BackgroundDespite the widespread use of inhalation therapy, patients with chronic obstructive pulmonary disease (COPD) frequently experience suboptimal disease control due to medication nonadherence, improper inhaler use technique, and inappropriate device selection, which collectively impair health-related quality of life (HRQoL). Pharmacist-led interventions may help address these gaps. Interventions based on the information-motivation-behavioral skills model and supported by digital tools can improve adherence and self-management. This study evaluates the efficacy of a multifaceted pharmaceutical care intervention for COPD delivered through digital tool support. ObjectiveThe primary objective is to compare the change in HRQoL, measured using the St George’s Respiratory Questionnaire, between the intervention and control groups from baseline to 12 months. Secondary objectives are to assess changes in medication adherence (Test of Adherence to Inhalers), quality of life (EQ-5D-5L), COPD-related medical costs, and patient-reported pharmacy service experience. MethodsThis 1-year cluster randomized controlled trial evaluates a multifaceted pharmaceutical care intervention in adults with moderate to very severe COPD (Global Initiative for Chronic Obstructive Lung Disease, stages 2-4) who have confirmed suboptimal inhaler practice but remain matched to an appropriate inhaler device based on peak inspiratory flow rate measured using a digital tool. In total, 34 hospital-based cough and wheeze pharmaceutical care clinics were recruited and randomized (1:1) to either an intervention or a control group. The target sample size is 15 patients per site. Participants in the intervention group will receive tailored support using electronic adherence monitoring, inhaler use technique assessments, and peak inspiratory flow rate to optimize device selection and self-management. Participants in the control group will receive usual pharmaceutical care. Descriptive statistics will be used to summarize participant characteristics and outcomes. Linear mixed effects models will be used to compare primary and secondary outcomes. Subgroup analyses will explore effects by age, sex, education level, place of residence, and smoking status. Pharmacy service survey data will be analyzed qualitatively. ResultsThe trial was registered on July 15, 2024. Recruitment started on November 9, 2024, and enrollment was completed by December 31, 2025. As of December 31, 2025, we enrolled 454 participants, of whom 16 (3.5%) had completed the 12-month follow-up. The trial is expected to be completed by December 31, 2026, with results planned for publication in 2027. ConclusionsThis multifaceted, pharmacist-led pharmaceutical care intervention may provide a scalable model for improving COPD management and HRQoL. If effective, the digitally supported program, grounded in the information-motivation-behavioral skills model, could be implemented in more than 1000 cough and wheeze pharmaceutical care clinics nationwide. Trial RegistrationChinese Clinical Trial Registry ChiCTR2400086943; https://tinyurl.com/75a9phbw International Registered Report Identifier (IRRID)DERR1-10.2196/82806

BACKGROUND:It is challenging to achieve sustained blood pressure (BP) lowering by traditional lifestyle guidance including exercise. OBJECTIVES:We aimed to evaluate the short-term effects of baduanjin on ambulatory BP with monitoring and long-term effects without monitoring among individuals with high-normal BP. METHODS:We conducted a multicenter, open-label, blinded-outcome randomized controlled trial at 7 communities. Participants aged ≥40 years with systolic blood pressure (SBP) 130 to 139 mm Hg and/or diastolic BP 85 to 89 mm Hg were randomly assigned in a 2:1:1 ratio to the baduanjin, self-directed exercise alone, or brisk walking arms for a 52-week intervention. The primary outcomes were the changes in 24-hour SBP from baseline to 12 and 52 weeks. Intention-to-treat analyses of primary outcomes followed a hierarchical testing sequence: 1) superiority of baduanjin vs self-directed exercise alone at 12 weeks; 2) superiority of baduanjin vs self-directed exercise alone at 52 weeks; and 3) superiority of baduanjin vs brisk walking at 52 weeks. RESULTS:Among 216 eligible participants (mean age 57.3 years; 64.8% women), 108, 54, and 54 participants were randomly assigned to the baduanjin, self-directed exercise alone, and brisk walking arms, respectively. The baduanjin arm obtained a significantly greater reduction in 24-hour SBP compared with the self-directed exercise alone arm at 12 weeks (-3.1 mm Hg; 95% CI: -5.9 to -0.2 mm Hg; P = 0.036) and 52 weeks (-3.3 mm Hg; 95% CI: -6.3 to -0.3 mm Hg; P = 0.031). There was no significant difference between the baduanjin and brisk walking arms (-0.7 mm Hg; 95% CI: -3.9 to 2.6 mm Hg; P = 0.683) at 52 weeks. The effects were not heterogeneous across subgroups. No significant difference in adverse events was detected across 3 arms. CONCLUSIONS:Baduanjin lowered SBP after 3 months of intervention in individuals with high-normal BP, with sustained BP-lowering effect until 1 year without monitoring, and showed comparable efficacy to brisk walking. (Baduanjin Lowering Elevated Blood PreSsure Study [BLESS]; NCT05397535).

