| Objective:To study the effect of clinical treatment,which is evidenced as effective,of CAD patients(including STEMI,NSTEMI,UAP and SAP),including the distribution of hazardous factors,medicinal treatment and intervention;and to study whether theintervention therapy in the first year follow-up of the post-discharge coronary artery disease(CAD)patients,a program participated by provincial,municipal and county hospitals in southwest China's Yunnan province,is an effective way to improve patient compliance witih secondary prevention and to reduce major adverse cardiovascular events(MACE).Methods:1.The Department of Cardiology at the First Affiliated Hospital of Kunming Medical University,as the leading unit,selected two municipal hospitals randomly,namely the Wenshan People's Hospital of Yunnan and Baoshan People's Hospital of Yunnan.To avoid two hospitals in the same city,it then selected the People's Hospital of Yulong County in Lijiang and People's Hospital of Luoping County in Qujing.All of them are qualified to conduct CAD intervention,based on which an online data platform and database are established for this study.This study doesn't interfere in those hospitals'medical operations.Information about CAD patients that were treated at and discharged from those five hospitals from September 1,2014 to August 31,2015 was selected based on their medical records,including basic information,sociological features,hazardous factors,medical history,clinical information this time,lab record,reperfusion therapy/vascular remodeling,medication in the hospital,discharge diagnosis,post-discharge medication,,length of hospitalization and expense.Personnel at those hospitals collected the information,input it online and submitted it to the backstage for review by specific personnel.Two percent of the medical records were selected randomly for on-site review.2.Altogether 2,119 CAD patients treated at and discharged from those five hospitals from September 1,2014 to August 31,2015 were recruited by the program with their approval,with 915 patients randomly assigned in the intervention group and 1,204 in the control group.The control group only received follow-up one year after discharge,but the intervention group received face-to-face interview before discharge and a one-year follow-up after discharge,including 13 phone calls and face-to-face interviews one month,6 months and 12 months after discharge.Contents of the interview included MACE,compliance with secondary prevention medicine and vital signs,lab results,and change of lifestyle.Results:I.Sample survey of CAD treatment status in Yunnan1.The top three hazardous factors of cardiovascular disease are smoking(52.6%),overweight/obesity(63.1%)and high blood pressure(46.3%).15.8.%of the patients had diabetes,11.1%had HLP,and 27.9%didn't do enough exercises.CAD patients under the age of 55 had a higher proportion of male,overweight,HLP,smoking and frequent use of greasy food than the group of and above 55 years old,and patients of and above 55 had a higher proportion than the group below 55 in the number of patients with only accompanied hypertension(51.2%vs 31.2%),the difference with statistical significance(P<0.001).Male patients had a higher proportion of smoking and hypertension than female ones,and the difference in smoking(64.7%vs 16.4%)and hypertension(49.3%vs 37.4%)was of statistical significance(P<0.001).STEMI patients had more accompanied hazardous factors subject to intervention than other CAD patients.2.In provincial,municipal and couty-level hospitals,the use rate of aspirin was 99.1%.99%and 97.2%,the use rate of clopidogrel was 98.9%,95.8%and 88.6%,and the use rate of statins was 83.6%,77.9%and 76.1%,the difference all of statistical significance(P<0.05).The use rate of anticoagulant was 63.1%,62.3%,63.5%,that of ACEI/ARB was 74.3%,73.5%and 73.7%,that of p-blocker was 75.3%,73.9%and 72.5%,and that of gastric acid inhibitor was 86.3%,87.9%and 85.1%,the difference of no statistical significance(P>0.05).3.With STEMI,NSTEMI and UAP patients,the use rate of aspirin was 99.6%,97.9%and 99.2%,the difference of statistical significance(P=0.001).The use rate of clopidogrel was 98.8%,97.1%and95.5%,that of statins was 86.4%,87.2%and 78.2%,and that of ?-blocker was 78%,77.1%and 73.9%,the difference of statistical significance(P<0.05).The use rate of ACEI/ARB was 73.8%,75.9%and 76.3%,the difference still of statistical significance(P=0.045).4.Of the 778 STEMI patients,342(43.96%)were sent to the hospital within 24 hours,and their PCI rate at the provincial hospital(76.6%)was obviously higher than in municipal(12.6%)and county-level hospitals(19.2%).46.4%of the patients at municipal hospitals received thrombolytic therapy,higher than the 28.8%in county-level hospitals and 3.7%in provincial hospital,and the reperfusion rate at the provincial hospital(80.3%)was higher than in municipal(59%)and county-level hospitals(48%),the difference all of statistical significance(P<0.001).5.With STEMI patients,in addition to aspirin and clopidogrel,the proportion of using statins,?