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Objective To determine if rt-PA intravenous thrombolysis has distinct short-term effects on individuals of different ages with acute ischemic stroke. Methods Seventy acute ischemic stroke patients admitted to Dongcheng Branch of The First Affiliated Hospital of Anhui Medical University from March 2018 to November 2021 were included, and were divided into an eld age group (≥ 70 years old, n = 38) and non-eld age group (< 70 years old, n = 32), and all received standard dose rt-PA intravenous thrombolysis at the time of admission and 2 h, 24 h and 7 d after thrombolysis, respectively. Neurological function was evaluated by National Institutes of Health Stroke Scale (NIHSS) at admission, and 2 h, 24 h and 7 d after thrombolysis. The prognosis was evaluated by modified Rankin Scale (mRS) before and 7 d after thrombolysis. Results There were significant differences in NIHSS (F = 12.555, P = 0.001) and mRS (F = 13.927, P = 0.004) scores before and after thrombolysis in different age groups, in which there was a significant group x time interaction effect in NIHSS score in 2 groups (F = 3.847, P = 0.010), but no interaction for mRS score (F = 0.646, P = 0.424). The NIHSS score after thrombolysis at 2 h (t = 7.506, P = 0.000; t = 6.391, P = 0.000), 24 h (t = 9.982, P = 0.000; t = 6.391, P = 0.000) and 7 d (t = 12.691, P = 0.000; t = 9.942, P = 0.000) were lower than those before thrombolysis in 2 groups, the NIHSS score at 7 d after thrombolysis was also lower than that of 2 h after thrombolysis (t = 5.185, P = 0.000; t = 3.551, P = 0.003) and 24 h after thrombolysis (t = 2.708, P = 0.043; t = 3.551, P = 0.003). The mRS score at 7 d after thrombolysis was also lower than that of before thrombolysis in 2 groups (P = 0.004). At 2 h, 24 h and 7 d after thrombolysis, there was no statistically significant difference in the rate of total effect (NIHSS score improvement rate ≥ 30%) between 2 groups [53.13% (17/32) vs. 47.37% (18/38), χ² = 0.461, P = 0.794; 75% (24/32) vs. 55.26% (21/38), χ² = 2.949, P = 0.229; 81.25% (26/32) vs. 65.79% (25/38), χ² = 3.061, P = 0.216]. The rate of favorable prognosis (mRS score 1-2) at discharge was more significant in the non-eld age group than in the eld age group [87.50% (28/32) vs. 57.89% (22/38); χ² = 6.080, P = 0.014]. There were no fatalities in 2 groups, and the frequency of cutaneous, oral and gingival bleeding within 48 h after thrombolysis in eld age group was more common than in non-eld age group [23.68% (9/38) vs. 6.25% (2/32); χ² = 3.986, P = 0.046]. Conclusions Patients with acute ischemic stroke in different age groups benefited from rt - PA intravenous thrombolysis, and the younger patients saw quicker, more noticeable improvements and fewer adverse effects. [ABSTRACT FROM AUTHOR]

Objective To investigate the predictive value of the National Institutes of Health Stroke Scale (NIHSS) score combined with serum high -sensitivity C -reactive protein (hs-CRP) on admission to ischemic stroke. Methods A total of 487 patients with acute ischemic stroke admitted to the Department of Neurology of Tangshan Gongren Hospital from May 2018 to December 2019 were selected. The clinical data of patients were collected such as gender, age, hypertension, diabetes, coronary heart disease, previous stroke history, smoking and drinking history, serum low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglyceride (TG), hs-CRP, homocysteine (Hcy), fasting blood glucose (FBG). The NIHSS scale was used to evaluate the degree of neurological deficit at admission, and the modified Rankin Scale (mRS) was used to evaluate the prognosis when the patient was discharged. The mRS score ≤ 2 was defined as good prognosis, and the mRS score > 2 was defined as poor prognosis. Univariate and multivariate forward Logistic regression analysis were used to screen risk factors for poor prognosis of ischemic stroke, and the receiver operating characteristic (ROC) curve was used to compare the predictive value of NIHSS and hs-CRP levels at admission alone or in combination for patient prognosis. Results Compared with the good prognosis group, the poor prognosis group had higher proportions of male patients (χ² = 4.729, P = 0.030), previous history of stroke (χ² = 13.665, P = 0.000), and drinking alcohol (χ² = 8.326, P = 0.004). The NIHSS score at admission (Z = -9.316, P = 0.000), serum FBG (Z =-3.234, P = 0.001), Hcy (Z =-3.652, P = 0.000) and hs-CRP (Z =-8.780, P = 0.000) level in poor prognosis group were higher than those in good prognosis group. Logistic regression analysis showed that the NIHSS score increased at admission (OR = 1.316, 95%CI: 1.223-1.417; P = 0.000), and the serum hs-CRP level increased (OR = 1.045, 95%CI: 1.032-1.058; P = 0.000) were risk factors for the prognosis of ischemic stroke. The area under the curve (AUC) predicted by the two combined (AUC = 0.903; 95%CI: 0.873-0.928, P = 0.000) exceeded than that of the NIHSS score at admission alone (AUC = 0.818; 95%CI: 0.781-0.852, P = 0.000) and the serum hs-CRP alone (AUC = 0.806; 95%CI: 0.768-0.840, P = 0.000); pairwise comparison found that the combination of the two was better than the NIHSS score at admission alone (Z = 3.187, P = 0.001) and serum hs-CRP alone (Z = 4.418, P = 0.000). Conclusions NIHSS score and high level of serum hs-CRP at admission are risk factors for poor prognosis of ischemic stroke. Combining NIHSS score and serum hs-CRP can provide an effective reference for clinical prediction of poor prognosis of ischemic stroke. [ABSTRACT FROM AUTHOR]

Objective To analyze the relationship between the preoperative relative blood glucose ratio and the safety of cerebrovascular bypass of ischemic moyamoya disease (MMD) patients. Methods A total of 178 patients with ischemic MMD who were hospitalized in Department of Neurosurgery of Qilu Hospital of Shandong University from December 2016 to December 2019. A total of 186 cases underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass. The fasting blood glucose and glycated albumin of all patients at admission were recorded to calculate the relative blood glucose ratio. After STA-MCA bypass, the incidence of postoperative complications was counted. Univariate and multivariate Logistic regression were used to analyze the risk factors of postoperative complications of ischemic MMD. Results 186 cases were divided into 4 groups based on relative blood glucose ratio, Q1 < 0.404, Q2 0.404-, Q3 0.456-, Q4 ≥ 0.534. The proportion of right surgery side in Q1 group was higher than that in Q3 group (χ² = 4.762, P = 0.029) and Q4 group (χ² = 22.087, P = 0.000), while the proportion of right surgery side in Q2 group (χ² = 16.331, P = 0.000) and Q3 group (χ² = 7.355, P = 0.007) was higher than that in Q4 group. The incidence of mild complications in Q1 group (χ² = 6.389, P = 0.011) and Q2 group (χ² = 4.040, P = 0.044) was higher than that in Q4 group. The incidence of postoperative complications was 28.49% (53/186), of which 8.60% (16/186) were severe type and 19.89% (37/186) were mild type, including transient neurological dysfunction 97.30% (36/37), subdural hemorrhage 2.70% (1/37). Logistic regression analysis showed that the relative blood glucose ratio increased (OR = 1.484, 95%CI: 1.071-2.058; P = 0.018), hypertension (OR = 3.696, 95%CI: 1.805-7.569; P = 0.000), operative interval < 2 months (OR = 2.186, 95%CI: 1.041-4.590; P = 0.039) was risk factors for postoperative complications. Conclusions In order to reduce the incidence of postoperative complications in patients with ischemic MMD, the operation interval after infarction can be extended to 2 months, and the preoperative relative blood glucose ratio should be closely monitored and the perioperative blood pressure should be controlled. [ABSTRACT FROM AUTHOR]

Objective To explore the efficacy and safety of cerebral revascularization treatment for the posterior circulation ischemic stroke with chronic vertebro-basilar artery steno-occlusion. Methods From January 2018 to January 2021, 11 patients with posterior circulation ischemic stroke by chronic vertebro-basilar artery steno-occlusion were diagnosed and treated in Tianjin Huanhu Hospital . We utilized MRI to locate the infarct, CTA to assess the steno-occlusive site and the stenosis rate, and DSA to evaluate the collateral compensation. These patients were treated by using occipital artery (OA)-vertebral artery (VA) bypass, external carotid artery (ECA) -VA bypass with radial artery (RA) graft, OA-posterior inferior cerebellar artery (PICA)/anterior inferior cerebellar artery (AICA) bypass and superficial temporal artery (STA)-posterior cerebral artery (PCA)/superior cerebellar artery (SCA) bypass. The prognosis was assessed through modified Rankin Scale (mRS). Results The steno-occlusive sites confirmed by CTA were located at basilar artery(BA, 2/11), bilateral vertebr-basilar artery as tander lesions (1/11), intracranial and extracranial segments of bilateral VA (2/11 and 11/11), unilateral intracranial segment of VA with contralateral extracranial segment of VA (4/11), initial segment of unilateral VA with tenderness of contralatieral VA (1/11). Collateral patterns confirmed by DSA included posterior communicating artery (PCoA, 7/11), cerebellar pial collateral (5/11; among PICA, AICA and SCA), ascending cervical artery (AA, 4/11), cerebral pial collateral [middle cerebral artery (MCA)-PCA, 3/11] and anterior spinal artery (ASA, 1/ 11). All the 11 patients underwent bypass operation successfully. Imaging [indoleocyanine green angiography (ICGA), DSA and CTA] suggested bypass vascular patency. Two patients suffered lung infection postoperatively, one patient was suspected with intracranial infection, and all the patients got better after antibiotic treatment. The median mRS score was 1. The mean follow-up time was 8 months. Nine patients had good prognosis at discharge (mRS score 0-1), 2 cases had a medial prognosis (mRS score 2-3). Conclusions Cerebral revascularization treatment of chronic symptomatic severe vertebro-basilar artery steno-occlusive with posterior circulation ischemic stroke is effective, safe, and feasible. [ABSTRACT FROM AUTHOR]

