Onset-to-FMC (min) | 144 (30–360) | 210 (109–613) | <0.001 |
| Onset-to-FMC time >12 h | 198/1548 (12.8) | 1091/4748 (23.0) | <0.001 |
| FMC-to-fibrinolysis time (min) | 20 (6–48) | 47 (28–80) | <0.001 |
| FMC-to-fibrinolysis ≤30 min | 279/439 (63.6) | 370/1269 (29.2) | <0.001 |
| FMC-to-PCI time (min) | 60 (36–138) | 65 (42–95) | 0.422 |
| FMC-to-PCI ≤90 min | 67/110 (60.9) | 1097/1506 (72.8) | 0.007 |
Data are presented as n/N (%) or median (IQR). FMC: First medical contact; IQR: Interquartile range; PCI: Percutaneous coronary intervention; STEMI: ST elevation myocardial infarction.
Figure 2.
Process of care among patients with STEMI. ACEI: Angiotensin-converting enzyme inhibitor; ARB: Angiotensin receptor blocker; STEMI: ST elevation myocardial infarction.
In parallel to the changes in the reperfusion strategy, the use of guideline-recommended drugs, such as antiplatelet agents, β-blockers, and statins, increased in 2016–2018 compared with that in 2011–2012 (P <0.001). The use of aspirin, P2Y12 antagonists, and statins increased to greater than 95%. However, the use of ACEIs/ARBs did not change, remaining at approximately 50% [Figure 2 and Supplementary Table 2, http://links.lww.com/CM9/B555].
Temporal change in outcome
The in-hospital mortality of patients in the 2011–2012 survey was 6.1% (95/1548) compared to 4.2% (198/4748) in the 2016–2018 registry [Supplementary Table 2, http://links.lww.com/CM9/B555]. After adjusting for sociodemographic variables, risk factors, medical history, clinical characteristics at admission, and receipt of all treatments, the risk of in-hospital mortality significantly decreased over time (OR: 0.67, 95% CI: 0.50–0.88, P = 0.005). Furthermore, delivering all recommended treatments to an ideal patient was associated with decreased in-hospital mortality (OR: 0.55, 95% CI: 0.37–0.81, P = 0.003) [Table 3].
Table 3.
Association between temporal changes, process of care, and in-hospital death.
| Characteristics | OR (95% CI) | P-value |
|---|---|---|
| Years 2016–2018 | 0.67 (0.50–0.88) | 0.005 |
| Receiving all treatments* | 0.55 (0.37–0.81) | 0.003 |
*Use of treatment determined among ideal patients. All treatments included reperfusion with thrombolysis or PCI within 12 h after onset, aspirin and P2Y12 antagonists within 24 h after admission, beta-blockers, ACEIs or ARBs, and statins during hospitalization.Adjusted for age, sex, hospital class, hypertension, diabetes, current smoker, prior ischemic stroke, prior coronary heart disease, cardiogenic shock, anterior MI, heart rate, and systolic blood pressure. ACEIs: Angiotensin-converting enzyme inhibitors; ARBs: Angiotensin receptor blockers; CI: Confidence interval; MI: Myocardial infarction; OR: Odds ratio; PCI: Percutaneous coronary intervention.
Discussion
We found a significant decrease in in-hospital mortality and a significant increase in the use of guideline-recommended treatments. However, large gaps still persist between clinical practices and recommended treatment guidelines for STEMI, such as delayed reperfusion and underuse of ACEIs/ARBs.
Data in the present study were derived from two observational studies: 2011–2012 data from a cross-sectional survey, using a randomized and stratified cluster sampling design to enroll 17 hospitals (8 tertiary hospitals and 9 secondary hospitals) in Henan,[13] and 2016–2018 data from a prospective registration study, which enrolled 5479 patients with STEMI in 66 hospitals covering 15 of 17 prefectures in Henan.[14] Both the studies tried to represent the STEMI patients in secondary and tertiary hospitals in Henan in terms of design methods and regional coverage, had the same purpose of assessing the process and outcome in secondary and tertiary hospitals, and adopted strict quality control. Therefore, comparison of the results of the two studies could reveal the changes in STEMI treatment process and outcome in Henan province from 2011 to 2018. However, due to different study designs, the hospitals involved in the two studies were different, and baseline data in the two studies were not exactly the same. In addition, the general profile of STEMI patients may change over time due to the following reasons: first, changes in lifestyle and an increasing aging population between 2011 and 2018.[3] Second, improvement in medical care, including the national healthcare reform launched in 2009 and STEMI quality improvement strategies launched in 2013.[8,10,11,12] Moreover, the present study aimed to assess the changes in process and outcome for STEMI in this context.
