BACKGROUND: The FAVOR (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients with Coronary Artery Disease) III China trial demonstrated that percutaneous coronary intervention (PCI) lesion selection using quantitative flow ratio (QFR) measurement, a novel angiography-based approach for estimating fractional flow reserve, improved two-year clinical outcomes compared with standard angiography guidance. This study aimed to assess the cost-effectiveness of QFR-guided PCI from the perspective of the current Chinese healthcare system. METHODS: This study is a pre-specified analysis of the FAVOR III China trial, which included 3825 patients randomized between December 25, 2018, and January 19, 2020, from 26 centers in China. Patients with stable or unstable angina pectoris or those ≥72 hours post-myocardial infarction who had at least one lesion with a diameter stenosis between 50% and 90% in a coronary artery with a ≥2.5 mm reference vessel diameter by visual assessment were randomized to a QFR-guided strategy or an angiography-guided strategy with 1:1 ratio. During the two-year follow-up, data were collected on clinical outcomes, quality-adjusted life-years (QALYs), estimated costs of index procedure hospitalization, outpatient cardiovascular medication use, and rehospitalization due to major adverse cardiac and cerebrovascular events (MACCE). The primary analysis calculated the incremental cost-effectiveness ratio (ICER) as the cost per MACCE avoided. An ICER of ¥10,000/MACCE event avoided was considered economically attractive in China. RESULTS: At two years, the QFR-guided group demonstrated a reduced rate of MACCE compared to the angiography-guided group (10.8% vs . 14.7%, P <0.01). Total two-year costs were similar between the groups (¥50,803 ± 21,121 vs . ¥50,685 ± 23,495, P = 0.87). The ICER for the QFR-guided strategy was ¥3055 per MACCE avoided, and the probability of QFR being economically attractive was 64% at a willingness-to-pay threshold of ¥10,000/MACCE avoided. Sensitivity analysis showed that QFR-guided PCI would become cost-saving if the cost of QFR were below ¥3682 (current cost: ¥3800). Cost-utility analysis yielded an ICER of ¥56,163 per QALY gained, with a 53% probability of being cost-effective at a willingness-to-pay threshold of ¥85,000 per QALY gained. CONCLUSION: In patients undergoing PCI, a QFR-guided strategy appears economically attractive compared to angiographic guidance from the perspective of the Chinese healthcare system. TRIAL REGISTRATION ClinicalTrials.gov , NCT03656848.
Humans ; Cost-Benefit Analysis ; Percutaneous Coronary Intervention/methods* ; Male ; Female ; Coronary Angiography/methods* ; Middle Aged ; Aged ; Coronary Artery Disease/surgery* ; Quality-Adjusted Life Years ; Fractional Flow Reserve, Myocardial/physiology*

Objective:To explore the association of frailty and serum C-terminal agrin fragment(CAF)with the prognosis of elderly patients with acute coronary syndrome(ACS).Methods:In this prospective cohort study, clinical data of 207 older patients with ACS between January 2020 and May 2022 were collected.Serum samples were obtained within 24 hours after enrollment to detect CAF levels.Meanwhile, the thrombolysis in myocardial infarction(TIMI)and frailty screening questionnaire(FSQ)scores were assessed on admission.Patients were followed up for major adverse cardiovascular and cerebrovascular events(MACCE)for 90 days.Multivariate logistic regression was used to analyze the influencing factors of MACCE.The receiver operating characteristic(ROC)curve was performed to evaluate the predictive ability of the FSQ score, serum CAF and their combination for MACCE.According to 90-day mortality, patients were divided into a survival group(n=176)and a death group(n=31). The Cox proportional hazards regression model was used for survival analysis.Results:The FSQ score( Z=4.412, P<0.001)and serum CAF( Z=6.702, P<0.001)in the MACCE group were higher than those in the non-MACCE group.Logistic regression analysis showed that after adjusting for age, sex, TIMI score and complete revascularization, frailty defined by FSQ( OR=1.714; 95% CI: 1.059-2.775; P=0.028)and high serum CAF( OR=1.230; 95% CI: 1.122-1.350; P<0.05)were independent risk factors for MACCE.The area under the ROC curve(AUC)of the FSQ score for predicting MACCE was 0.797(95% CI: 0.735-0.850; P<0.001), the predictive cut-off point was an FSQ score >2, and the Youden index(YI)was 0.419, yielding a sensitivity of 0.708 and a specificity of 0.711.In addition, the AUC of serum CAF for predicting MACCE was 0.766(95% CI: 0.701-0.822; P<0.001), the predictive cut-off point was >6.01 μg/L, and YI was 0.460, yielding a sensitivity of 0.750 and a specificity of 0.710.The predictive ability of FSQ combined with CAF for MACCE was higher than FSQ( Z=2.294, P=0.022)or CAF( Z=2.545, P=0.011)alone.Cox regression analysis showed that frailty defined by FSQ( HR=3.487; 95% CI: 1.329-9.153; P=0.011)was independently associated with all-cause mortality within 90 days after ACS. Conclusions:Frailty assessment and serum CAF detection can improve the risk stratification of elderly patients with ACS.