Introduction Chronic obstructive pulmonary disease (COPD) represents a major public health challenge in China, with management delivered across all levels of the health system. Medication burden may undermine medication adherence and health-related quality of life (HRQoL), yet the pathways linking these factors remain unclear. This study evaluated the association between medication burden and HRQoL and examined whether medication adherence mediates this relationship from a multilevel health system perspective. Methods A multicentre cross-sectional study was conducted across healthcare institutions participating in the Cough and Wheeze Pharmaceutical Care Clinic network between September 2023 and September 2024. Medication burden was assessed using the total prescribed drugs and the Medication Regimen Complexity Index (MRCI). HRQoL was measured using the EuroQol 5-Dimension 5-Level Questionnaire, and adherence was evaluated with the Adherence to Refills and Medications Scale. Structural equation modelling assessed direct and indirect pathways, and mediation effects were estimated using percentile bootstrapping with 5000 resamples. Sensitivity analyses examined the robustness of the findings. Results A total of 2125 patients with COPD were included. Participants had a median of 1 (IQR 0–2) prescribed medications and a median MRCI of 8.0 (range 0.0–13.5). A higher number of medications was significantly associated with poorer HRQoL both directly (estimate = –0.025, 95% CI –0.038 to –0.012) and indirectly via lower adherence (estimate = –0.007, 95% CI –0.010 to –0.003). While MRCI demonstrated no significant direct association with HRQoL, an indirect effect through adherence was observed (estimate = –0.001, 95% CI –0.002 to –0.001). All findings remained consistent across sensitivity analyses. Conclusions Across multiple levels of the healthcare system, medication adherence partially mediated the association between medication burden and HRQoL in patients with COPD. These findings highlight medication regimen optimisation and adherence support as important public health strategies for improving patient-centred COPD care.

BACKGROUND:The multicenter, randomized, sham-controlled FAVOR III China trial (Comparison of Quantitative Flow Ratio-Guided and Angiography-Guided Percutaneous Intervention in Patients with Coronary Artery Disease) demonstrated that quantitative flow ratio (QFR)-guided percutaneous coronary intervention (PCI) resulted in better outcomes compared with angiographic guidance at 1-year and 2-year follow-up. Whether these benefits are sustained over long-term follow-up remains uncertain. OBJECTIVES:The purpose of this study was to evaluate the long-term effectiveness and safety of a QFR-guided PCI strategy compared with angiography-guided PCI at 5 years. METHODS:Patients with at least 1 angiographically intermediate coronary lesion (50%-90% diameter stenosis) in a vessel ≥2.5 mm diameter were randomized to a QFR-guided (PCI performed only if QFR ≤0.80) or angiography-guided strategy. The primary endpoint was major adverse cardiac events (a composite of all-cause death, myocardial infarction, or ischemia-driven revascularization) at 1 year; 5-year outcomes data are reported herein. RESULTS:At 5 years, major adverse cardiac events composite was lower with QFR guidance than with angiography guidance (17.5% vs 21.1%; HR: 0.80; 95% CI: 0.69-0.92; P = 0.002), driven by fewer myocardial infarctions (5.8% vs 9.0%; HR: 0.63; 95% CI: 0.49-0.80; P < 0.0001) and ischemia-driven revascularizations (9.6% vs 12.0%; HR: 0.78; 95% CI: 0.64-0.95; P = 0.02) in the QFR-guided group. All-cause death did not differ between groups. Landmark analysis showed that the benefit of QFR guidance accrued predominantly within the first 2 years (8.5% vs 12.5%; HR: 0.66; 95% CI: 0.54-0.81; P < 0.0001), with similar outcomes between 2 and 5 years (10.2% vs 11.2%; HR: 0.90; 95% CI: 0.73-1.11; P = 0.32; P for interaction = 0.001). CONCLUSIONS:Compared with angiography guidance, QFR-guided strategy improved 5-year clinical outcomes, with benefits primarily achieved within the first 2 years. (The FAVOR III China Study; NCT03656848).