Objective To screen the risk factors of bacterial meningitis complicated with ischemic stroke and initially construct a risk prediction nomogram model. Methods A retrospective research analysis was performed for baseline data, clinical characteristics, laboratory or imaging examinations about 176 patients with bacterial meningitis diagnosed and treated in Xijing Hospital, Air Force Military Medical University of Chinese PLA from June 2008 to June 2018. Univariate and multivariate Logistic regression screened the risk factors for bacterial meningitis complicated with ischemic stroke. A prediction nomogram model was established by R software, using receiver operating characteristic (ROC) curve and calibration curve to evaluate the discrimination and calibration of the model. Results Fifteen of the 176 patients with bacterial meningitis complicated with ischemic stroke, the incidence was about 8.52%. Logistic regression analysis showed that age ≥ 55 years (OR = 6.350, 95%CI: 1.750-23.046; P = 0.005), seizures (OR = 5.114, 95%CI: 1.363-19.193; P = 0.016), neurological deficit (OR = 10.409, 95%CI: 2.781-39.480; P = 0.001) and cerebrospinal fluid white blood cell count < 1634 X 106/L (OR = 3.538, 95%CI: 1.014-12.345; P = 0.048) were risk factors for patients with bacterial meningitis complicated with ischemic stroke. The risk prediction nomogram model was constructed based on the above four indicators, and the probability of bacterial meningitis complicated with ischemic stroke was 66.8%. The area under the ROC curve was 0.859 (95%CI: 0.749-0.968, P = 0.001), which indicated that the model had excellent performance. The calibration chart showed that the trend of the model curve and the ideal curve was more consistent, which indicated that the model had better prediction performance. Conclusions Prediction of ischemic stroke in patients with bacterial meningitis has an excellent discrimination and calibration based on the currently constructed nomogram model for the risk. This prediction model contributes to the early detection of ischemic stroke in patients with bacterial meningitis, which has clinical significance to make a further study. [ABSTRACT FROM AUTHOR]

Objective To investigate the efficacy and safety of low dose rt-PA combined with transcranial Doppler ultrasonography (TCD) in the intravenous thrombolysis treatment of acute ischemic stroke. Methods A total of 139 patients with acute ischemic stroke admitted to Anhui No. 2 Provincial People's Hospital from July 2016 to May 2019 were randomly divided into the rt-PA standard dose group (0.90 mg/kg, total dose ≤ 90 mg), low dose group (0.60 mg/kg, total dose ≤ 60 mg) and low dose combined with TCD group (combined treatment group). TCD was used to continuously monitor the blood flow of middle cerebral artery for 2 h at the beginning of thrombolysis in the combined treatment group. TCD was only performed before and 2 h after thrombolysis in the standard dose group and low dose group. Two hours after thrombolysis, the recanalization rates of intracranial vessels in different treatment groups were compared. National Institutes of Health Stroke Scale (NIHSS) score was used to evaluate the severity of clinical symptoms in each group, and the incidence of symptomatic intracranial hemorrhage 24-48 h after thrombolysis was recorded. The self-care ability of 90 d after thrombolytic therapy was evaluated by modified Rankin Scale (mRS), and the mortality rate was calculated. Results The recanalization rate in the combined treatment group were higher than those in the standard dose group (P = 0.037) and low dose group (P = 0.030), and the NIHSS score 2 h after thrombolysis was lower than that in the standard dose group (P = 0.046) and low dose group (P = 0.026); the incidence of symptomatic intracranial hemorrhage (P = 0.017, 0.024) and 90 d mortality (P = 0.005, 0.016) in the low dose group and combined treatment group were lower than those in the standard dose group. Conclusions Low dose rt-PA combined with TCD assisted intravenous thrombolysis can improve the recanalization rate without increasing the risk of symptomatic intracranial hemorrhage and death. [ABSTRACT FROM AUTHOR]

Background: Stroke has become a significant public health issue in China. Although studies have shown that women's age at first live birth (AFLB) might be associated with incident stroke, there is limited evidence on this relationship among Chinese parous women. Likewise, the nature of this association across urban-rural socioeconomic status (SES) has yet to be explored. In this prospective study, we sought to investigate the associations of women's AFLB with the risk of incident stroke and its subtypes (ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage) and to explore the differences of these associations as well as the population-level impacts across SES classes., Methods: We used data on 290 932 Chinese parous women from the China Kadoorie Biobank who were recruited in the baseline survey between 2004 and 2008 and followed up until 2015. We used latent class analysis to identify urban-rural SES classes and Cox proportional hazard regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for AFLB's association with incident stroke. We then calculated population attributable fraction (PAF) to demonstrate the population-level impact of later AFLB on stroke., Results: Around 8.9% of parous women developed stroke after AFLB. Compared with women with AFLB <22 years, those with older AFLB had a higher risk of total stroke, with fully adjusted HRs (95% CI) of 1.71 (95% CI = 1.65-1.77) for 22-24 years and 3.37 (95% CI = 3.24-3.51) for ≥25 years. The associations of AFLB with ischaemic stroke were stronger among rural-low-SES participants. We found the highest PAFs of ischaemic stroke (60.1%; 95% CI = 46.2-70.3) associated with later AFLB for urban-high-SES individuals., Conclusions: Older AFLB was associated with higher risks of incident stroke and its subtypes among Chinese parous women, with stronger associations between AFLB and ischaemic stroke among rural-low-SES participants. Targeted medical advice for pregnant women of different ages could have long-term benefits for stroke prevention., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2024 by the Journal of Global Health. All rights reserved.)

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Background: As stroke has become the leading cause of death and disability in China, it has induced a heavy disease burden on society, families, and patients. Despite much attention within the literature, the effect of multiple risk factors on length of stay (LOS) and inpatient costs in China is still not fully understood., Aim: To analyse the association between the number of risk factors combined and inpatient costs among adults with stroke and explore the mediating effect of LOS on inpatient costs., Methods: A retrospective cross-sectional study was conducted among stroke patients in a tertiary hospital in Nantong City from January 2018 to December 2019. Lifestyle factors (smoking status, exercise), personal disease history (overweight, hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation), family history of stroke, and demographic characteristics were interviewed by trained nurses. Inpatient costs and LOS were extracted from electronic medical records. Hierarchical multiple linear regression models and mediation analysis were used to examine the direct and indirect effects of the number of risk factors combined for stroke on inpatient costs., Results: A total of 620 individuals were included, comprising 391 ischaemic stroke patients and 229 haemorrhagic stroke patients, and the mean age was 63.2 years, with 60.32% being male. The overall mean cost for stroke inpatients was 30730.78 CNY ($ 4444.91), and the average length of stay (LOS) was 12.50 days. Mediation analysis indicated that the greater number of risk factors was not only directly related to higher inpatient costs (direct effect = 0.16, 95%CI:[0.11,0.22]), but also indirectly associated with inpatient cost through longer LOS (indirect effect = 0.08, 95% CI: [0.04,0.11]). Furthermore, patients with high risk of stroke had longer LOS than those in low-risk patients, which in turn led to heavier hospitalization expenses., Conclusions: Both the greater number of risk factors and high-risk rating among stroke patients increased the length of stay and inpatient costs. Preventing and controlling risk behaviors of stroke should be strengthened., (© 2024. The Author(s).)