Objective:To establish a 14-day prognosis model for emergency patients with acute ischemic cerebral stroke and evaluate its predictive efficacy.Methods:A prospective cohort study was conducted. Patients with acute ischemic stroke admitted to the emergency department of Beijing Bo’ai Hospital within 72 hours of onset from October 2018 to December 2020 were enrolled. Univariate and multivariate logistic regression analysis were used to screen the risk factors of poor prognosis. The ROC curve was drawn to determine the cut-off value of continuous variables and discretise data with reference to clinical practice. The corresponding scores were set up according to the β regression coefficient of each variable, and the clinical scale prediction model of short-term prognosis of acute cerebral infarction was established. Patients with ischemic stroke in the hospital from January to December 2021 were selected as the internal validation, to verify the constructed predictive model.Results:A total of 321 patients were included in the study, including 223 in the training set and 98 in the internal validation set. Multivariate logistic regression analysis showed that age, hypersensitive C-reactive protein, prealbumin (PA), infarct volume, Frailty Screening Questionnaire (FSQ) and National Institute of Health Stroke Scale (NIHSS) were independent risk factors for poor short-term prognosis of acute cerebral infarction. The total score of the clinical prediction scoring system for short-term prognosis of acute cerebral infarction in the emergency department was 15 points, including age ≥74 years (1 point), PA ≤373 mg/L (2 points), large artery atherosclerosis (1 point), cardiogenic embolism (2 points), infarct volume ≥ 2.18 cm 3 (2 points), FSQ ≥3 points (1 point), NIHSS ≥4 points (6 points); The area under the ROC curve (AUC) of the scoring system for predicting short-term poor prognosis of acute cerebral infarction was 0.927 (95% CI: 0.894-0.960). The optimal cut-off value was ≥5 points, and the sensitivity and specificity were 0.770 and 0.976, respectively. In the internal validation set, the scoring system had similar predictive value for poor outcomes (AUC=0.892, 95% CI:0.827-0.957). Conclusion:The scoring system for short-term prognosis prediction of acute ischemic cerebral infarction has good diagnostic efficacy, and could guide clinicians to judge the prognosis of emergency patients in the early stage.