Corporate cash holdings reflect a trade-off between the precautionary benefits of internal liquidity and the opportunity and agency costs of retaining cash. We examine how foreign (northbound) ownership affects this trade-off in China’s A-share market. Using quarterly data from 2016 to 2025, we find that cash holdings are positively associated with persistent realized northbound ownership, but not with short-term ownership changes. Formal Stock Connect access alone does not explain the pattern. Realized ownership is the more relevant margin. Cash-based sorting tests indicate that the result is not driven by foreign investors simply selecting firms with high pre-existing cash balances. The association is stronger when precautionary liquidity demand is high and internal cash-generation capacity is strong. Cash holdings are also more positively associated with firm valuation when persistent northbound ownership is higher. Overall, the evidence qualifies a uniform external-substitution view of foreign ownership and supports an agency-discount and conditional-complementarity interpretation: persistent realized foreign ownership is associated with higher cash buffers when retained liquidity remains valuable and feasible to accumulate.

PURPOSE:This study assessed whether China's workday-rescheduling policy is associated with short-term and long-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI), particularly in occupational groups more likely to be affected by rescheduling. METHODS:A prospective cohort study was conducted using data from the China Acute Myocardial Infarction registry between January 2013 and September 2014. A total of 15 854 STEMI patients were included. Since individual adherence to workday rescheduling is not directly measured in the registry, occupational category was used as a proxy to define groups more likely versus less likely to be affected by the workday-rescheduling policy. The primary outcome was in-hospital all-cause mortality. Secondary outcomes included in-hospital major adverse cardiovascular and cerebrovascular events (MACCE) and 2 year all-cause mortality. Multivariable logistic and Cox regression models were used for analysis. FINDINGS:Using occupational category as a proxy for the likelihood of exposure to workday rescheduling, we stratified patients into a rescheduling-likely group (n=3141) and a rescheduling-unlikely group (n=12 713). Among patients in the rescheduling-likely occupational group, in-hospital mortality was significantly higher during abnormal workdays than conventional weekdays (7.8% vs 3.44%; adjusted OR=3.01; 95% CI 1.40 to 6.45). Two-year mortality was also higher (adjusted HR=1.99; 95% CI 1.20 to 3.30). Among 12 713 patients in the rescheduling-unlikely occupational group, no significant mortality differences were observed across temporal groups. Within the rescheduling-likely group, baseline characteristics and care quality indicators were generally comparable across the four temporal groups. CONCLUSIONS:Workday-rescheduling-induced abnormal work cycles are associated with higher in-hospital and 2 year adverse events in affected ST-segment elevation myocardial infarction patients. These findings should be interpreted as heterogeneity in the association between abnormal workdays and mortality by occupational likelihood of rescheduling exposure rather than as a direct individual-level causal effect of rescheduling.