According to the research progress in recent years, "Chinese guidelines for diagnosis and treatment of acute ischemic stroke 2018" has greatly revised and supplemented the criteria for the diagnosis and treatment of acute ischemic stroke. Based on the new clinical research evidence published in the past four years, this paper interprets the revisions and supplements of the guidelines 2018. [ABSTRACT FROM AUTHOR]

Background: Few large-scale, nationwide studies have assessed cause-specific mortality risks and burdens associated with temperature variability (TV)., Objective: To estimate associations between TV and cause-specific mortality and quantify the mortality burden in China., Methods: Data on daily total and cause-specific mortality in 272 Chinese cities between 2013 and 2015 were recorded. TVs were computed as the standard deviations of daily minimum and maximum temperatures over a duration of 2 to 7 days. The time-series quasi-Poisson regression model with adjustment of the cumulative effects of daily mean temperature over the same duration was applied to evaluate the city-specific associations of TV and mortality. Then, we pooled the effect estimates using a random-effects meta-analysis and calculated the mortality burdens., Results: Overall, TV showed significant and positive associations with total and cause-specific mortality. The TV-mortality associations were generally stronger when using longer durations. A 1 °C increase in TV at 0-7 days (TV 0-7 ) was associated with a 0.79 % [95 % confidence interval (CI): 0.55 %, 0.96 %] increase in total mortality. Mortality fractions attributable to TV 0-7 were 4.37 % for total causes, 4.75 % for overall cardiovascular disease, 4.37 % for coronary heart disease, 5.05 % for stroke, 8.28 % for ischaemic stroke, 1.08 % for haemorrhagic stroke, 6.93 % for respiratory disease, and 6.81 % for COPD, respectively. The mortality risk and burden were generally higher in the temperate monsoon zone, females, and elders., Conclusion: This nationwide study indicated that TV was an independent risk factor of mortality, and could result in significant burden for main cardiorespiratory diseases., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Stroke is characterised by high mortality and disability rate in China. This study aimed to explore the temporal trends in years of life lost (YLL) and loss of life expectancy due to stroke and its subtypes in urban and rural areas in China during 2005-2020. Data were obtained from China National Mortality Surveillance System. Abbreviated life and stroke-eliminated life tables were generated to calculate loss of life expectancy. The YLL and loss of life expectancy due to stroke in urban and rural areas at both national and provincial level during 2005-2020 were estimated. In China, the age-standardised YLL rate due to stroke and its subtypes were higher in rural areas than in urban areas. The YLL rate due to stroke showed a downward trend in both urban and rural residents from 2005 to 2020, decreased by 39.9% and 21.5%, respectively. Loss of life expectancy caused by stroke decreased from 1.75 years to 1.70 years from 2005 to 2020. During which, loss of life expectancy due to intracerebral haemorrhage (ICH) decreased from 0.94 years to 0.65 years, while that of ischaemic stroke (IS) increased from 0.62 years to 0.86 years. A slightly upward trend was observed in loss of life expectancy caused by subarachnoid haemorrhage (SAH), from 0.05 years to 0.06 years. Loss of life expectancy due to ICH and SAH was always higher in rural areas than in urban areas, whereas that of IS was higher in urban areas than in rural areas. Rural males suffered the greatest loss of life expectancy due to ICH and SAH, while the highest loss of life expectancy caused by IS was found in urban females. Furthermore, Heilongjiang (2.25 years), Tibet (2.17 years) and Jilin (2.16 years) were found to have the highest loss of life expectancy caused by stroke in 2020. Loss of life expectancy caused by ICH and SAH was higher in western China, while the disease burden of IS was heavier in northeast China. Stroke remains a major public health problem in China, although the age-standardised YLL rate and loss of life expectancy due to stroke decreased. Evidence-based strategies should be conducted to reduce the premature death burden caused by stroke and prolong life expectancy in Chinese population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Stroke is the most common cerebrovascular disease worldwide, which seriously affects life quality of survivals and results in huge economic burden of families and society. In terms of clinical treatment for ischemic stroke, apart from thrombolytic therapy with recombinant tissue - type plasminogen activator (rt - PA), the occurrence and successful application of endovascular thrombectomy in patients of ischemic stroke is a major breakthrough. Meanwhile, many novel clinical drugs for ischemic stroke therapy have entered into clinical trials. Most of basic and clinical researches have showed promising results in ischemic stroke therapy. This review mainly summarizes the progress of research during the period of Twelfth Five - Year Plan for National Economic and Social Development on treatment of ischemic stroke, including omics technologies, gene therapy, microRNA (miRNA) interference and stem cell therapy. Stem cell therapy has shown great potential since many clinical trials have been completed or are ongoing. The development and mutual transformation of basic and clinical research will provide valuable and comprehensive information for the precise treatment of ischemic stroke. [ABSTRACT FROM AUTHOR]

Stroke has become the leading common cause of disability and the second most common cause of death in China. Endovascular treatment emerged in recent years as a promising treatment method with a higher recanalization rate and better functional outcome in patients with acute ischemic stroke caused by large vessel occlusion. This paper selected 4 high - quality retrospective studies by Chinese scholars regarding endovascular treatment in patients with acute ischemic stroke, which were published in foreign journals during past 3 years, and focused on study methods and results. [ABSTRACT FROM AUTHOR]