Background::A phase II trial on recombinant human tenecteplase tissue-type plasminogen activator (rhTNK-tPA) has previously shown its preliminary efficacy in ST elevation myocardial infarction (STEMI) patients. This study was designed as a pivotal postmarketing trial to compare its efficacy and safety with rrecombinant human tissue-type plasminogen activator alteplase (rt-PA) in Chinese patients with STEMI.Methods::In this multicenter, randomized, open-label, non-inferiority trial, patients with acute STEMI were randomly assigned (1:1) to receive an intravenous bolus of 16 mg rhTNK-tPA or an intravenous bolus of 8 mg rt-PA followed by an infusion of 42 mg in 90 min. The primary endpoint was recanalization defined by thrombolysis in myocardial infarction (TIMI) flow grade 2 or 3. The secondary endpoint was clinically justified recanalization. Other endpoints included 30-day major adverse cardiovascular and cerebrovascular events (MACCEs) and safety endpoints.Results::From July 2016 to September 2019, 767 eligible patients were randomly assigned to receive rhTNK-tPA ( n = 384) or rt-PA ( n = 383). Among them, 369 patients had coronary angiography data on TIMI flow, and 711 patients had data on clinically justified recanalization. Both used a –15% difference as the non-inferiority efficacy margin. In comparison to rt-PA, both the proportion of patients with TIMI grade 2 or 3 flow (78.3% [148/189] vs. 81.7% [147/180]; differences: –3.4%; 95% confidence interval [CI]: –11.5%, 4.8%) and clinically justified recanalization (85.4% [305/357] vs. 85.9% [304/354]; difference: –0.5%; 95% CI: –5.6%, 4.7%) in the rhTNK-tPA group were non-inferior. The occurrence of 30-day MACCEs (10.2% [39/384] vs. 11.0% [42/383]; hazard ratio: 0.96; 95% CI: 0.61, 1.50) did not differ significantly between groups. No safety outcomes significantly differed between groups. Conclusion::rhTNK-tPA was non-inferior to rt-PA in the effect of improving recanalization of the infarct-related artery, a validated surrogate of clinical outcomes, among Chinese patients with acute STEMI.Trial registration::www.ClinicalTrials.gov (No. NCT02835534).

Objective To investigate the predictive value of the prognostic nutritional index(PNI)in all-cause mortality in pa-tients with acute and critical illness.Methods Acute and critically ill patients admitted to the Department of Emergency,Beijing Chao-yang Hospital,Capital Medical University,from March to July 2021 were selected as study subjects,and the relevant clinical data within 24h of their admission to the emergency department were collected and analyzed descriptively.The receiver operating characteristic(ROC)curve of PNI was drawn with all-cause mortality of patients within 28days as the endpoint,and the patients were divided into high PNI and low PNI groups according to the optimal cut-off value,and the clinical characteristics of the two groups were compared.Patients were divided into survival and death groups according to whether they died within 28days,and the clinical characteristics of the two groups were compared,and univariate and multivariate Logistic regression analysis was used to explore the risk factors for all-cause mortality within 28days in patients with acute and critical illness.Results A total of 603 patients were included,and the optimal cut-off value of PNI was 43.825,according to which all patients were divided into the high PNI group(n=334)and low PNI group(n=269),and it was found that the proportion of patients who all-cause mortality within 28days was significantly higher in the low PNI group than in the PNI group(P＜0.05).All patients died within 28days of admission to the emergency department in 127 cases,and the pro-portion of malnourished patients was significantly higher in the death group than that in the survival group(P＜0.05).Logistic regression analysis showed that malnutrition at admission to the emergency department screened by PNI was an independent risk factor for all-cause mortality within 28days in patients with acute and critical illness(OR=1.805,95％CI:1.157-2.817,P=0.009),and advanced age,low body mass index,and low hemoglobin levels were also independent risk factors for all-cause mortality within 28days.Conclu-sion Patients with acute and critical illness are at high risk of malnutrition,and malnutrition at admission to the emergency department,advanced age,low body mass index,and low hemoglobin levels screened by PNI are independent risk factors for all-cause mortality with-in 28 days.