It has been shown that factors associated with lower economic or social status and poorer health status, such as age >65 years, prior MI, higher heart rate, and cardiac shock on admission, contributed to refusing PCI.[17] Moreover, the proportion of these factors was higher in 2011–2012 in our study. However, the proportion of farmers in 2016–2018 in our study was similar to that of the CPACS-3 study (67.2% in central China in 2011–2014).[18] The proportion of prior stroke in our study was similar to national studies, such as the China Patient-centered Evaluative Assessment of Cardiac Events (China PEACE) (10.1% in central China in 2011–2015)[19] and China Acute Myocardial Infarction (CAMI) (8.6% in province level hospitals, 9.3% in prefecture level hospitals, and 9.6% in county level hospitals in 2013–2014) studies.[20] Similarly, the rate of prior MI was similar to that of the CAMI study (6.9% in province level hospitals, 7.0% in prefecture level hospitals, and 6.0% in county level hospitals in 2013–2014), but lower than the results of the China PEACE study (8.7% in central China in 2011–2015).[19,20] Increased rates of abnormal SBP and HR in 2016–2018 may be related to more patients with cardiogenic shock. The differences of the patient characteristics might lead to difference in the implementation of the guideline-recommended treatments. Therefore, we used generalized linear mixed models to adjust for the impact of baseline data on the results.
We recorded a significantly increased proportion of reperfusions between 2011 and 2018, which was mainly due to the increased use of primary PCI. Furthermore, the increased proportion of timely PCI indicated that the efficiency of PCI improved with the development of CPCs in China.[21] The CPC accreditation program was officially initiated in China in 2013 using Chinese standards, and aimed to promote the management of patients with acute chest pain by establishing a regional emergency care network.[21] Further, the number of CPCs in Henan increased from six in 2016 to 43 in 2018.
Prolonged treatment delays pose a challenge to reperfusion success. Our results showed that pre-hospital delay increased significantly from 2011 to 2018, with a median time of >3 h. Pre-hospital delay is challenging in China and the result of both patient-related and system-related factors.[18,22,23] In Henan, more than half the patients were farmers lacking knowledge regarding STEMI symptoms, and very few hospitals were certified as CPCs to provide a 24 h/7 day service for primary PCI. In 2018, only 43 (13 secondary hospitals and 30 tertiary hospitals) were certified by China CPC. Therefore, the patients do not always recognize the symptoms of STEMI immediately, and they usually prefer to self-transport to the hospital,[22] which leads to prolonged pre-hospital treatment delay. Moreover, our results showed that <30% of fibrinolytic treatment was performed within ≤30 min after FMC. Some studies have shown that longer time to obtain informed consent of reperfusion, longer emergency department stay, doctors' concerns/worries on patient safety/adverse events, and inadequate or no healthcare insurance to cover the cost may be related to prolonged FMC-to-fibrinolysis time.[18,22,23]
Although our study showed that the use rate of thrombolytic therapy did not change and even the treatment delay was significantly prolonged, the use of specific thrombolytic agents increased, indicating the successful promotion of thrombolytic treatment for STEMI in Henan.[12] Urokinase was the most common thrombolytic agent used in 2011.[22,24] Currently, specific thrombolytic drugs, such as reteplase and pro-urokinase, have been introduced into the health insurance system at reduced prices, allowing easier implementation of thrombolytic therapy in China.
Timely reperfusion therapy for STEMI is pivotal to reduce mortality. Therefore, fibrinolytic therapy should not be neglected in the promotion of CPCs. A pharmaco-invasive strategy, which includes intravenous fibrinolysis followed by transfer to a PCI center for secondary coronary angiography ± PCI, should be the priority when primary PCI is not possible.[4,5,20,25,26,27] With the potential for prolonged pre-hospital delays, it will be necessary to optimize reperfusion strategies, and further promote the construction of CPCs to improve reperfusion use in predominantly rural central China.