Background: There is a growing body of research evidence to guide acute stroke care. Receiving care in a stroke unit improves access to recommended evidence-based therapies and patient outcomes. However, even in stroke units, evidence-based recommendations are inconsistently delivered by healthcare workers to patients with stroke. Implementation interventions are strategies designed to improve the delivery of evidence-based care., Objectives: To assess the effects of implementation interventions (compared to no intervention or another implementation intervention) on adherence to evidence-based recommendations by health professionals working in acute stroke units. Secondary objectives were to assess factors that may modify the effect of these interventions, and to determine if single or multifaceted strategies are more effective in increasing adherence with evidence-based recommendations., Search Methods: We searched CENTRAL, MEDLINE, Embase, CINAHL, Joanna Briggs Institute and ProQuest databases to 13 April 2022. We searched the grey literature and trial registries and reviewed reference lists of all included studies, relevant systematic reviews and primary studies; contacted corresponding authors of relevant studies and conducted forward citation searching of the included studies. There were no restrictions on language and publication date., Selection Criteria: We included randomised trials and cluster-randomised trials. Participants were health professionals providing care to patients in acute stroke units; implementation interventions (i.e. strategies to improve delivery of evidence-based care) were compared to no intervention or another implementation intervention. We included studies only if they reported on our primary outcome which was quality of care, as measured by adherence to evidence-based recommendations, in order to address the review aim., Data Collection and Analysis: Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias and certainty of evidence using GRADE. We compared single implementation interventions to no intervention, multifaceted implementation interventions to no intervention, multifaceted implementation interventions compared to single implementation interventions and multifaceted implementation interventions to another multifaceted intervention. Our primary outcome was adherence to evidence-based recommendations., Main Results: We included seven cluster-randomised trials with 42,489 patient participants from 129 hospitals, conducted in Australia, the UK, China, and the Netherlands. Health professional participants (numbers not specified) included nursing, medical and allied health professionals. Interventions in all studies included implementation strategies targeting healthcare workers; three studies included delivery arrangements, no studies used financial arrangements or governance arrangements. Five trials compared a multifaceted implementation intervention to no intervention, two trials compared one multifaceted implementation intervention to another multifaceted implementation intervention. No included studies compared a single implementation intervention to no intervention or to a multifaceted implementation intervention. Quality of care outcomes (proportions of patients receiving evidence-based care) were included in all included studies. All studies had low risks of selection bias and reporting bias, but high risk of performance bias. Three studies had high risks of bias from non-blinding of outcome assessors or due to analyses used. We are uncertain whether a multifaceted implementation intervention leads to any change in adherence to evidence-based recommendations compared with no intervention (risk ratio (RR) 1.73; 95% confidence interval (CI) 0.83 to 3.61; 4 trials; 76 clusters; 2144 participants, I 2 =92%, very low-certainty evidence). Looking at two specific processes of care, multifaceted implementation interventions compared to no intervention probably lead to little or no difference in the proportion of patients with ischaemic stroke who received thrombolysis (RR 1.14, 95% CI 0.94 to 1.37, 2 trials; 32 clusters; 1228 participants, moderate-certainty evidence), but probably do increase the proportion of patients who receive a swallow screen within 24 hours of admission (RR 6.76, 95% CI 4.44 to 10.76; 1 trial; 19 clusters; 1,804 participants; moderate-certainty evidence). Multifaceted implementation interventions probably make little or no difference in reducing the risk of death, disability or dependency compared to no intervention (RR 0.93, 95% CI 0.85 to 1.02; 3 trials; 51 clusters ; 1228 participants; moderate-certainty evidence), and probably make little or no difference to hospital length of stay compared with no intervention (difference in absolute change 1.5 days; 95% CI -0.5 to 3.5; 1 trial; 19 clusters; 1804 participants; moderate-certainty evidence). We do not know if a multifaceted implementation intervention compared to no intervention result in changes to resource use or health professionals' knowledge because no included studies collected these outcomes., Authors' Conclusions: We are uncertain whether a multifaceted implementation intervention compared to no intervention improves adherence to evidence-based recommendations in acute stroke settings, because the certainty of evidence is very low., (Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Aims: Publicized adverse events after vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) raised concern among patients with coronary atherosclerosis disease (CAD). We sought to study the association between SARS-CoV-2 vaccines and long-term clinical outcomes including ischaemic and bleeding events among patients with CAD., Methods and Results: Inpatients diagnosed with CAD by coronary angiography, without a history of SARS-CoV-2 infection and vaccination, were included between 1 January and 30 April 2021, and underwent follow-up until 31 January 2022. Two doses of inactivated whole-virion SARS-CoV-2 vaccine (CoronaVac, BBIBPCorV, or WIBP-CorV) were available after discharge, and the group was stratified by vaccination. The primary composite outcomes were cardiovascular death, non-fatal myocardial infarction, stent thrombosis, unplanned revascularization, ischaemic stroke, venous thrombo-embolism, or peripheral arterial thrombosis. The bleeding outcomes were Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding. Cox regression models with vaccination status as a time-dependent covariate were used to calculate the hazard ratio (HR) for the outcomes. A propensity score matching method was used to reduce confounding biases. This prospective cohort study included 2078 individuals with CAD, 1021 (49.1%) were vaccinated. During a median follow-up of 9.1 months, 45 (4.3%) primary composite outcomes occurred in the unvaccinated group, and 33 (3.2%) in the vaccinated group. In Cox regression, the adjusted HR was 1.13 [95% confidence interval (CI) 0.65-1.93]. The adjusted HR for the bleeding outcomes associated with vaccination was 0.81 [95% CI 0.35-1.19]. After matching, the adjusted HR for the primary composite outcomes associated with vaccination was 1.06 [95% CI 0.57-1.99] and for the bleeding outcomes was 0.91 [95% CI 0.35-2.38]. Similar results were found in the seven prespecified subgroups. No grade 3 adverse reactions after vaccination were recorded., Conclusion: Our results indicated no evidence of an increased ischaemic or bleeding risk after vaccination with inactivated SARS-CoV-2 vaccine among Chinese patients with CAD, with limited statistical power., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: The aims of the study were to assess the management of low-density lipoprotein cholesterol (LDL-C) and the goal achievement, as well as to investigate the association between baseline LDL-C level, lipid-lowering treatment (LLT), and stroke recurrence in patients with ischaemic stroke or transient ischaemic attack (TIA)., Design: Our study was a post hoc analysis of the Third China National Stroke Registry (CNSR-III)., Setting: We derived data from the CNSR-III - a nationwide clinical registry of ischaemic stroke and TIA based on 201 participating hospitals in mainland China., Participants: 15,166 patients were included in this study with demographic characteristics, etiology, imaging, and biological markers from August 2015 to March 2018., Primary and Secondary Outcome Measures: The primary outcome was a new stroke, LDL-C goal (LDL-C<1.8mmol/L and LDL-C<1.4mmol/L, respectively) achievement rates, and LLT compliance within 3, 6, and 12 months. The secondary outcomes included major adverse cardiovascular events (MACE) and all caused death at 3 and 12 months., Results: Among the 15,166 patients, over 90% of patients received LLT during hospitalization and 2 weeks after discharge; the LLT compliance was 84.5% at 3 months, 75.6% at 6 months, and 64.8% at 12 months. At 12 months, LDL-C goal achievement rate for 1.8mmol/L and 1.4mmol/L was 35.4% and 17.6%, respectively. LLT at discharge was associated with reduced risk of ischemic stroke recurrence (HR=0.69, 95% CI: 0.48-0.99, p=0.04) at 3 months. The rate of LDL-C reduction from baseline to 3-month follow-up was not associated with a reduced risk of stroke recurrence or major adverse cardiovascular events (MACE) at 12 months. Patients with baseline LDL-C ≤1.4mmol/L had a numerically lower risk of stroke, ischemic stroke and MACE at both 3 months and 12 months., Conclusions: The LDL-C goal achievement rate has increased mildly in the stroke and TIA population in mainland China. Lowered baseline LDL-C level was significantly associated with a decreased short- and long-term risk of ischemic stroke among stroke and TIA patients. LDL-C<1.4mmol/L might be a safe standard for this population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED) showed that a low-dose alteplase was safe but not clearly non-inferior to standard-dose alteplase in acute ischemic stroke (AIS). Given the significant cost of this medicine, we undertook a cost-effectiveness analysis to determine the probability that low-dose is cost-effective relative to standard-dose alteplase in China., Methods: For ENCHANTED participants in China with available health cost data, cost-effectiveness and cost-utility analyses were undertaken in which death or disability (modified Rankin scale scores 2-6) at 90 days and quality-adjusted life-years (QALYs) were used as outcome measures, respectively. There was adherence to standard guidelines for health economic evaluations alongside non-inferiority trials and according to a health-care payer's perspective. The equivalence margin for cost and effectiveness was set at USD 691 and -0.025 QALYs, respectively, for the base-case analysis. Probabilistic sensitivity analyses were used to evaluate the probability of low-dose alteplase being non-inferior., Results: While the mean cost of alteplase was lower in the low-dose group (USD 1,569 vs. USD 2,154 in the standard-dose group), the total cost was USD 56 (95% confidence interval [CI]: -1,000-1,113) higher compared to the standard-dose group due to higher hospitalization costs in the low-dose group. There were 462 (95% CI: 415-509) and 410 (95% CI: 363-457) patients with death or disability per 1,000 patients in the low-dose and standard-dose groups, respectively. The low-dose group had marginally lower (0.008, 95% CI: -0.016-0.001) QALYs compared to their standard-dose counterparts. The low-dose group was found to have an 88% probability of being non-inferior based on cost-effectiveness versus the standard-dose group., Conclusions: This health economic evaluation alongside the ENCHANTED indicates that the use of low-dose alteplase does not save overall healthcare costs nor lead to a gain in QALYs in the management of Chinese patients with AIS compared to the use of standard dose. There is little justification on economic grounds to shift from standard-of-care thrombolysis in AIS., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Background: Temporal trends and geographical variations in cardiovascular disease attributable to high systolic blood pressure in China are not yet fully understood. The aim of this study was to quantify the cardiovascular disease burden attributable to high systolic blood pressure at national and provincial levels in China., Methods: In this population-based study, we evaluated systolic blood pressure and estimated the number of deaths, age-standardised mortality rates, and years of life lost (YLLs) due to cardiovascular disease and its subcategories (including ischaemic heart disease, ischaemic stroke, haemorrhagic stroke, and other cardiovascular diseases) attributable to high systolic blood pressure, at the national level and by 31 provincial levels, in China, from 2005 to 2018. We pooled blood pressure data of 1·30 million adults aged 25 years and older from the China Chronic Disease and Risk Factor Surveillance project, the China National Nutrition Survey, and the China Hypertension Survey. We applied a temporal-spatial Bayesian hierarchical model to estimate age-specific, sex-specific, province-specific, and year-specific average systolic blood pressure, and a comparative risk assessment method to compute the cardiovascular disease burden attributable to high systolic blood pressure by age, sex, year, and province., Findings: Nationally, age-standardised mean systolic blood pressure was 132·5 mm Hg (95% uncertainty interval [UI] 124·6-140·3) in men and 129·4 mm Hg (121·7 to 137·2) in women. 2·67 million (95% UI 2·61 to 2·72) cardiovascular disease deaths in China were attributable to high systolic blood pressure, including 1·12 million deaths (1·07 to 1·16) due to ischaemic heart disease, 0·63 million deaths (0·60 to 0·65) due to ischaemic stroke, 0·58 million deaths (0·57 to 0·60) due to haemorrhagic stroke, and 0·34 million deaths (0·32 to 0·36) due to other cardiovascular disease. The age-standardised cardiovascular disease mortality rates associated with high systolic blood pressure were 268·99 per 100 000 people (95% UI 264·11 to 273·51) in 2005 and 220·84 per 100 000 people (216·30 to 224·76) in 2018, a percentage change of -17·90%; the rate changed by an average of -1·50% (95% UI -1·55% to -1·45%) per year from 2005 to 2018 nationally. YLL rates for total cardiovascular disease caused by high systolic blood pressure varied substantially across provinces, ranging from 3078·33 (95% UI 2807·40 to 3303·57) per 100 000 people in Beijing to 7189·98 (95% UI 6817·18 to 7507·99) per 100 000 people in Heilongjiang in 2018. Age-standardised YLL rates for ischaemic heart disease and ischaemic stroke attributable to high systolic blood pressure were particularly high in northeastern provinces, including Heilongjiang, Liaoning, and Jilin., Interpretation: The deaths and YLLs for cardiovascular disease attributable to high systolic blood pressure in China increased between 2005 and 2018, and age-standardised cardiovascular disease mortality rates decreased in the same timeframe. Our findings could help policy makers in promoting blood pressure control measures and implementing effective and locally adapted preventive interventions to reduce the prevalence of high systolic blood pressure and reduce the burden of systolic blood pressure-related cardiovascular disease in China., Funding: China National Key Research and Development Program, China National Science & Technology Pillar Program, and National Health Commission of the People's Republic of China., Translation: For the Chinese translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Anxiety might be a potentially modifiable risk factor of cardiovascular diseases (CVDs). Evidence relating anxiety symptoms and generalized anxiety disorder (GAD) to CVDs from prospective cohort study was still lacking in China., Methods: Participants aged 30 to 79 years old from 10 areas across China were recruited during 2004-2008 and were followed up until 2017. 487,209 participants without CVDs at baseline remained for analyses. Anxiety symptoms (panic attacks and continuous anxiety) during the past 12 months were identified in a face-to-face interview. Participants with continuous anxiety were further assessed for GAD using Composite International Diagnostic Interview-Short Form. The primary outcomes were incident CVD, ischaemic heart disease (IHD), haemorrhagic stroke (HS), and ischaemic stroke (IS)., Results: During 4.7 million person-years of follow-up, we documented 140,365 incident cases of CVD. For panic attacks, the multivariable-adjusted HRs (95 % CI) were 1.08 (1.04-1.13), 1.10 (1.02-1.19), 1.20 (1.05-1.38) and 1.20 (1.11-1.30) for CVD, IHD, HS and IS, respectively. Continuous anxiety was positively associated with incident CVD and IHD, and the corresponding HRs were 1.12 (1.04-1.20) and 1.21 (1.07-1.37)., Limitations: Anxiety symptoms were examined according to self-reported questionnaires, which could constitute key study limitations., Conclusions: Among the Chinese adults, those with anxiety symptoms or GAD might be important at-risk population of CVD., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background and Purpose: Low-income and middle-income countries have the greatest stroke burden, yet remain understudied. This study compared the utility of Framingham versus novel risk scores for prediction of total stroke and stroke types in Chinese adults., Methods: China Kadoorie Biobank (CKB) is a prospective study of 512 726 adults, aged 30-79 years, recruited from 10 areas in China in 2004-2008. By 1 January 2018, 43 234 incident first stroke cases (36 310 ischaemic stroke (IS); 8865 haemorrhagic stroke (HS)) were recorded in 503 842 participants with no history of stroke at baseline. We compared the predictive utility of the Framingham Stroke Risk Profile (FSRP) with novel CKB stroke risk scores and included recalibration, refitting, stratifying by study area and addition of other risk factors. Discrimination was assessed using area under the receiver operating characteristic curve (AUC) and calibration was assessed using Greenwood-Nam-D'Agostino χ 2 statistics., Results: Incidence of total stroke varied fivefold by area in China. The FSRP had good discrimination for total stroke (AUC (95% CI); men: 0.78 (0.77 to 0.79), women: 0.77 (95% CI 0.76 to 0.78)), but poor calibration (χ 2 ; men: 1,825, women: 3,053), substantially underestimating absolute risks. Recalibration reduced χ 2 by >80%, but did not improve discrimination. Refitting the FSRP did not materially improve discrimination, but further improved calibration. Stratification by area improved discrimination (AUC; men: 0.82 (0.82 to 0.83); women: 0.82 (0.82 to 0.83)), but not calibration. Adding other risk factors yielded modest, but statistically significant, improvements in the AUCs. The findings for IS and HS were similar to those for total stroke., Conclusions: The FSRP reliably differentiated Chinese adults with incident stroke, but substantially underestimated the absolute risks of stroke. Novel local risk prediction equations that took account of differences in stroke incidence within China enhanced risk prediction of total stroke and major stroke pathological types., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Stroke incidence and case-fatality in Mainland China, Hong Kong, and Macao vary by geographic region and rates often differ across and within regions. This systematic review and meta-analysis (SR) estimated the pooled incidence and short-term case-fatality of acute first ever stroke in mainland China, Hong Kong, and Macao., Methods: Longitudinal studies published in English or Chinese after 1990 were searched in PubMed/Medline, EMBASE, CINAHL, Web of Science, SinoMed and CQVIP. The incidence was expressed as Poisson means estimated as the number of events divided by time at risk. Random effect models calculated the pooled incidence and pooled case-fatality. Chi-squared trend tests evaluated change in the estimates over time. When possible, age standardised rates were calculated. Percent of variation across studies that was due to heterogeneity rather than chance was tested using the I2 statistic.The effect of covariates on heterogeneity was investigated using meta-regressions. Publication bias was tested using funnel plots and Egger's tests., Results: Overall, 72 studies were included. The pooled incidences of total stroke (TS), ischaemic stroke (IS) and haemorrhagic stroke (HS) were 468.9 (95% confidence interval (CI): 163.33-1346.11), 366.79 (95% CI: 129.66-1037.64) and 106.67 (95% CI: 55.96-203.33) per 100,000 person-years, respectively, varied according to the four economic regions (East Coast, Central China, Northeast and Western China) with the lowest rates detected in the East Coast. Increased trends over time in the incidence of TS and IS were observed (p<0.001 in both). One-month and three-to-twelve-month case-fatalities were 0.11 (95% CI: 0.04-0.18) and 0.15 (95% CI: 0.12-0.17), respectively for IS; and 0.36 (95% CI: 0.26-0.45) and 0.25 (95% CI: 0.18-0.32), respectively for HS. One-month case-fatality of IS and HS decreased over time for both (p<0.001). Three-to-twelve-month fatalities following IS increased over time (p<0.001). Publication bias was not found., Conclusions: Regional differences in stroke incidence were observed with the highest rates detected in less developed regions. Although 1-month fatality following IS is decreasing, the increased trends in 3-12-month fatality may suggest an inappropriate long-term management following index hospital discharge., Registration: Registration-URL: https://www.crd.york.ac.uk/prospero/; Reference code: CRD42020170724., Competing Interests: The authors have declared that no competing interests exist.