Objective:To develop and validate a predictive nomogram for 28-day mortality among very older patients with sepsis, to identify high-risk patients early and improve prognosis.Methods:This study was conducted from January 1, 2022, to November 30, 2022. Very older patients aged≥80 years with sepsis admitted to the emergency department of Beijing Chao-Yang Hospital, Capital Medical University were consecutively recruited. Their clinical data within 24 h of admission and 28-day mortality was recorded. The participants were divided into training (70%) and validation cohort (30%) (random number). In the training cohort, the risk factors of 28-day mortality were selected via least absolute shrinkage and selection operator (LASSO) regression analysis and multivariable Cox proportional hazard model, and a nomogram was developed. The prediction model was verified in validation cohort.Results:In total, 507 very older patients with sepsis were included, among which the mortality rate was 31.2%. In training cohort, the independent risk factors for 28-day mortality were identified: increased age [hazard ratio ( HR)=1.059, 95% confidence interval (95% CI)=1.017-1.103, P=0.005], cognitive impairment ( HR=2.100, 95% CI=1.322-3.336, P=0.002), frailty ( HR=2.561, 95% CI=1.183-5.545, P=0.017), decreased mean arterial pressure ( HR=0.987, 95% CI=0.976-0.998, P=0.017), decreased prealbumin ( HR=0.997, 95% CI=0.994-1.000, P=0.040), increased blood urea nitrogen ( HR=1.028, 95% CI=1.010-1.045, P=0.001), increased procalcitonin ( HR=1.008, 95% CI=1.001-1.016, P=0.019) via LASSO regression analysis and multivariable Cox regression analysis. The nomogram was developed using these seven predictors. In the training and validation cohorts, the calibration curves, time-dependent AUC curves, and decision curve analysis showed that the nomogram had good calibration degree, discrimination and clinical net benefits. Conclusions:Increased age, cognitive impairment, frailty, decreased mean arterial pressure, decreased prealbumin, increased blood urea nitrogen, and increased procalcitonin are independent risk factors for 28-day mortality in very older patients with sepsis. The nomogram, which included the seven predictors, have good predictive performance, and might be helpful for prognosis assessment.

Objective:To investigate the association between serum interleukin (IL) -6 and silent information regulator (SIRT) -1 and frailty in elderly patients in the emergency department.Methods:This was a cross-sectional study. Patients aged 60 years and above treated in the emergency department of Beijing Bo'Ai Hospital from January to December 2022 were collected. Blood routine, biochemical indicators, and serum IL-6 were detected within 24 h after enrollment. At the same time, fasting venous blood 2 mL was collected and the serum was stored at minus 80℃ after centrifugation. The level of SIRT-1 was detected by enzyme-linked immunosorbent assay. Nutritional risk screening 2002 was performed within 72 h, Barthel index was used to assess the ability of daily living and grip strength was measured. The patients were divided into frailty and non-frailty groups according to Fried frailty phenotype (FP). The differences of clinical data and laboratory indicators were compared between the two groups. Multivariable logistic regression model was used to analyze the association between serum IL-6, SIRT-1 and frailty. The predictive ability of serum IL-6 and SIRT-1 for frailty was evaluated by the receiver operating characteristic (ROC) curve.Results:A total of 316 elderly patients in the emergency department were included in this study and divided into frailty group ( n=156) and non-frailty group ( n=160) according to Fried FP criteria. Univariate analysis showed that serum IL-6 [33.3 (13.0, 69.2) ng/L vs. 20.0 (9.2, 41.3) ng/L, P=0.001] and SIRT-1 [(9.98±1.23) μg/L vs. (8.98±1.65) μg/L, P<0.001] of patients in the frailty group were higher than those in the non-frailty group. Multivariable logistic regression analysis showed that serum IL-6 ( OR=1.006, 95% CI: 1.001-1.011, P=0.036) and SIRT-1 ( OR=1.838, 95% CI: 1.475-2.290, P<0.001) were independently associated with frailty after adjusting for age, sex, body mass index, Barthel index and grip strength. The area under the curve (AUC) of serum IL-6 for predicting frailty was 0.671 (95% CI: 0.604-0.738, P<0.001), the predictive cut-off point was 33.8 ng/L. The AUC of SIRT-1 for predicting frailty was 0.736 (95% CI: 0.674-0.799, P<0.001), the predictive cut-off point was 9.13 μg/L. The AUC of the model of IL-6 combined with SIRT-1 was 0.765 (95% CI: 0.707-0.823, P<0.001), the sensitivity and specificity were 0.776 and 0.726, respectively, and its predictive efficacy was superior to that of IL-6 alone ( Z=2.119, P=0.034). Conclusion:Serum IL-6 and SIRT-1 are independent predictors of frailty in elderly patients in the emergency department.