The composite use of guideline-recommended treatments increased significantly between 2011 and 2018. The use of guideline-recommended drugs in the 2016–2018 registry study, such as antiplatelet agents, β-blockers, and statins, was greater than that in a national study in 2014–2015, which reported that an increasing trend was maintained until 2018 in central China.[19] However, the use of guideline-recommended ACEIs/ARBs was lower in our study compared to that in other studies in China.[19,20] A retrospective study for non-ST-segment elevation acute coronary syndrome in three regions of China (Beijing, Henan, and Jilin) shows that the proportion of ACEIs/ARBs was 50.8% in 2015.[28]
Our principal finding was the significant decrease in in-hospital mortality from 2011 to 2018 that was accompanied by an increased composite use of guideline-recommended treatments. Shorter length of stay also reflected the improvement in treatment of STEMI in predominantly rural central China. Limited by the Henan STEMI survey, the in-hospital mortality in our study did not include patients who withdrew from treatment. In China, many patients withdraw from treatment upon reaching the terminal status, which may be attributed to culture or affordability. As shown in the China PEACE study, the proportion of patients who withdrew from treatment was higher than in-hospital mortality.[7] Therefore, the true in-hospital mortality was higher than that in developed countries.[29–31] Public awareness, reperfusion strategy, and construction of CPCs need to be further improved to reduce pre-hospital delay and increase the use of guideline-recommended treatments.
Our study had several limitations. First, the hospitals involved in the two studies were different. However, the Henan STEMI survey used a randomized and stratified cluster sampling design to select a representative sample of the population with STEMI in Henan province. Although the centers in the Henan STEMI registry (as for most registries) were not randomly selected but volunteered to participate, the geographic diversity (15 of 17 prefectures) gives an indication of the usefulness of these data. Second, the Henan STEMI survey was a retrospective study. Therefore, data that included educational levels, annual income, pre-hospital care, coronary angiography 2–24 h post-fibrinolysis, and patients who withdrew treatment were not available. Despite these limitations, the study has provided comprehensive overview of changes in the reperfusion strategy and in-hospital mortality for STEMI in predominantly rural central China between 2011 and 2018.
In conclusion, from 2011 to 2018, in-hospital mortality rates have improved significantly with the increased use of early reperfusion and guideline-recommended drugs. However, gaps still persist between clinical practice and treatment guidelines. To further improve the quality of STEMI care, efforts should be directed at raising public awareness, optimizing reperfusion strategies, and promoting the construction of more CPCs.
Funding
This work was supported by the grant from Project of Scientific and Technological Support Plan of Health and Family Planning Commission of Henan Province in 2016 [No. 201602210].
Conflicts of interest
None.
Supplementary Material
Footnotes
You Zhang and Shan Wang contributed equally to this work.
How to cite this article: Zhang Y, Wang S, Qi DT, Wang XP, Li MW, Zhu ZY, Cheng QQ, Hu DY, MD, Gao CY. Changes in process and outcome for ST elevation myocardial infarction in central China from 2011 to 2018. Chin Med J 2023;136:2203–2209. doi: 10.1097/CM9.0000000000002698
References
- 1.GBD 2017 Causes of Death Collaborators . Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392: 1736–1788. doi: 10.1016/S0140-6736(18)32203-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Liu S Li Y Zeng X Wang H Yin P Wang L, et al. Burden of cardiovascular diseases in China, 1990-2016: Findings from the 2016 global burden of disease study. JAMA Cardiol 2019; 4: 342–352. doi: 10.1001/jamacardio.2019.0295. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.The writing committee of the report on cardiovascular health and diseases in China . Report on cardiovascular health and diseases in China 2019: An updated summary. Chin Circ J 2020;35: 833–854. doi: 10.3969/j.issn.1000-3614.2020.09.001. [Google Scholar]