Dysglycemia are involved in the development of functional impairment after acute ischemic stroke (AIS). The aim of the study was to evaluate the association between acute glycemic variability and functional outcome in patients with AIS. Cohort studies were obtained by search Medline, Web of Science, Embase, Wanfang, and China National Knowledge Infrastructure databases from inception to November, 2021. A random-effect model which incorporates the intra-study heterogeneity was chosen to pool the results. Ten cohort studies including 3038 patients were included, and 1319 (43.4%) had poor functional outcome (modified Rankin Scale >2) up to three months after disease onset. Pooled results showed that higher acute GV was associated with an increased risk of poor functional outcome, as evidenced by GV evaluated by the standard deviation of blood glucose (SDBG, OR: 1.91, 95% CI: 1.38 to 2.65, I2=60%, p<0.001), the coefficient of variation of blood glucose (OR: 2.03, 95% CI: 1.15 to 3.58, I2=17%, p=0.02), the range of glucose (OR: 1.43, 95% CI: 1.11 to 1.83, I2=22%, p=0.005), and the mean amplitude of glycemic excursion (OR: 1.59, 95% CI: 1.10 to 2.31, I2=0%, p=0.01). Subgroup analyses did not support that difference in study design, treatments for AIS, mean age of the patients, duration for GV measuring, or study quality would significantly affect the association between SDBG and functional outcome after AIS. In conclusion, higher acute glycemic variability may predict poor functional outcome within 3 months after AIS., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Abstract: Intravenous tissue plasminogen activator (tPA) at 0.9mg/kg improves outcome in acute ischemic stroke. The dose response to tPA may be different in Chinese patients compared with Western populations, but this has not been systematically examined. We aimed to compare the efficacy and safety of different doses of tPA in Chinese stroke patients. We included all acute ischemic stroke patients treated with tPA within 4.5 hours of onset. Patients were treated with three dose regimens of tPA (0.6–0.7mg/kg, 0.8mg/kg, 0.9mg/kg). The following data were collected: patient demographics; vascular risk factors; neuroimaging results; time of tPA administration; clinical assessment before treatment, at 24 hours and 3months; and modified Rankin Scale (mRS) score at 3months. A total of 105 patients with stroke of Han Chinese origin were included in the study. The baseline characteristics of the three dose groups were well matched. In the 0.9mg/kg group (n =51), 51.1% had favorable outcome at 3months, compared with 38.7% of patients in the 0.8mg/kg group (n =31) (odds ratio [OR] to 0.9mg/kg group, 0.57; 95% CI, 0.19–1.73; p =0.32) and 34.8% in the 0.6–0.7mg/kg group (n =23) (OR to 0.9mg/kg group, 0.31; 95% CI, 0.08–1.16; p =0.08). There were no statistically significant differences in the incidence of symptomatic intracerebral hemorrhage and mortality rate. There was a higher proportion of patients with good functional outcomes in the 0.9mg/kg group. Although not significant, these results strongly support the feasibility and urgent need for a dose ranging trial to establish an optimal tPA dose in Chinese stroke patients. [Copyright &y& Elsevier]