Objective:To examine the prevalence of frailty among elderly patients in the emergency department and to investigate the potential relationship between vitamin D nutritional status and frailty.Methods:This study collected clinical data from elderly patients aged over 65 years in the emergency intensive care unit and emergency observation ward of Beijing Bo'Ai Hospital from January to September 2021.The data included blood routine, biochemical indicators, circulating interleukin-6, cortisol, thyrotropin, and 25-hydroxyvitamin D[25(OH)D], which were detected within 24 hours after enrollment.Additionally, the Frailty Screening Questionnaire(FSQ), FRAIL scale, and Clinical Frailty Scale(CFS)were used to score the patients.Based on the scores, the patients were divided into frail or non-frail groups, and the prevalence of frailty was reported accordingly using the criteria of the aforementioned scales.The consistency of the three scales was evaluated using the Spearman rank test and Kappa coefficient.We compared the differences in clinical data and laboratory indicators of patients between the frail and non-frail groups.Additionally, we used a multivariable Logistic regression model to analyze the association between vitamin D nutritional status and frailty.We also analyzed the prevalence of frailty in different vitamin D nutritional statuses and evaluated the predictive ability of serum 25(OH)D for frailty using the receiver operating characteristic(ROC)curve.Results:A total of 317 patients were included in the study.The prevalence of frailty in elderly patients in the emergency department was found to be 47.0%, 55.2%, and 69.4% according to the FSQ, FRAIL, and CFS scales, respectively.The study evaluated the consistency of these three scales, revealing a Spearman rank correlation coefficient of 0.761(95% CI: 0.715-0.806, P<0.001)and a Kappa coefficient of 0.536(95% CI: 0.451-0.621, P<0.001)between FSQ and FRAIL, which were the highest correlations observed.Logistic regression analysis, after adjusting for age, gender, BMI, and other factors, indicated that vitamin D deficiency( OR=5.994, 95% CI: 1.232-29.169, P=0.027)was independently associated with an increased prevalence of frailty as defined by FSQ criteria.The prevalence of frailty increased with the severity of vitamin D malnutrition.In the vitamin D deficiency group, the prevalence was higher compared to the vitamin D insufficiency and sufficiency groups( P<0.05 for all).The area under the ROC curves(AUCs)of serum 25(OH)D levels to predict frailty, as defined by FSQ, FRAIL, and CFS, were 0.806(95% CI: 0.744-0.868), 0.748(95% CI: 0.679-0.817), and 0.768(95% CI: 0.701-0.826)( P<0.001 for all).The optimal cut-off values were 12.0, 9.76, and 11.65 μg/L, respectively, yielding a Youden index of 0.553, 0.419, and 0.462. Conclusions:FSQ, FRAIL, and CFS demonstrated a strong level of consistency in assessing frailty.Additionally, serum 25(OH)D can serve as an independent predictor of frailty, aiding in the identification of frail individuals and enhancing the risk stratification of elderly patients in the emergency department.