BACKGROUND:The novel thin-strut sirolimus-eluting iron bioresorbable scaffold (IBS) demonstrated safety and efficacy in a nonrandomized first-in-human study. OBJECTIVES:The objective of this study was to compare the IBS with contemporary metallic cobalt chromium everolimus-eluting stents (CoCr-EES) in patients with coronary artery disease. METHODS:IRONMAN-II was a prospective, multicenter, single-blinded, noninferiority randomized trial across 36 centers in China. Eligible patients had myocardial ischemia and 1 or 2 de novo target lesions. Patients were randomly assigned (1:1) to IBS or CoCr-EES, with allocation masked. Optical coherence tomography (OCT) was performed in the first 25 participant pairs. Clinical follow-up was scheduled at 1, 6, and 12 months, and annually to 5 years, with angiographic and OCT follow-up at 2 years. The primary endpoint was 2-year angiographic in-segment late lumen loss (LLL). Powered secondary endpoints included target vessel quantitative flow ratio (QFR) and OCT-derived cross-sectional mean flow area. Other secondary endpoints included target lesion failure (cardiac death, target vessel myocardial infarction [MI], or ischemia-driven target vessel revascularization), the patient-oriented composite endpoint (all-cause death, MI, or any revascularization), their individual components, and device thrombosis. RESULTS:Between March 10 and December 13, 2022, 518 patients were randomized to IBS (n = 259) or CoCr-EES (n = 259). At 2 years, lesion-level in-segment LLL was 0.28 (0.52) mm with IBS and 0.23 (0.43) mm with CoCr-EES (difference: 0.08 mm; 95% CI: -0.02 to 0.18; Pnoninferiority = 0.03). Mean QFR was 0.90 (0.13) with IBS and 0.92 (0.09) with CoCr-EES (difference: -0.02; 95% CI: -0.04 to 0; Pnoninferiority = 0.05). Mean OCT flow area was 6.92 (3.48) mm2 with IBS and 6.64 (2.44) mm2 with CoCr-EES (difference: 0.27; 95% CI: -0.09 to 0.63; Pnoninferiority < 0.0001). Two-year target lesion failure occurred in 7.4% of IBS patients and 5.4% of CoCr-EES patients (HR: 1.37; 95% CI: 0.69-2.73; P = 0.37). No significant between-group differences in the rates of patient-oriented composite endpoint, death, or MI were present between the 2 groups. No scaffold thromboses occurred in the IBS group, whereas 1 stent thrombosis occurred with CoCr-EES. Binary restenosis and revascularization rates were higher with IBS, however, most such events were non-ischemia-driven. CONCLUSIONS:In IRONMAN-II, the sirolimus-eluting IBS was noninferior to CoCr-EES for 2-year in-segment LLL, QFR, and OCT-derived flow area. Clinical event rates were also comparable between groups although non-ischemia-driven revascularization rates were higher after IBS. Longer-term follow-up is necessary to demonstrate whether late benefits are realized after complete IBS resorption. (A Clinical Investigation to Evaluate the Safety and Efficacy of IBS in Patients With Coronary Artery Disease; NCT05206084).