Objectives: To compare hospital treatments for major stroke types in Chinese adults by stroke pathological types, sex, age, calendar year, hospital tier, region and other factors., Design: Cross-sectional analysis of medical records retrieved from 20 229 stroke cases in the China Kadoorie Biobank., Setting: Ten diverse areas (five urban, five rural) in China., Participants: First-incident stroke cases who were recruited during an 11-year follow-up of 0.5M participants in the China Kadoorie Biobank., Methods: Electronic copies of medical records of stroke cases were retrieved for clinical adjudication by local neurologists. Stroke cases were classified as ischaemic stroke (IS) (including lacunar infarction (LACI) and non-LACI (non-LACI)), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH) and unspecified stroke types., Results: Among 20 299 first-ever stroke cases, 17 306 (85%) had IS, 7123 had non-LACI, 6690 had LACI, 3493 had silent LACI, 2623 (13%) had ICH and 370 (2%) had SAH. Among IS cases, antiplatelet treatment was used by 64% (65% non-LACI, 66% LACI, 56% silent LACI), lipid-lowering by 50% (52% non-LACI, 53% LACI, 43% silent LACI) and blood pressure-lowering by ~42% of all IS types, with positive trends in the use of these treatments by calendar year and hospital tier. Among ICH cases, 53% used blood pressure-lowering and 10% used lipid-lowering treatments, respectively. In contrast, traditional Chinese medicines (TCMs) were used by 59% of IS (50% non-LACI, 62% LACI, 74% silent LACI), 38% of ICH and 30% of SAH cases, with positive trends by calendar year and by hospital tier., Conclusions: Among IS cases, use of antiplatelet and lipid-lowering medications increased in recent years, but use of TCM still exceeded use of blood pressure-lowering treatment. In contrast, blood pressure-lowering treatment was widely used for ICH, but only half of all ICH cases used blood pressure-lowering treatment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Acute respiratory infections have been associated with a transient increase in cardiovascular risk. However, whether such an association persists beyond 1 month and the potential modifying effect of cardiovascular risk factors on such an association are less well established., Methods: The China Kadoorie Biobank enrolled 512 726 participants aged 30-79 years from 10 areas across China during 2004-2008. By the end of 2017, a total of 5444 participants with new-onset ischaemic heart disease (IHD) and 4846 with ischaemic stroke (IS) who also had at least a record of hospitalization for pneumonia during follow-up were included. We used a self-controlled case-series method and calculated the age- and season-adjusted relative incidences (RIs) and 95% confidence intervals (CIs) for ischaemic cardiovascular disease (CVD) after pneumonia., Results: The risk of ischaemic CVD increased during days 1-3 after pneumonia hospitalization, with an RI (95% CI) of 4.24 (2.92-6.15) for IHD and 1.85 (1.02-3.35) for IS. The risk gradually reduced with longer duration since pneumonia hospitalization but remained elevated until days 92-365 for IHD (1.23, 1.12-1.35) and days 29-91 for IS (1.25, 1.05-1.48). Pre-existing cardiovascular risk factors amplified the associations between pneumonia and ischaemic CVD risks, such as chronic obstructive pulmonary disease for both IHD and IS, and diabetes and smoking for IHD (all Pinteraction < 0.05). Besides, the risk of ischaemic CVD was also higher among the participants aged ≥70 years (Pinteraction < 0.001 for IHD and 0.033 for IS)., Conclusion: Among middle-aged and older Chinese adults, pneumonia hospitalization was associated with both short- and long-term increases in ischaemic CVD risk for ≤1 year., (© The Author(s) 2021; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Objective: To explore the relationship between body mass index (BMI), waist circumference (WC) and the risk for ischemic stroke in adults in China. Methods: A total of 36 632 adults were selected from 60 surveillance areas (25 urban surveillance areas and 35 rural surveillance areas) in China Chronic Disease Surveillance Project in 2010 for a follow up study from 2016 to 2017 based on the baseline data in 2010. The follow up was completed for 27 762 adults. Cox proportional hazard regression model was used to analyze the association of body mass index and waist circumference with the risk for ischemic stroke in different populations. The death and hypercholesterolemia cases were excluded by sensitivity analysis. Results: A total of 26 907 adults were included in the analysis. During the follow up period, 1 128 ischemic stroke events were observed (491 in men and 637 in women). After adjusting the related confounding factors and taking normal BMI/normal WC group as the reference, the risk for ischemic stroke increased by 50% in normal BMI/abdominal obesity group ( HR =1.50, 95% CI :1.07-2.08), 51% in overweight/abdominal obesity group ( HR =1.51, 95% CI :1.20-1.91), 46% in obesity/abdominal obesity group ( HR =1.46, 95% CI :1.09-1.96), and 63% in normal BMI/abdominal obesity group ( HR =1.63, 95% CI :1.12-2.38), 56% in overweight/abdominal obesity group ( HR =1.56, 95% CI : 1.20-2.03) and 45% in obesity/abdominal obesity group ( HR =1.45, 95% CI : 1.05-2.01) respectively in men and in men with CVD risk factors. There was no increased risks in the overweight/normal WC group. The risk increased by 40% in overweight/abdominal obesity group ( HR =1.40, 95% CI :1.15-1.72) and 46% in obesity/abdominal obesity group ( HR =1.46, 95% CI :1.16-1.83), and 35% in overweight/abdominal obesity group ( HR =1.35, 95% CI :1.08-1.69) and 30% in obesity/abdominal obesity group ( HR =1.30, 95% CI :1.01-1.67) respectively in women and women with CVD risk factors. There were no risk increases in overweight/normal WC group and normal BMI/abdominal obesity group. Sensitivity analysis results showed no change. Conclusion: Overweight/obesity with abdominal obesity or abdominal obesity alone could increase the risk for stroke in men, and overweight/obesity with abdominal obesity could increase the risk for ischemic stroke in women; suggesting that BMI and WC should be used jointly to evaluate obesity in population for weight control to prevent ischemic stroke.

Aims: The potential difference in the impacts of lifestyle factors (LFs) on progression from healthy to first cardiometabolic disease (FCMD), subsequently to cardiometabolic multimorbidity (CMM), and further to death is unclear., Methods and Results: We used data from the China Kadoorie Biobank of 461 047 adults aged 30-79 free of heart disease, stroke, and diabetes at baseline. Cardiometabolic multimorbidity was defined as the coexistence of two or three CMDs, including ischaemic heart disease (IHD), stroke, and type 2 diabetes (T2D). We used multi-state model to analyse the impacts of high-risk LFs (current smoking or quitting because of illness, current excessive alcohol drinking or quitting, poor diet, physical inactivity, and unhealthy body shape) on the progression of CMD. During a median follow-up of 11.2 years, 87 687 participants developed at least one CMD, 14 164 developed CMM, and 17 541 died afterwards. Five high-risk LFs played crucial but different roles in all transitions from healthy to FCMD, to CMM, and then to death. The hazard ratios (95% confidence intervals) per one-factor increase were 1.20 (1.19, 1.21) and 1.14 (1.11, 1.16) for transitions from healthy to FCMD, and from FCMD to CMM, and 1.21 (1.19, 1.23), 1.12 (1.10, 1.15), and 1.10 (1.06, 1.15) for mortality risk from healthy, FCMD, and CMM, respectively. When we further divided FCMDs into IHD, ischaemic stroke, haemorrhagic stroke, and T2D, we found that LFs played different roles in disease-specific transitions even within the same transition stage., Conclusion: Assuming causality exists, our findings emphasize the significance of integrating comprehensive lifestyle interventions into both health management and CMD management., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The effect of the overall diet quality on cardiometabolic diseases has been well studied in the Western population. However, evidence is still in need regarding dietary patterns depicting unique Chinese dietary habits and their associations with cardiometabolic diseases., Methods: A prospective cohort recruited around 0.5 million Chinese residents aged 30-79 years from 10 diverse survey sites during 2004-08. Dietary patterns were obtained using factor analysis based on the habitual consumption of 12 food groups collected at baseline. Among 477,465 eligible participants free of prior heart disease, stroke and cancer, linkages to multiple registries and health insurance database recorded 137,715 cardiovascular diseases (CVD) and 17,412 diabetes cases (among 451,846 non-diabetic participants) until 31 December 2017. Adjusted hazard ratios (HRs) were estimated to compare the risks of cardiometabolic diseases across quintiles of dietary pattern scores using the Cox regression., Results: Two dietary patterns were derived: the traditional northern pattern, characterised by wheat, other staples, egg and dairy products; and the modern pattern, featured with fresh fruit, meat, poultry, fish, dairy products and soybean. Adherence to either dietary pattern was associated with lower risks of major cardiometabolic diseases in a dose-response relationship way. After multivariate adjustment, participants adhering to the traditional northern pattern the most had an 8% (95%CI: 5-11%) lower risk of CVD in comparison with those adhering the least. Corresponding risk reductions were 12% (11-32%) for haemorrhagic stroke (HS), 14% (8-19%) for ischaemic stroke (IS), and 15% (6-24%) for diabetes, respectively. When comparing extreme quintiles of the modern pattern, the adjusted HR of HS was 0.67 (95%CI: 0.59-0.77). Corresponding HRs were 0.89 (0.86-0.92) for CVD, 0.88 (0.77-0.99) for MCE, 0.85 (0.80-0.89) for IS, and 0.89 (0.81, 0.97) for diabetes., Conclusion: Among Chinese adults, both traditional northern and modern dietary patterns were associated with lower risks of cardiovascular disease and diabetes beyond other risk factors., (© 2021. The Author(s).)

