Research from JAMA — Predictive Value for the Chinese Population of the Framingham CHD Risk Assessment Tool Compared With the Chinese Multi-provincial Cohort Study — ContextThe Framingham Heart Study helped to establish tools to assess coronary heart disease (CHD) risk, but the homogeneous nature of the Framingham population prevents simple extrapolation to other populations. Recalibration of Framingham functions could permit various regions of the world to adapt Framingham tools to local populations.ObjectiveTo evaluate the performance of the Framingham CHD risk functions, directly and after recalibration, in a large Chinese population, compared with the performance of the functions derived from the Chinese Multi-provincial Cohort Study (CMCS).Design, Setting, and ParticipantsThe CMCS cohort included 30 121 Chinese adults aged 35 to 64 years at baseline. Participants were recruited from 11 provinces and were followed up for new CHD events from 1992 to 2002. Participants in the Framingham Heart Study were 5251 white US residents of Framingham, Mass, who were 30 to 74 years old at baseline in 1971 to 1974 and followed up for 12 years.Main Outcome Measures"Hard" CHD (coronary death and myocardial infarction) was used as the end point in comparisons of risk factors (age, blood pressure, smoking, diabetes, total cholesterol, and high-density lipoprotein cholesterol [HDL-C]) as evaluated by the CMCS functions, original Framingham functions, and recalibrated Framingham functions.ResultsThe CMCS cohort had 191 hard CHD events and 625 total deaths vs 273 CHD events and 293 deaths, respectively, for Framingham. For most risk factor categories, the relative risks for CHD were similar for Chinese and Framingham participants, with a few exceptions (ie, age, total cholesterol of 200-239 mg/dL [5.18-6.19 mmol/L], and HDL-C less than 35 mg/dL [0.91 mmol/L] in men; smoking in women). The discrimination using the Framingham functions in the CMCS cohort was similar to the CMCS functions: the area under the receiver operating characteristic curve was 0.705 for men and 0.742 for women using the Framingham functions vs 0.736 for men and 0.759 for women using the CMCS functions. However, the original Framingham functions systematically overestimated the absolute CHD risk in the CMCS cohort. For example, in the 10th risk decile in men, the predicted rate of CHD death was 20% vs an actual rate of 3%. Recalibration of the Framingham functions using the mean values of risk factors and mean CHD incidence rates of the CMCS cohort substantially improved the performance of the Framingham functions in the CMCS cohort.ConclusionsThe original Framingham functions overestimated the risk of CHD for CMCS participants. Recalibration of the Framingham functions improved the estimates and demonstrated that the Framingham model is useful in the Chinese population. For regions that have no established cohort, recalibration using CHD rates and risk factors may be an effective method to develop CHD risk prediction algorithms suited for local practice.

High blood cholesterol is typically considered a feature of wealthy western countries ^1,2 . However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world ³ and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health ^4,5 . However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol—which is a marker of cardiovascular risk—changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million–4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Objective: To assess the relationship between fine particulate matter (PM_2.5) concentration and ischaemic heart disease (IHD) morbidity and mortality. Methods: A time-series study conducted in Beijing from 1 January 2010 to 31 December 2012. Data on 369 469 IHD cases and 53 247 IHD deaths were collected by the Beijing Monitoring System for Cardiovascular Diseases, which covers all hospital admissions and deaths from IHD from Beijing's population of 19.61 million. Results: The mean daily PM_2.5 concentration was 96.2 μg/m³ with a range from 3.9 to 493.9 μg/m³. Only 15.3% of the daily PM_2.5 concentrations achieved WHO Air Quality Guidelines target (25 μg/m³) in the study period. The dose–response relationships between PM_2.5 and IHD morbidity and mortality were non-linear, with a steeper dose–response function at lower concentrations and a shallower response at higher concentrations. A 10 μg/m³ increase in PM_2.5 was associated with a 0.27% (95% CI 0.21 to 0.33%, p<2.00×10⁻¹⁶) increase in IHD morbidity and a 0.25% (95% CI 0.10 to 0.40%, p=1.15×10⁻³) increase in mortality on the same day. During the 3 years, there were 7703 cases and 1475 deaths advanced by PM_2.5 pollution over expected rates if daily levels had not exceeded the WHO target. Conclusions: PM_2.5 concentration was significantly associated with IHD morbidity and mortality in Beijing. Our findings provide a rationale for the urgent need for stringent control of air pollution to reduce PM_2.5 concentration.

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

To estimate individual and household economic impact of cardiovascular disease (CVD) in selected low- and middle-income countries (LMIC). Empirical evidence on the microeconomic consequences of CVD in LMIC is scarce. We surveyed 1,657 recently hospitalized CVD patients (66% male; mean age 55.8 years) from Argentina, China, India, and Tanzania to evaluate the microeconomic and functional/productivity impact of CVD hospitalization. Respondents were stratified into three income groups. Median out-of-pocket expenditures for CVD treatment over 15 month follow-up ranged from 354 international dollars (2007 INT$, Tanzania, low-income) to INT$2,917 (India, high-income). Catastrophic health spending (CHS) was present in >50% of respondents in China, India, and Tanzania. Distress financing (DF) and lost income were more common in low-income respondents. After adjustment, lack of health insurance was associated with CHS in Argentina (OR 4.73 [2.56, 8.76], India (OR 3.93 [2.23, 6.90], and Tanzania (OR 3.68 [1.86, 7.26] with a marginal association in China (OR 2.05 [0.82, 5.11]). These economic effects were accompanied by substantial decreases in individual functional health and productivity. Individuals in selected LMIC bear significant financial burdens following CVD hospitalization, yet with substantial variation across and within countries. Lack of insurance may drive much of the financial stress of CVD in LMIC patients and their families.