- 4.Ibanez B James S Agewall S Antunes MJ Bucciarelli-Ducci C Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39: 119–177. doi: 10.1093/eurheartj/ehx393. [DOI] [PubMed] [Google Scholar]
- 5.Chinese Society of Cardiology of Chinese Medical Association; Editorial Board of Chinese Journal of Cardiology . [2019 Chinese Society of Cardiology (CSC) guidelines for the diagnosis and management of patients with ST-segment elevation myocardial infarction] (in Chinese). Chin J Cardiol 2019;47: 766–783. doi: 10.3760/cma.j.issn.0253-3758.2019.10.003. [DOI] [PubMed] [Google Scholar]
- 6.Levine GN Bates ER Blankenship JC Bailey SR Bittl JA Cercek B, et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation elevation myocardial infarction: An update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol 2016; 67: 1235–1250. doi: 10.1016/j.jacc.2015.10.005. [DOI] [PubMed] [Google Scholar]
- 7.Li J Li X Wang Q Hu S Wang Y Masoudi FA, et al. ST-segment elevation myocardial infarction in China from 2001 to 2011 (The China PEACE-retrospective acute myocardial infarction study): A retrospective analysis of hospital data. Lancet 2015;385: 441–451. doi: 10.1016/S0140-6736(14)60921-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Chen Z. Launch of the health-care reform plan in China. Lancet 2009;373: 1322–1324. doi: 10.1016/S0140-6736(09)60753-4. [DOI] [PubMed] [Google Scholar]
- 9.Henan Municipal Bureau Statistics; NBS Survey Office in Henan . Henan statistical yearbook 2015. Beijing: China Statistical Press, 2015. Available from: http://oss.henan.gov.cn/sbgt-wztipt/attachment/hntjj/hntj/lib/tjnj/2015/indexch.htm. [Last accessed on 2021 August 31]. [Google Scholar]
- 10.Zhang Y Yu B Han Y Wang J Yang L Wan Z, et al. Protocol of the China ST-segment elevation myocardial infarction (STEMI) care project (CSCAP): A 10-year project to improve quality of care by building up a regional STEMI care network. BMJ Open 2019;9: e026362. doi: 10.1136/bmjopen-2018-026362. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kaifoszova Z Kala P Alexander T Zhang Y Huo Y Snyders A, et al. Stent for life initiative: Leading example in building STEMI systems of care in emerging countries. EuroIntervention 2014;10(Suppl T): T87–T95. doi: 10.4244/EIJV10STA14. [DOI] [PubMed] [Google Scholar]
- 12.Liu XY Zhang Y Li MW Wang XP Qi DD Hao PY, et al. [Efficacy of thrombolytic therapy using reteplase in cases with acute ST-segment elevation myocardial infarction: Results from a multicenter clinical trial] (in Chinese). Chin J Cardiol 2016;44: 766–770. doi: 10.3760/cma.j.issn.0253-3758.2016.09.007. [DOI] [PubMed] [Google Scholar]
- 13.Zhang Y Gao C Duan G Liu X Zhang H Zhang C, et al. [Survey on the early reperfusion therapy status in patients with ST-segment elevation myocardial infarction hospitalized in tertiary and secondary hospitals in Henan province] (in Chinese). Chin J Cardiol 2015;43: 858–862. doi: 10.3760/cma.j.issn.0253-3758.2015.10.005. [PubMed] [Google Scholar]
- 14.Zhang Y Wang S Yang S Yin S Cheng Q Li M, et al. Rationale and design of the Henan ST elevation myocardial infarction (STEMI) registry: A regional STEMI project in predominantly rural central China. BMC Cardiovasc Disord 2019;19: 271. doi: 10.1186/s12872-019-1250-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Thygesen K Alpert JS Jaffe AS Simoons ML Chaitman BR White HD, et al. Third universal definition of myocardial infarction. Circulation 2012;126: 2020–2035. doi: 10.1161/CIR.0b013e31826e1058. [DOI] [PubMed] [Google Scholar]
- 16.Peterson ED DeLong ER Masoudi FA O'Brien SM Peterson PN Rumsfeld JS, et al. ACCF/AHA 2010 position statement on composite measures for healthcare performance assessment: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to develop a position statement on composite measures). Circulation 2010;121: 1780–1791. doi: 10.1161/CIR.0b013e3181d2ab98. [DOI] [PubMed] [Google Scholar]