Objectives: Diabetes mellitus has been associated with stroke. However, the association between fasting blood glucose (FBG) and stroke risk in a general population remains not clear. The purpose of our study was to examine the FBG levels on subsequent stroke risk in a community-based cohort in China., Design: Prospective cohort study, employing Cox proportional hazard model to analyse the association of FBG levels with stroke risk., Setting: A community-based cohort study included adults participating in a baseline survey conducted in 2013 in Changshu, eastern China., Participants: 16 113 participants were recruited with a multistage sampling method, excluding participants with severe disability, severe cancer, severe psychiatric disturbance or previous stroke before enrolment., Primary Outcome Measures: Stroke events., Results: During a median follow-up of 5.5 years, 417 incident cases of stroke were identified. The adjusted HR for total and ischaemic stroke for participants in the fourth quartile of FBG compared with the first quartile was 1.44 (95% CI 1.07 to 1.94) and 1.57 (95% CI 1.11 to 2.21), respectively. FBG levels of ≥7.0 mmol/L were associated with an increased risk of stroke based on two clinical classifications (American Diabetes Association: 1.68 (1.24 to 2.27); WHO: 1.62 (1.21, 2.13)). In stratified analyses, risk associations existed in women (HR: 1.92, 95% CI 1.22 to 3.01) and postmenopausal women (HR: 1.68, 95% CI 1.06 to 2.68) for the fourth quartile versus the first. More importantly, the meta-analysis observed a positive association between FBG levels and stroke risk (pooled HR: 1.70, 95% CI 1.27 to 2.29; n=7))., Conclusions: Higher FBG level was independently associated with an increased risk of stroke in Chinese adults, especially significant in women., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: Identifying risks of stroke-associated pneumonia (SAP) is important for clinical management. We aimed to evaluate the association between gut microbiome composition and SAP in patients with acute ischemic stroke (AIS)., Methods: A prospective observational study was conducted, and 188 AIS patients were enrolled as the training cohort. Fecal and serum samples were collected at admission. SAP was diagnosed by specialized physicians, and disease severity scores were recorded. Fecal samples were subjected to 16S rRNA V4 tag sequencing and analysed with QIIME and LEfSe. Associations between the most relevant taxa and SAP were analysed and validated with an independent cohort. Fecal short-chain fatty acid (SCFA), serum D-lactate (D-LA), intestinal fatty acid-binding protein (iFABP) and lipopolysaccharide binding protein (LBP) levels were measured., Results: Overall, 52 patients (27.7%) had SAP in the training cohort. The gut microbiome differed between SAP and non-SAP patients; specifically, Roseburia depletion and opportunistic pathogen enrichment were noted in SAP patients, as confirmed in the validation cohort (n=144, 28 SAP [19.4%]). Based on multivariate analysis, Roseburia was identified as a protective factor against SAP in both cohorts (training, aOR 0.52; 95% CI, 0.30-0.90; validation, aOR 0.44; 95% CI, 0.23-0.85). The combination of these taxa into a microbial dysbiosis index (MDI) revealed that dysbiosis increased nearly 2 times risk of SAP (training, aOR 1.95; 95% CI, 1.19-3.20; validation, aOR 2.22; 95% CI, 1.15-4.26). Lower fecal SCFA levels and higher serum D-LA levels were observed in SAP patients. Furthermore, SAP was an independent risk factor of 30-day death and 90-day unfavorable outcome., Conclusion: We demonstrate that a microbial community with depleted Roseburia and enriched opportunistic pathogens is associated with increased risk of SAP among AIS patients. Gut microbiota screening might be useful for identifying patients at high risk for SAP and provide clues for stroke treatment., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Xia, Zhang, Wu, Wang, Zhou, He and Yin.)

Purpose: Plasma osmolality, a marker of dehydration, is associated with cardiovascular mortality. We aimed to investigate whether elevated plasma osmolality is associated with case fatality within 1 year after severe acute ischemic stroke., Materials and Methods: We included severe ischemic stroke patients (defined as National Institutes of Health Stroke Scale ≥15 score) within 24 hours from symptom onset admitted to the Department of Neurology, West China Hospital between January 2017 and June 2019. Admission plasma osmolality was calculated using the equation 1.86*(sodium+potassium)+1.15*glucose+urea+14. Elevated plasma osmolality was defined as plasma osmolality >296 mOsm/kg, indicating a state of dehydration. Study outcomes included 3-month and 1-year case fatalities. Multivariable logistic regression was performed to determine independent associations between plasma osmolality and case fatalities at different time points., Results: A total of 265 patients with severe acute ischemic stroke were included. The mean age was 71.2±13.1 years, with 51.3% being males. Among the included patients, case fatalities were recorded for 31.7% (84/265) at 3 months and 39.6% (105/265) at 1 year. Elevated plasma osmolality (dehydration) was associated with 3-month case fatality [odds ratio (OR) 1.98, 95% confidence interval (CI) 1.07-3.66, p =0.029], but not 1-year case fatality (OR 1.51, 95% CI 0.84-2.72, p =0.165), after full adjustment for confounding factors., Conclusion: Elevated plasma osmolality was independently associated with 3-month case fatality, but not 1-year case fatality, for severe acute ischemic stroke., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2021.)

Objectives: Patients admitted to hospital with acute myocardial infarction (AMI) have considerable variability in in-hospital risks, resulting in higher demands on healthcare resources. Simple risk-assessment tools are important for the identification of patients with higher risk to inform clinical decisions. However, few risk assessment tools have been built that are suitable for populations with AMI in China. We aim to develop and validate a risk prediction model, and further build a risk scoring system., Design: Data from a nationally representative retrospective study was used to develop the model. Patients from a prospective study and another nationally representative retrospective study were both used for external validation., Setting: 161 nationally representative hospitals, and 53 and 157 other hospitals were involved in the above three studies, respectively., Participants: 8010 patients hospitalised for AMI were included as development sample, and 4485 and 11 223 other patients were included as validation samples in their corresponding studies., Primary and Secondary Outcome Measures: The in-hospital major adverse cardiovascular events (MACE) was defined as death from any cause, recurrent AMI, or ischaemic stroke., Results: The proportion of in-hospital MACE was 11.7%, 8.8% and 11.4% among the development sample and two external-validation samples, respectively. Nine predictors (ie, age, sex, left ventricular ejection fraction, Killip class, systolic blood pressure, creatinine, white blood cell count, heart rate and blood glucose) were independently associated with in-hospital MACE. The model performed well on both discrimination and calibration capability, with areas under the Receiver Operating Characteristic Curve (ROC) curve of 0.85, 0.74 and 0.80, and calibration slopes of 0.98, 0.84 and 0.97 in the development sample and two external validation samples, respectively. A point-based risk scoring system was built with good discrimination and reclassification ability., Conclusions: A prediction model using readily available clinical parameters was developed and externally validated to estimate risks of in-hospital MACE among patients with AMI, thereby better informing decision-making in improving clinical care., Competing Interests: Competing interests: JLi reported receiving research grants, through Fuwai Hospital, from the People’s Republic of China for work to improve the management of hypertension and blood lipids and to improve care quality and patient outcomes of cardiovascular disease; receiving research agreements, through the National Center for Cardiovascular Diseases and Fuwai Hospital, from Amgen for a multicentre clinical trial assessing the efficacy and safety of omecamtiv mecarbil and for patient with dyslipidaemia registration; receiving a research agreement, through Fuwai Hospital, from Sanofi for a multicentre clinical trial on the effects of sotagliflozin; receiving a research agreement, through Fuwai Hospital, with the University of Oxford for a multicentre clinical trial of empagliflozin; receiving a research agreement, through the National Center for Cardiovascular Diseases, from AstraZeneca for clinical research methods training outside the submitted work; and receiving a research agreement, through the National Center for Cardiovascular Diseases, from Lilly for physician training outside the submitted work. No other disclosures were reported., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Accurate prediction of ischemic stroke is required for deciding anticoagulation use in patients with atrial fibrillation (AF). Even though only 6% to 8% of AF patients die from stroke, about 90% are indicated for anticoagulants according to the current AF management guidelines. Therefore, we aimed to develop an accurate and easy-to-use new risk model for 1-year thromboembolic events (TEs) in Chinese AF patients., Methods: From the prospective China Atrial Fibrillation Registry cohort study, we identified 6601 AF patients who were not treated with anticoagulation or ablation at baseline. We selected the most important variables by the extreme gradient boosting (XGBoost) algorithm and developed a simplified risk model for predicting 1-year TEs. The novel risk score was internally validated using bootstrapping with 1000 replicates and compared with the CHA2DS2-VA score (excluding female sex from the CHA2DS2-VASc score)., Results: Up to the follow-up of 1 year, 163 TEs (ischemic stroke or systemic embolism) occurred. Using the XGBoost algorithm, we selected the three most important variables (congestive heart failure or left ventricular dysfunction, age, and prior stroke, abbreviated as CAS model) to predict 1-year TE risk. We trained a multivariate Cox regression model and assigned point scores proportional to model coefficients. The CAS scheme classified 30.8% (2033/6601) of the patients as low risk for TE (CAS score = 0), with a corresponding 1-year TE risk of 0.81% (95% confidence interval [CI]: 0.41%-1.19%). In our cohort, the C-statistic of CAS model was 0.69 (95% CI: 0.65-0.73), higher than that of CHA2DS2-VA score (0.66, 95% CI: 0.62-0.70, Z = 2.01, P = 0.045). The overall net reclassification improvement from CHA2DS2-VA categories (low = 0/high ≥1) to CAS categories (low = 0/high ≥1) was 12.2% (95% CI: 8.7%-15.7%)., Conclusion: In Chinese AF patients, a novel and simple CAS risk model better predicted 1-year TEs than the widely-used CHA2DS2-VA risk score and identified a large proportion of patients with low risk of TEs, which could potentially improve anticoagulation decision-making., Trial Registration: www.chictr.org.cn (Unique identifier No. ChiCTR-OCH-13003729)., (Copyright © 2021 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the CC-BY-NC-ND license.)