ObjectiveTo investigate the association between serum 25-hydroxy vitamin D [25(OH)D] and the occurrence and outcome of stroke-associated pneumonia (SAP) in patients with acute ischemic stroke (AIS) in emergency ward. MethodsThe clinical data of 256 patients with AIS from January, 2019 to December, 2021 were collected in the emergency department of Beijing Bo'ai Hospital. Blood routine, biochemical indicators and serum concentration of 25(OH)D were detected within 24 hours after enrollment; meanwhile, National Institute of Health Stroke Scale (NIHSS) and A2DS2 score were evaluated. The patients were divided into non-SAP group (n = 164) and SAP group (n = 92) according to whether pneumonia occurred during hospitalization. Multivariable logistic regression model was used to analyze the influencing factors of SAP. The predictive ability of serum 25(OH)D and A2DS2 for SAP were evaluated by receiver operating characteristic (ROC) curves. The 28-day survival of patients with SAP was followed up. Multivariable Cox proportional hazard regression model was used to investigate the association between vitamin D nutritional status and 28-day all-cause mortality. ResultsSerum 25(OH)D was significantly lower in the SAP group than that in the non-SAP group (Z = 6.896, P < 0.001). After adjusting age, sex, infarct volume, A2DS2 score and other factors, lower serum 25(OH)D level (OR = 0.934, 95%CI 0.884 to 0.986, P = 0.014) was an independent risk factor for SAP. The areas under curve (95%CI) of serum 25(OH)D, A2DS2 score and their combined model for predicting SAP were 0.774 (0.718 to 0.824), 0.832 (0.781 to 0.876) and 0.851 (0.802 to 0.893) (P < 0.001), respectively; and the optimum cut-off values were 25(OH)D < 10.2 ng/mL, A2DS2 score > 5 points, combined prediction > 0.207, and the Youden index were 0.493, 0.662 and 0.616, respectively. A2DS2 score could improve the prediction efficiency of serum 25(OH)D (Z = 2.106, P = 0.035). After adjusting age, sex, infarct volume and NIHSS score, vitamin D deficiency was an independent risk factor for all-cause mortality after 28 days of SAP (HR = 2.871, 95%CI 1.004 to 8.208, P = 0.049) . ConclusionSerum 25(OH)D is independently associated with the occurrence and outcome of SAP in patients with AIS in emergency ward, which could serve as an independent predictor for SAP.

Objective:To explore the predictive value and prognosis effect of calprotectin on acute kidney injury (AKI) in patients with sepsis.Methods:A prospective observational study was conducted. From December 2018 to November 2020, patients with sepsis admitted to the Emergency Department of China Rehabilitation Research Center were enrolled. General clinical data of patients were collected continuously, and the acute physiology and chronic health evaluationⅡ (APACHEⅡ) score, sequential organ failure assessment (SOFA) score and calprotectin were evaluated in 24 h after admission. The patients were divided into the AKI group and non-AKI group according to the occurrence of AKI within 7 days after admission. Calprotectin level and other clinical data were compared between the two groups. Logistic regression was used to analyze the risk factors for AKI in patients with sepsis, and receiver operating characteristic (ROC) curve was plotted to evaluate the predictive value of calprotectin for AKI in patients with sepsis. The patients with AKI were further divided into the survival group and death group according to the 28-day outcome, and the calprotectin levels between the two groups were compared.Results:A total of 207 patients with sepsis were enrolled, and the incidence of AKI was 68.12% (141/207). The level of calprotectin in patients with AKI was higher than that in patients without AKI [4.65 (3.25, 5.61) μg/mL vs. 3.42 (2.29, 4.09) μg/mL, P < 0.001]. Multivariable Logistic regression analysis showed that APACHEⅡ score ( OR=1.090, 95% CI: 1.043-1.139), C-reactive protein ( OR=1.004, 95% CI: 1.001-1.008) and calprotectin ( OR=1.590, 95% CI: 1.269-1.991) were independent risk factors for AKI in patients with sepsis. The area under ROC curve (AUC) of calprotectin for predicting AKI was 0.716 (95% CI: 0.643-0.788). The cutoff value of prediction was 4.63 μg/mL with the Yoden index of 0.405, which yielded a sensitivity of 0.511 and a specificity of 0.894. When calprotectin was combined with APACHE II score and SOFA score respectively, the predictive ability was significantly improved with the AUC of 0.768 (95% CI: 0.701-0.834) and 0.769 (95% CI: 0.701-0.837), respectively. We further divided patients with AKI into the survival group and non-survival group according to the 28-day outcome and there was no significant difference in calprotectin between the two groups [4.80 (3.40, 5.76) μg/mL vs. 4.19 (2.89, 5.29) μg/mL, P < 0.05]. Conclusions:The level of calprotectin in the AKI group is higher than that in the non-AKI group. Calprotectin can be regarded as an effective predictor of AKI in patients with sepsis, and the combination with APACHEⅡ score or SOFA score will improve its predictive efficacy. However, there is no significant difference in the concentration of calprotectin for patients with sepsis associated AKI with different prognosis.