BACKGROUND:The routine implementation of heart teams for patients with complex coronary artery disease (CAD) is challenging due to the insufficient multidisciplinary specialist resources for face-to-face discussion. A real-time heart team during the angiography, based on an online meeting, offers the potential to efficiently integrate resources. OBJECTIVES:In this study, we sought to evaluate the implementation value and safety of a "real-time heart team" decision making approach. METHODS:This noninferiority randomized controlled trial enrolled patients with de novo left main or 3-vessel CAD at 3 cardiac centers. Patients were randomly assigned to the conventional heart team group (discussed by a face-to-face meeting after the angiography) or the real-time heart team group (discussed by an online meeting during the angiography). Implementation value outcomes included care efficiency (waiting time for treatment, recatheterization, specialist workload, and economic outcomes) and process evaluation metrics (discussion adequacy, surgeon participation, and shared decision making). The safety outcomes were a composite of 1-year major adverse cardiovascular and cerebrovascular events (MACCE) (including all-cause mortality, myocardial infarction, stroke, unplanned revascularization, and readmission due to reangina) and revascularization decision making. RESULTS:Overall, 490 complex CAD patients were included, with 245 patients in each group. Waiting time for final therapy (median: 2 days [Q1-Q3: 0-7 days] vs 5 days [Q1-Q3: 2-10 days]; P < 0.001), recatheterization rate (12.5% vs 98.9%; P < 0.001), specialist high workload rate (5.3% vs 29.0%; P < 0.001), and percutaneous coronary intervention (PCI) hospitalization cost (percentage of decrease: 18.0%; P < 0.001) were significantly reduced in the real-time group. More discussion time spent (4.0 ± 1.8 min vs 3.4 ± 1.6 min), better specialist satisfaction (based on NASA Task Load Index scale), more chief surgeon participation (26.5% vs 18.8%), but less multidisciplinary synchronous shared decision making (2.0% vs 11.5%) were found in the real-time group. The real-time heart team group was noninferior to the conventional group in 1-year MACCE (8.2% vs 10.6%; risk difference: -2.45%; 95% CI: -7.61%-2.71%; P for noninferiority < 0.001). The proportions of PCI, coronary artery bypass grafting, and medical therapy were similar between the 2 groups (P = 0.892). CONCLUSIONS:Compared with the conventional heart team, the real-time heart team significantly improved care efficiency and process evaluation metrics, with similar clinical outcomes and decision making. However, insufficient shared decision making and intercenter generalizability should be optimized before widespread implementation of this approach. (Feasibility and Effectiveness of a Real-Time Heart Team Approach in Complex CAD [EHEART; NCT05514210]).

Abstract Background Secondary prevention of coronary heart disease (CHD) remains suboptimal due to fragmented care and therapeutic inertia. While digital health interventions offer a promising strategy, few existing tools provide comprehensive, closed-loop management of multidimensional risk factors without increasing clinician workload. This study aimed to evaluate the efficacy of an artificial intelligence (AI)–enhanced management system (AIM-CHD) in improving multidimensional risk factor control among patients with CHD. Methods This single-center, open-label, parallel-group, randomized clinical trial was conducted from November 2024 to June 2025 in China. A total of 1100 adults with confirmed CHD were randomized 1:1 to receive either the AIM-CHD intervention ( n = 549) or usual care ( n = 551) for 3 months. The AIM-CHD system featured automated multi-source data capture, guideline-directed risk stratification, and closed-loop feedback via smartphone. The primary outcome was the low-density lipoprotein cholesterol (LDL-C) level at 3 months. Secondary outcomes included goal attainment rates for LDL-C (< 70 mg/dL) and blood pressure (BP, < 130/80 mm Hg), glycated hemoglobin, smoking cessation, body mass index (BMI), medication adherence, and a composite cardiovascular endpoint at 3 months. Analysis was performed on an intention-to-treat (ITT) basis. Results Of 1100 randomized participants (mean age 61 years; 75.3% male), 943 (85.7%) completed the 3-month follow-up. The intervention group achieved a significantly lower mean LDL-C level compared with the control group (60.4 ± 23.4 vs. 63.7 ± 26.0 mg/dL), with an adjusted mean difference of − 3.2 mg/dL (95% CI, − 6.2 to − 0.3; p = 0.03). Furthermore, participants in the intervention group were more likely to achieve the LDL-C target (71% vs. 64%; RR, 1.10; 95% CI, 1.01–1.20; p = 0.03) and the BP target (45% vs. 35%; RR, 1.27; 95% CI, 1.09–1.48; p = 0.002). No significant differences were observed for HbA1c, BMI, or medication adherence. Conclusions The AIM-CHD system significantly improved short-term lipid and BP control compared with usual care. These findings support interoperable, low-burden digital management systems as a scalable strategy in routine secondary prevention. Trial registration ClinicalTrials.gov Identifier: NCT06686056. Registered on 11 November 2024.