Background and Purpose: A variety of definitions for minor stroke have been proposed. We aimed to compare the clinical characteristics and outcomes of minor stroke defined as the National Institutes of Health Stroke Scale (NIHSS) score ≤5 versus ≤3., Methods: We retrieved acute ischemic stroke patients with NIHSS score ≤5 in the CSCA study (China Stroke Center Alliance) between August 2015 and 2019. In-hospital clinical outcomes including all-cause mortality, stroke, and myocardial infarction were compared between the NIHSS score ≤5 and NIHSS score ≤3 groups using absolute standardized differences (ASD)., Results: A total of 1 006 798 patients were registered in the CSCA program from 1476 hospitals, 472 352 patients had NIHSS score ≤5, of whom 356 314 patients had NIHSS score ≤3. The in-hospital composite events of death, myocardial infarction, or recurrent stroke were not significantly different between the NIHSS score ≤5 and NIHSS score ≤3 groups (5.6% [26 346/472 352] versus 5.2% [18 682/356 314]; ASD, 1.8). The in-hospital all-cause mortality (0.1% [443/472 352] versus 0.1% [255/356 314]; ASD, <0.01), recurrent ischemic stroke (5.3% [25 026/472 352] versus 5.0% [17 777/356 314]; ASD, 1.4), and hemorrhagic stroke (0.5% [2151/472 352] versus 0.4% [1475/356 314]; ASD, 1.5) were not significantly different between both the NIHSS score ≤5 and NIHSS score ≤3 groups., Conclusions: Our large-scale study identified that minor stroke using NIHSS scores ≤5 and ≤3 as the definition was comparable with each other regarding in-hospital all-cause mortality, recurrent stroke, and hemorrhagic stroke. This observation may be useful for future comparison studies and clinical trial design.

The aim of this paper was to explore the key genes and pathogenesis of ischemic stroke(IS) by bioinformatics, and predict the potential traditional Chinese medicines for IS. Based on the gene-chip raw data set of GSE22255 from National Center of Biotechnology Information(NCBI), the article enrolled in 20 patients with ischemic stroke and 20 sex-and age-matched controls, and differentially expressed genes(DEGs) were screened based on R language software. The DAVID tool and R language software were used to perform gene ontology(GO) biological process enrichment analysis and Kyoto encyclopedia of genes and gnomes(KEGG) pathway enrichment analysis. The DEGs were imported into STRING to construct a protein-protein interaction network, and the Molecular Complexity Module(MCODE) plug-in of Cytoscape software was used to visualize and analyze the key functional modules. Moreover, the core genes and the medical ontology information retrieval platform(Coremine Medical) were mapped to each other to screen the traditional Chinese medicines and construct drug-active ingredient-target network. Compared with healthy controls, 14 DEGs were obtained, of which 12 genes were up-regulated and 2 genes were down-regulated. DEGs were mainly involved in immune response, inflammatory process, signal transduction, and cell proliferation regulation. The interleukin-17(IL-17), nuclear factor kappaB(NF-κB), tumor necrosis factor(TNF), nucleotide binding oligomerization domain(NOD)-like receptor and other signaling pathways were involved in KEGG pathway enrichment analysis. The key modules of the DEGs-encoding protein interaction network mainly focused on 7 genes of TNF, JUN, recombinant immediate early response 3(IER3), recombinant early growth response protein 1(EGR1), prostaglandin-endoperoxide synthase 2(PTGS2), C-X-C motif chemokine ligand 8(CXCL8) and C-X-C motif chemokine ligand 2(CXCL2), which were involved in biological processes widely such as neuroinflammation and immunity. TNF and JUN were the key nodes in this module, which might become potential biological markers for diagnosis and prognosis evaluation of IS. The potential traditional Chinese medicines for the treatment of IS includes Salviae Miltiorrhizae Radix et Rhizoma, Croci Stigma, Scutellariae Radix, and Cannabis Fructus. The occurrence of stroke was the result of multiple factors. Dysregulation of genes and pathways related to immune regulation and inflammation may be the key link for the development of IS. This study provided research direction and theoretical basis for further exploring the mechanism of action of traditional Chinese medicine in the treatment of IS and searching for potential drug targets.

The adverse impact of ozone on public health has attracted worldwide attention. However, few studies have addressed the contribution of ozone to disease burden caused by cardiovascular diseases. This study aimed to examine the association between short-term ozone exposure and years of life lost (YLL) from stroke in 48 Chinese cities. City-specific relative change of YLL was estimated by a generalized additive model, then pooled using random-effects meta-analysis. The potential effect modification of individual, climatic, and city-level characteristics was also evaluated. A 10 μg/m 3 increase in three-day moving average of ozone concentration was associated with 0.54% (95% CI: 0.41%, 0.66%), 0.25% (95% CI: 0.10%, 0.40%), and 0.70% (95% CI: 0.48%, 0.92%) relative increment in YLL from stroke, haemorrhagic stroke, and ischaemic stroke, respectively. The association magnitudes were larger in elderly people, females, or higher quartile groups of temperature (all p < 0.01). The potential avoidable life lost due to YLL from stroke was 5.5 days per deceased person if ozone concentration could reduce to the standard recommended by the World Health Organization (100 μg/m 3 ). Our findings provided robust evidence on the impact of short-term ozone exposure on YLL from stroke and called for more stringent regulation of ozone., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background and Purpose: There is limited nationwide evidence about the standard management characteristics of stroke types and prognosis in China. This study aimed to assess clinical characteristics, in-hospital and after-discharge management characteristics and prognosis for stroke types in China., Methods: A nationwide registry recruited 14 244 imaging-confirmed first-ever incident strokes from 132 hospitals across 31 provinces of China during 2007-2008, recording presenting characteristics, diagnostic procedures and in-hospital treatment. After hospital discharge, patients were followed up for 6 months. Conventional statistical methods were used to examine the patterns of management and prognosis., Results: Overall, 68.7%, 26.9% and 4.4% were ischaemic stroke (IS), intracerebral haemorrhage (ICH), and subarachnoid haemorrhage (SAH), respectively. Only 20% were managed in a dedicated stroke unit. Among IS, 1.3% received thrombolysis within 3 hours after symptom onset, whereas the proportions of receiving in-hospital antiplatelet therapy, neuroprotective agents and traditional Chinese medicines (TCM) were 88.4%, 69.7% and 70.6%, respectively. For ICH, 63.3% and 36.3% received neuroprotective agents and TCM in hospital, respectively. At discharge, 70.7% and 38.0% of the patients with IS were given antiplatelet and statin therapies, respectively, decreasing to 64.8% and 23.9%, respectively, at 6 months. In-hospital mortality was 3.2%, 9.3% and 10.1% for IS, ICH and SAH, respectively, with a further 8.6%, 18.2% and 22.0%, respectively, died by 6 month. Meanwhile, in-hospital recurrence rate was 2.6%, 1.9% and 7.2% for IS, ICH and SAH, respectively, with a further 8.0%, 5.1% and 7.5%, respectively, recurred by 6 month., Conclusions: In China, the mortality rate of stroke is lower than that reported from west populations, though most strokes are not managed in specialised stroke unit. There is widespread use of some unproven therapies but limited proven treatments, especially after discharge, leading to unnecessary recurrent risks., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: We aimed to investigate the prognostic impact of the burden of new-onset atrial fibrillation (NOAF) on long-term cardiovascular outcomes in patients with acute myocardial infarction (AMI)., Methods and Results: This retrospective analysis consecutively included patients without a documented atrial fibrillation (AF) history who admitted for AMI at Shanghai Tenth People's Hospital between February 2014 and March 2018. Atrial fibrillation burden was measured as the percentage of time spent in AF, and its optimal cut-off value of 10.87% was identified by X-tile software. Of 2399 patients (mean age: 65.8 years, 76.6% of men), 278 (11.6%) developed NOAF during hospitalization. During a median follow-up of 2.7 years, the incidence of all-cause death was 3.19, 9.00, and 17.41 per 100 person-years in the sinus rhythm (SR), low-burden (AF burden ≤ 10.87%), and high-burden (AF burden > 10.87%) groups, respectively. After adjustment for confounders, it was the high-burden NOAF [hazard ratio (HR): 1.94, 95% confidence interval (CI): 1.28-2.95] rather than the low-burden one (HR: 1.47, 95% CI: 0.97-2.21) that was significantly associated with increased mortality compared with SR. Concordant results were obtained in our propensity score-matched analyses [2.55 (1.57-4.16) and 1.32 (0.85-2.05) for high- and low-burden NOAF, respectively). In addition, post-myocardial infarction NOAF was associated with an increased risk of heart failure irrespective of its burden. Only those high-burden individuals were at heightened risk of ischaemic stroke. The restricted cubic spline curves illustrated a dose-response relationship of NOAF burden with outcomes., Conclusion: In patients with NOAF complicating AMI, high AF burden was strongly associated with long-term outcomes., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Objective: To investigate the associations between short-term exposure to fine particular matter (PM 2.5 ) and ischemic stroke (IS) in Yancheng, China, from 2017 to 2019., Methods: We designed a time-series study based on generalized additive models to explore the association of PM 2.5 and IS admitted in two major hospitals in Yancheng. We built different lag patterns and conducted stratification analyses by age, gender, and season. Moreover, we examined the robustness of the associations adopting two-pollutant models and fitted the concentration-response curves., Result: We observed positive and significant associations at lag 0 day. Every 10 μg/m 3 increase in PM 2.5 (lag0) was associated with 1.06% (95% CI: 0.21%-1.91%) increases in hospitalizations for IS. The association remained stable and statistically significant to the adjustment of carbon monoxide and ozone. We observed that the associations were stronger in females and during cold seasons. The overall concentration-response relationship curve was linear positive and increased slowly but rose sharply at higher concentrations in the cold season., Conclusion: Our study added to the evidence that short-term exposure to PM 2.5 may induce IS, and the government should take action to address the air pollution issues and protect susceptible populations., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)