-blocker,ACEI/ARB and anticoagulant decreased from the low-risk to the high-risk group based on GRACE rating,and the high-risk group had the lowest proportion of receiving the recommended medicine.In provincial,municipal and county-level hospitals,the reperfusion rate of STEMI patients in the GRACE low-risk group was 87.5%,56.25%and 66.7%,the difference of no statistical significance(P=0.083),that in the medium-risk group was 93.75%,63.5%and 57.1%,and that in the high-risk group was 68.6%,55.8%and 40.6%,the difference of statistical significance(P=0.042).High-risk patients had a lower proportion of using reperfusion therapy than low-risk and medium-risk patients.II.Randomized comparison of CAD patients in one-year post-discharge follow-up1.992 patients(82.4%)in the control group completed the interviews one year after discharge;in the intervention group,863(94.3%)completed the one-month interview,816(89.2%)completed the six-month interview,and 780 patients(85.2%)completed the one-year interview.One year after discharge,the differences between the two groups had no statistical significance(P=0.079).27.7%of the patients in the intervention group had face-to-face interview in that year,higher than the 22.7%in the control group,and the difference had statistical significance(P<0.01).Municipal hospitals had 95%interview completion rate,higher than the 86.2%in county-level hospitals and 75.8%in provincial hospital,the difference of statistical significance(P<0.001).But county-level hospitals had the highest completion rate of face-to-face interview(57.6%),far higher than the 25.2%in municipal hospitals and 17.3%in provincial hospital,the difference of statistical significance(P<0.001),2.One year after discharge,the difference between the intervention group and control group in death,non-fatal MI,PCI,CABG,stroke and bleeding had no statistical significance(P>0.05).The intervention group had fewer unplanned revascularization,unplanned hospitalization and MACE than control group(P<0.05).3.NSTEMI patients had a higher incidence rate of MACE,unplanned revascularization and unplanned hospitalization than STEMI,UAP and SAP patients,the difference of statistical significance(P<0.05).GRACE high-risk patients had the MACE incidence rate of 39%,higher than medium-risk group(23.9%)and low-risk group(15.2%),the difference of statistical significance(P<0.001).The incidence rate of death and unplanned hospitalization in the high-risk group was 8.2%and 22.4%,respectively,higher than the medium-risk group(4.7%,14.1%)and low-risk group(1.8%,8.7%),the difference of statistical significance(P=0.012,P?0.001).4.The differences between the intervention group and control group in BMI,SBP,DBP and frequency of exercise had no statistical significance(P>0.05)one year after discharge.The intervention group had fewer RHR and LDL-C than the control group and higher LVEF,average time of exercise and medicine fee than the control group(P<0.05).5.One year after discharge,the differences between the two groups in the use of ACEI/ARB and p-blocker had no statistical significance(P?0.05).The intervention group had a higher proportion of using aspirin,Clopidogrel and statins than the control group(P<0.05).But the use of aspirin,Clopidogrel,?-blocker and ACEI/ARB was obviously reduced from the use during hospitalization.NSTEMI and STEMI patients had higher medicine compliance than UAP and SAP patients.6.Multi-factor logistic regression analysis showed that smoking[OR=2.43,95%CI(1.47,4.21)],frequent exercise[OR=0.88,95%CI(0.83,0.93)],snoring at night[OR=1.21,95%CI(1.08,1.41)],diabetes[OR=1.05,95%CI(1.01,1.09)],and aspirin[OR=0.66,95%CI(0.52,0.83)]are factors that affect the incidence of MACE(P ?0.05).Conclusions:1.66.6%of the CAD patients in this program had at least two correctible cardiovascular hazardous factors.Classic factors such as smoking,overweight/obesity,hypertension,diabetes and HLP were poorly controlled.2.The situation with level-2 CAD prevention medicine was similar in hospitals of the three different levels and was consistent with the latest research data in China,but the use rate of ?-blocker and ACEI/ARB was low,indicating much room for improvement.3.Only 43.96%of the STEMI patients were sent to hospital within 24 hours.80.3%patients at the provincial hospital received reperfusion treatment,which was applied less in municipal and county-level hospitals.More efforts should be made to foster the cardiologic team and promote the application of the guide in the clinical treatment of cardiovascular disease.4.ACS patients in the GRACE high-risk group had a lower proportion of accepting revascularization and recommended medicinal treatment.Evidence-based treatment of high-risk patients in strict accordance with the guide can improve clinical prognosis and the quality of treatment.5.The one-year follow-up intervention therapy on CAD patients from provincial,municipal and county-level hospitals in Yunnan province can improve the patient's lifestyle,increase their compliance with secondary prevention and reduce MACE.6.Multi-factor logistic regression analysis showed that smoking,frequent exercise,snoring at night,diabetes,and aspirin are factors that affect the incidence of MACE... |
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