OBJECTIVES:The win ratio (WR) has been used with increasing frequency in clinical trials with hierarchical composite end points. This meta-epidemiological study aims to systematically evaluate the contemporary use of the WR in clinical trials. Specifically, we sought to (1) describe temporal trends in WR application, (2) quantify its use across therapeutic areas, and (3) examine component directional contributions and conclusion consistency between analyses summarized by the WR and the original analyses. METHODS:We conducted a systematic review (PRISMA 2020) of PubMed, Embase, and Web of Science (search date: 26 March 2025). Eligible studies were published clinical trials or reanalyses that summarized treatment effects using the WR based on individual data. Studies were classified by application type (prespecified vs reanalysis) and mapped to International Classification of Diseases (ICD-10) categories. After inclusion, we further screened for studies with comparable data, then performed two comparisons: first, the component directional contribution between end point component and the overall WR result; and second, the conclusion-level consistency between each WR-reported analyses and the conclusions of the original trials. RESULTS:A total of 90 studies were included: 35 prespecified end point analyses and 55 reanalyses. Circulatory system trials accounted for about 80% of the applications. We included 57 studies for comparison, and discrepancies between component-level results and overall conclusions were common. In prespecified end point analyses, 36 of 139 components (25.9%) had directional discordance or neutrality with the overall WR point estimate, compared with 17.0% in reanalyses, although the difference was not statistically significant (generalized linear mixed-effects model with study as a random effect, P = .114). Among the 35 studies included for conclusion-level comparison, 22 reached WR-reported conclusions that were consistent with those of the original trials. Nearly all observed discrepancies in conclusions were associated with changes in the selection or prioritization of end point components. CONCLUSION:The use of the WR in clinical research has steadily increased and is expanding beyond cardiovascular trials. Hierarchical composite end points constructed using the WR may differ from conventional composites in component selection, and directional discordance among components is not uncommon. In WR-reported reanalyses, changes to end point components may influence clinical interpretation. Careful attention to the appropriate use of the analytical framework, end point definition, and result interpretation is essential to ensure the interpretability and validity of WR-reported analyses.

BACKGROUND:Prolonged sedentary time is associated with adverse outcomes, but evidence in low-exposure ranges remains limited. The health effects of reallocating time between sitting, physical activity, and sleep have not been comprehensively examined. METHODS:We analyzed 41,733 adults (mean age = 50.6 years) from the Prospective Urban Rural Epidemiology (PURE)-China cohort, recruited between 2005 and 2009 and followed for a median of 11.9 years. Sitting, physical activity, and sleep were assessed using validated questionnaires. The primary outcome was a composite of all-cause mortality and major cardiovascular events. Cox frailty and isotemporal substitution models were applied. RESULTS:Median sitting time was 3.0 h/day (interquartile range (IQR): 1.7-4.6). Sitting showed a J-shaped association with outcomes, with lowest risk around 4 h/day. Both low (<2 h/day) and high (≥6 h/day) sitting were associated with higher risk. Among participants sitting ≥4 h/day, replacing 30 min of sitting with physical activity was associated with a 3%-4% lower risk of the composite outcome, with stronger associations observed for all-cause mortality (6%-7%). In contrast, among those sitting <4 h/day, reallocating 30 min of physical activity or prolonged sleep to sitting was associated a 4%-6% lower risk of the composite outcome and a 4%-10% lower risk of all-cause mortality. CONCLUSION:Sitting time demonstrates context-dependent associations with health. The finding that moderate sitting was protective in highly active individuals reflects a potential "sitting paradox". Our study highlights the bidirectional effects of reallocating sitting, activity, and sleep, underscoring the need for more context-specific guidance.