- 17.Zhang H Zheng W Wu S Ma JJ Wang GM Li Y, et al. Analysis of potential factors contributing to refusal of invasive strategy after ST-segment elevation myocardial infarction in China. Chin Med J 2021;134: 524–531. doi: 10.1097/CM9.0000000000001171. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Feng L Li M Xie W Zhang A Lei L Li X, et al. Prehospital and in-hospital delays to care and associated factors in patients with STEMI: An observational study in 101 non-PCI hospitals in China. BMJ Open 2019;9: e031918. doi: 10.1136/bmjopen-2019-031918. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Zhong Q Gao Y Zheng X Chen J Masoudi FA Lu Y, et al. Geographic variation in process and outcomes of care for patients with acute myocardial infarction in China from 2001 to 2015. JAMA Netw Open 2020;3: e2021182. doi: 10.1001/jamanetworkopen.2020.21182. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Xu H Yang Y Wang C Yang J Li W Zhang X, et al. Association of hospital-level differences in care with outcomes among patients with acute ST-segment elevation myocardial infarction in China. JAMA Netw Open 2020;3: e2021677. doi: 10.1001/jamanetworkopen.2020.21677. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Sun P Li J Fang W Su X Yu B Wang Y, et al. Effectiveness of chest pain centre accreditation on the management of acute coronary syndrome: A retrospective study using a national database. BMJ Qual Saf 2021;30: 867–875. doi: 10.1136/bmjqs-2020-011491. [DOI] [PubMed] [Google Scholar]
- 22.Zhang Y Tian Y Dong P Xu Y Yu B Li H, et al. Treatment delay and reperfusion management of acute ST-segment elevation myocardial infarction: Analysis of the China STEMI care project phase 1. QJM 2021;114: 299–305. doi: 10.1093/qjmed/hcaa186. [DOI] [PubMed] [Google Scholar]
- 23.Ranasinghe I Rong Y Du X Wang Y Gao R Patel A, et al. System barriers to the evidence-based care of acute coronary syndrome patients in China: Qualitative analysis. Circ Cardiovasc Qual Outcomes 2014;7: 209–216. doi: 10.1161/CIRCOUTCOMES.113.000527. [DOI] [PubMed] [Google Scholar]
- 24.Li J Li X Ross JS Wang Q Wang Y Desai NR, et al. Fibrinolytic therapy in hospitals without percutaneous coronary intervention capabilities in China from 2001 to 2011: China PEACE-retrospective AMI study. Eur Heart J Acute Cardiovasc Care 2017;6: 232–243. doi: 10.1177/2048872615626656. [DOI] [PubMed] [Google Scholar]
- 25.Han YL Liu JN Jing QM Ma YY Jiang TM Pu K, et al. The efficacy and safety of pharmacoinvasive therapy with prourokinase for acute ST-segment elevation myocardial infarction patients with expected long percutaneous coronary intervention-related delay. Cardiovasc Ther 2013;31: 285–290. doi: 10.1111/1755-5922.12020. [DOI] [PubMed] [Google Scholar]
- 26.Pu J Ding S Ge H Han Y Guo J Lin R, et al. Efficacy and safety of a pharmaco-invasive strategy with half-dose alteplase versus primary angioplasty in ST-segment-elevation myocardial infarction: EARLY-MYO trial (early routine catheterization after alteplase fibrinolysis versus primary PCI in acute ST-segment-elevation myocardial infarction). Circulation 2017;136: 1462–1473. doi: 10.1161/CIRCULATIONAHA.117.030582. [DOI] [PubMed] [Google Scholar]
- 27.Danchin N Popovic B Puymirat E Goldstein P Belle L Cayla G, et al. Five-year outcomes following timely primary percutaneous intervention, late primary percutaneous intervention, or a pharmaco-invasive strategy in ST-segment elevation myocardial infarction: The FAST-MI programme. Eur Heart J 2020;41: 858–866. doi: 10.1093/eurheartj/ehz665. [DOI] [PubMed] [Google Scholar]
- 28.Liu R Sun YQ Hou XX Zheng Y Huffman MD Anderson CS, et al. Temporal trends in diagnosis, treatment, and outcome for non-ST-segment elevation acute coronary syndrome in three regions of China, 2008-2015. Chin Med J 2021;134: 1997–1999. doi: 10.1097/CM9.0000000000001664. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Peterson ED Roe MT Chen AY Fonarow GC Lytle BL Cannon CP, et al. The NCDR ACTION registry-GWTG: Transforming contemporary acute myocardial infarction clinical care. Heart 2010;96: 1798–1802. doi: 10.1136/hrt.2010.200261. [DOI] [PubMed] [Google Scholar]
- 30.Puymirat E Simon T Cayla G Cottin Y Elbaz M Coste P, et al. Acute myocardial infarction: Changes in patient characteristics, management, and 6-month outcomes over a period of 20 years in the FAST-MI program (French registry of acute ST-elevation or non-ST-elevation myocardial infarction) 1995 to 2015. Circulation 2017;136: 1908–1919. doi: 10.1161/CIRCULATIONAHA.117.030798. [DOI] [PubMed] [Google Scholar]
- 31.Szummer K Wallentin L Lindhagen L Alfredsson J Erlinge D Held C, et al. Improved outcomes in patients with ST-elevation myocardial infarction during the last 20 years are related to implementation of evidence-based treatments: Experiences from the SWEDEHEART registry 1995-2014. Eur Heart J 2017;38: 3056–3065. doi: 10.1093/eurheartj/ehx515. [DOI] [PMC free article] [PubMed] [Google Scholar]