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Background The evidence for the comparative effectiveness and safety of ticagrelor versus clopidogrel in older patients with acute coronary syndrome (ACS) is limited, especially in the acute phase of ACS. This study aimed to compare the in-hospital outcomes of ticagrelor versus clopidogrel in older patients with ACS. Methods Hospitalised ACS patients aged ≥75 years who were recruited to the Improving Care for Cardiovascular Disease in China-ACS project between November 2014 and December 2019 and received aspirin and P2Y12 receptor inhibitors within 24 h after first medical contact were included. The primary outcomes were in-hospital major adverse cardiovascular events (MACE) and major bleeding. Multivariable Cox regression was performed to evaluate the comparative effectiveness and safety of ticagrelor and clopidogrel. Inverse probability of treatment weighting (IPTW) and propensity score matching analyses were performed to evaluate the robustness of the results. Results Of 18,244 ACS patients, 18.5% received ticagrelor. Multivariable-adjusted analysis revealed comparable risks of in-hospital MACE between patients receiving ticagrelor and clopidogrel (hazard ratio [HR] 1.12, 95% confidence interval [CI] 0.92–1.35). However, ticagrelor use was associated with 45% higher risk of in-hospital major bleeding compared with clopidogrel use (HR 1.45, 95% CI 1.09–1.91). Similar results were found in the IPTW analysis. Conclusions ACS patients aged ≥75 years receiving ticagrelor during the acute phase had similar risk of in-hospital MACE, but higher risk of in-hospital major bleeding compared with those receiving clopidogrel. More evidence is needed to guide the use of P2Y12 receptor inhibitors during hospitalisation in older patients with ACS. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616. [ABSTRACT FROM AUTHOR]

The optimal P2Y 12 inhibitor in high bleeding risk (HBR) patients with acute coronary syndrome (ACS) remains unclear. We compared the in-hospital efficacy and safety of ticagrelor versus clopidogrel in ACS patients at HBR. We identified 22,120 hospitalized ACS patients with HBR treated with aspirin combined with either clopidogrel (n = 17,420) or ticagrelor (n = 4700) in the Improving Care for Cardiovascular Disease in China-ACS (CCC-ACS) project between November 2014 and December 2019. The median length of hospital stay was 10 days (interquartile range, 7–14 days). Compared with clopidogrel, ticagrelor was associated with a higher risk of in-hospital TIMI major or minor bleeding (4.8% vs 3.8%; adjusted OR 1.20; 95% CI 1.03–1.41; P = 0.022). The incidence of TIMI major bleeding (1.7% vs 1.1%, P = 0.005) and intracranial bleeding (0.8% vs 0.5%, P = 0.005) were also higher in the ticagrelor group than in the clopidogrel group. There was no significant difference in the rate of in-hospital major adverse cardiovascular and cerebrovascular event (MACCE) (a composite of all-cause death, myocardial infarction, stent thrombosis, or ischemic stroke) with ticagrelor compared with clopidogrel therapy (4.2% vs 4.3%; adjusted OR 1.08; 95% CI 0.90–1.28; P = 0.411). Outcomes in the propensity-matched cohorts and in sensitivity analyses were consistent with the those of the main analysis. Among ACS patients with HBR, ticagrelor as compared with clopidogrel was associated with an increased risk of in-hospital major bleeding without a significant reduction in in-hospital MACCE. https://www.clinicaltrials.gov. Unique identifier: NCT02306616. [ABSTRACT FROM AUTHOR]

Background: A systematic evaluation of quality of care for patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) as well as the hospital-level variations in quality of care is lacking in China. Methods: The study was based on Improving Care for Cardiovascular Disease in China (CCC) -ACS project, an ongoing collaborative registry and quality improvement project of American Heart Association (AHA) and Chinese Society of Cardiology (CSC). A total of 26186 patients from 124 hospitals reported to the registry between November 2014 and March 2018 were included. Application of 9 class I guidelines recommended care processes with a level of evidence A were evaluated among eligible patients. The overall quality of care for NSTE-ACS patients was evaluated by calculating the proportion of patients receiving defect-free evidence-based care. The variations in quality of care across hospitals were examined by aggregating the data to the hospital level. Results: Information on eligibility for all the care processes was available for 25956 patients. Overall, only 1789 patients (6.9%) received evidence-based defect-free care. The proportion varied across hospitals, ranging from 0 to 32.4%. The proportion of patients receiving each care process was 91.9% for cardiac troponin measurement, 55.2% for risk stratification, 88.8% for dual antiplatelet therapy (DAPT) within 24 hours, 17.9% for percutaneous coronary intervention (PCI) within recommended times, 83.6%, 57.4%, 66.3% and 92.3% for DAPT, ACEI/ARB, β blocker and statin at discharge, respectively. Different degree of variability existed across hospitals for each care process. Proportion of patients receiving cardiac troponin measurement, DAPT within 24 hours, and statin at discharge exhibited low degree of variance across hospitals. Great variability existed in proportion of patients receiving risk stratification (0 to 100%), PCI within recommended times (0 to 72.7%), ACEI/ARB at discharge (13.2% to 84.8%), β blocker at discharge (9.8% to 93.3%), and smoking cessation counseling (0 to 98.1%). Conclusions: Great care gaps existed in the management of NSTE-ACS patients between guideline recommendations and clinical practice in China. There are substantial differences in the quality of care for NSTE-ACS patients across hospitals. [ABSTRACT FROM AUTHOR]