Dyslipidemia is a major contributor to cardiovascular disease. The C-reactive protein - triglyceride - glucose index (CTI), which reflects insulin resistance and systemic inflammation, has increasingly been recognized as a potential marker for metabolic disturbances. However, its predictive value for incident dyslipidemia remains uncertain, and the role of physical activity in this association requires further clarification. This study prospectively examined the association between CTI and the risk of dyslipidemia, and further assessed whether physical activity modifies this relationship in middle-aged and older Chinese adults. A total of 7,954 participants aged ≥45 years without dyslipidemia at baseline were enrolled, using data from the China Health and Retirement Longitudinal Study (2011-2020). Physical activity was assessed using the CHARLS physical activity questionnaire, which captures the frequency and duration of vigorous, moderate, and light activities. Based on the frequency and duration of these activities, participants were categorized into low, moderate, and high physical activity groups. CTI was derived from high-sensitivity C-reactive protein, fasting plasma glucose, and triglyceride levels. Incident dyslipidemia was defined based on abnormal lipid profiles, ongoing lipid-lowering treatment, or a physician’s clinical diagnosis. Cox proportional hazards regression with restricted cubic splines was applied to evaluate associations, with stratified analyses by sex, age, and physical activity level. During 10 years of follow-up, 2,011 new cases of dyslipidemia were recorded. Each 1-unit increase in CTI corresponded to approximately a 9% higher risk of dyslipidemia (HR = 1.09, 95% CI: 1.01-1.18). Individuals in the highest CTI quartile had a 15% greater risk compared with those in the lowest quartile (HR = 1.15, 95% CI: 1.01-1.30). Stronger associations were observed in men (HR = 1.20, 95% CI: 1.05-1.36) and adults aged 45-59 years (HR = 1.22, 95% CI: 1.08-1.39), whereas no significant effect was found in women. When stratified by physical activity, a 1-unit CTI increase was linked to about a 10% higher risk in the light and moderate activity groups, and to a 28% higher risk in the vigorous activity group, with risk plateauing at higher CTI levels. Elevated CTI was prospectively associated with an increased risk of dyslipidemia, particularly in men and individuals in midlife. Physical activity appeared to influence this relationship, suggesting that CTI could serve as a practical marker for early risk stratification. These findings underscore the importance of regular exercise in preventing dyslipidemia.

Background: Although prolonged sedentary time is linked to adverse health outcomes, evidence regarding its dose–response relationship in the low-exposure ranges remains limited. Moreover, the effects of reallocating time between sedentary behavior, physical activity, and sleep on all-cause mortality and cardiovascular disease have not been comprehensively examined. To address these gaps, we evaluated bidirectional time reallocations among sedentary behavior, physical activity, and sleep in a Chinese cohort. Methods: We analyzed data from the PURE-China study, which recruited 47,931 participants aged 35 to 70 years from 115 communities across 12 provinces between 2005 and 2009 in China and followed up every three years Sitting time, physical activity, and sleep duration were assessed using validated questionnaires. The primary outcome was a composite of all-cause mortality and major cardiovascular events. Cox frailty models were used to examine the associations of sitting time with outcomes. Isotemporal substitution models were applied to estimate the bidirectional reallocations of time between sedentary behavior, physical activity, and sleep. Results: Among 41,733 participants with a median follow-up of 11.9 years, the mean age was 50.6 ± 9.7 years, and the median sitting time was 3.0 hours/day (IQR: 1.7–4.6). Sitting time showed a J-shaped association with the composite outcome, with the lowest risk observed at 2–4 h/day. Both low (<2 h/day) and high (≥6 h/day) levels of sitting were associated with increased risks of all-cause mortality and composite outcome. Among participants sitting ≥4 h/day, replacing 30 minutes of sitting with moderate-to-vigorous physical activity (MVPA) or work-related activity was associated with a 3–7% reduction in mortality risk. Conversely, among those sitting <4 h/day, reallocating time from physical activity or prolonged sleep to sitting time was associated with a 4%-10% reduction risk of mortality. Conclusions: Sedentary behavior shows context-dependent associations with health, where both low and high levels relate to higher risks. The “sitting paradox” observed in highly active individuals highlights the bidirectional effects of reallocating time between sitting, physical activity, and sleep. These findings underscore the need for more nuanced public health recommendations tailored to baseline activity and sedentary patterns.