Previous studies reported regional variations in in-hospital acute coronary syndrome (ACS) mortality, but the reasons for that were not clearly defined. We explored whether differences in patient characteristics could explain regional variation. The Improving Care for Cardiovascular Disease in China (CCC)-ACS project is an ongoing national registry and quality improvement project, involving 150 tertiary hospitals from 30 provinces across China. We applied a prediction model that included patient-specific variables to calculate the expected in-hospital mortality. For each province, we reported the observed, expected in-hospital mortality and the risk-adjusted ratio which is based on the observed divided by the expected mortality. From 2014 to 2018, 79 585 ACS patients were enrolled. The average in-hospital mortality was 1.8%. There was a wide variation in the in-hospital mortality among different provinces (0.2-3.9%). Patient characteristics explained part of this variation because of differences in the expected in-hospital mortality (0.7-2.8%). There was a substantial variation in the risk-adjusted ratio among provinces (0.2-3.5), which suggests that the variations in the mortality cannot be completely explained by the differences in patient characteristics. In conclusion, we observed a wide regional variation in mortality for ACS, part of which could be explained by the difference in patient characteristics. [ABSTRACT FROM AUTHOR]

Background: Coronary heart disease is a leading cause of mortality among women. Systematic evaluation of the quality of care and outcomes in women hospitalized for acute coronary syndrome (ACS), an acute manifestation of coronary heart disease, remains lacking in China.Methods: The CCC-ACS project (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) is an ongoing nationwide registry of the American Heart Association and the Chinese Society of Cardiology. Using data from the CCC-ACS project, we evaluated sex differences in acute management, medical therapies for secondary prevention, and in-hospital mortality in 82 196 patients admitted for ACS at 192 hospitals in China from 2014 to 2018.Results: Women with ACS were older than men (69.0 versus 61.1 years, P<0.001) and had more comorbidities. After multivariable adjustment, eligible women were less likely to receive evidence-based acute treatments for ACS than men, including early dual antiplatelet therapy, heparins during hospitalization, and reperfusion therapy for ST-segment-elevation myocardial infarction. With respect to strategies for secondary prevention, eligible women were less likely to receive dual antiplatelet therapy, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins at discharge, and smoking cessation and cardiac rehabilitation counseling during hospitalization. In-hospital mortality rate was higher in women than in men (2.60% versus 1.50%, P<0.001). The sex difference in in-hospital mortality was no longer observed in patients with ST-segment-elevation myocardial infarction (adjusted odds ratio, 1.18; 95% CI, 1.00 to 1.41; P=0.057) and non-ST-segment elevation ACS (adjusted odds ratio, 0.84; 95% CI, 0.66 to 1.06; P=0.147) after adjustment for clinical characteristics and acute treatments.Conclusions: Women hospitalized for ACS in China received acute treatments and strategies for secondary prevention less frequently than men. The observed sex differences in in-hospital mortality were mainly attributable to worse clinical profiles and fewer evidence-based acute treatments provided to women with ACS. Specially targeted quality improvement programs may be warranted to narrow sex-related disparities in quality of care and outcomes in patients with ACS.Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02306616. [ABSTRACT FROM AUTHOR]

Introduction: Despite advance in the treatment of ST-elevation myocardial infarction (STEMI), how the current clinical practice varies across hospitals in China is less known. This study evaluated the variation in hospital management of STEMI from data collected in the Improving Care for Cardiovascular Disease in China (CCC) Project. Methods: As a nation-wide quality improvement registry in China, the CCC project was established among 150 tertiary hospitals in collaboration of American Heart Association (AHA) and Chinese Society of Cardiology. Clinical information of AHA/ACC guidelines recommended therapies were collected from November 2014 to March 2018. Average level and variation in hospital management of STEMI were evaluated. Results: A total of 45240 patients with STEMI across China were included in this study. The mean age of the participants was 61.7±12.6 years and 78.2% of them were men. The median of hospital stays was 10 days, with substantial variation across the hospitals (inter-quartile range, 7-13 days). The performances for quality measure were low for β-blocker at discharge (67.3%, 12.5%-96.9%), ACEI/ARB at discharge (55.9%, range across hospitals: 8.3%-94.9%) and smoking cessation advice (34.6%, 0%-97.2%) in eligible patients, with high variability across hospitals. High-performing measures included P2Y12 inhibitor at discharge (96.5%, 38.1%-100%), aspirin at arrival (96.3%, 76.1%-100%) and discharge (93.7%, 35.2%-100%), statins at discharge (92.4%, 36.9%-100%) in eligible patients. After excluding transferred patients, reperfusion for STEMI was performed in 61.1% (6.7%-98.1%) of the 21 908 patients admitted directly with STEMI. Primary PCI and fibrinolysis accounted for 97% and 3% of these reperfusions, respectively. Conclusions: The quality of care for patients hospitalized with STEMI is not satisfactory in China, even among tertiary hospitals. Large disparities exist across hospitals and continuous quality improvement projects are warranted. [ABSTRACT FROM AUTHOR]