Aims To investigate the diagnostic performance of computed tomography (CT)-based radiomics in detecting cardiac amyloidosis (CA) in patients with diffuse myocardial thickening. Methods and results Patients with diffuse myocardial thickening who underwent coronary CT angiography were retrospectively enrolled from five hospitals. Patients from one hospital were randomly divided into training and internal test cohorts at a 7:3 ratio, and the other four hospitals constituted the external test cohort. The diagnosis of CA followed established guidelines. Regions of interest of myocardium were delineated to extract radiomics features to construct the radiomics model, and myocardial CT attenuation was measured. The diagnostic performance and clinical utility of the radiomics model and myocardial CT attenuation were compared with the area under the curve and decision curve analysis. The correlation between radiomics score and left ventricular function was analysed. A total of 378 patients (median age, 57 years; 257 men) were enrolled. Ten features were selected to construct the radiomics model. The areas under the curve of radiomics model were significantly higher than myocardial CT attenuation in the training (0.95 vs. 0.58, P < 0.001), internal test (0.95 vs. 0.59, P < 0.001), and external test cohorts (0.91 vs. 0.64, P < 0.001). Decision curve analysis indicated the radiomics model provided a greater net benefit than myocardial CT attenuation across cohorts. Radiomics scores were correlated with N-terminal proB-type natriuretic peptide and left ventricular diastolic diameter across cohorts (P < 0.05). Conclusion The radiomics model exhibited good diagnostic performance for CA detection in patients with hypertrophic phenotypes, outperforming myocardial CT attenuation.

Background:The benefits of physiology-guided management in acute coronary syndrome (ACS) remain inconclusive due to limited evidence. In our FAVOR III China trial, a quantitative flow ratio (QFR)-based physiology-guided strategy versus standard angiography guidance improved the 1-year primary outcome among participants with coronary artery disease (CAD). We aimed to investigate, in a prespecified analysis, the outcomes of QFR-based physiological guidance in the FAVOR III China participants with low-risk ACS. Methods:This pre-specified secondary analysis included patients diagnosed with low-risk ACS who were enrolled in the FAVOR III China trial. The trial was a prospective, randomised study that assigned 3825 CAD patients to receive QFR-guided or angiography-guided percutaneous coronary intervention (PCI) at 26 hospitals in China between December, 2018 and January, 2020. The primary outcome of interest for this study was major adverse cardiac events (MACE), defined as a composite of all-cause death, myocardial infarction, and ischaemia-driven revascularisation, at 1-year (primary outcome of FAVOR III China) and 2-year follow-up. Secondary outcomes included PCI strategy change and the procedural characteristics. FAVOR III China is registered with ClinicalTrials.gov, NCT03656848. Findings:Of the 2371 participants with low-risk ACS (93.7% unstable angina and 6.3% non-ST elevation myocardial infarction [NSTEMI]) in the FAVOR III China trial, the QFR-guided strategy changed the original intended treatment plan in 23.6% of the low-risk ACS patients, resulting in more PCI deferrals (19.0% vs 3.8%; P < 0.001), less stenting (1.5 ± 1.1 vs 1.6 ± 1.0 per participant; P = 0.034), and shorter fluoroscopy time (13.7 ± 7.7 min vs 14.6 ± 7.1 min; P = 0.01) compared with the angiography-guided strategy. During follow-up, there was some evidence that the QFR guided strategy is superior to the angiography-guided approach at reducing the risk of MACE at 1-year follow-up (6.1% vs 8.2%; HR, 0.74; 95% CI, 0.54-1.01, P = 0.055), with a significant risk reduction at 2-year follow-up (8.3% vs 11.7%; HR, 0.70; 95% CI, 0.54-0.91, P = 0.009). The landmark analysis indicated consistent patterns both before and after 1 year (P interaction = 0.35). Interpretation:Our findings favoured the superiority of QFR-guided lesion selection strategy over standard angiography guidance in reducing long-term MACE for the low-risk ACS population. The benefits associated with QFR need to be confirmed by future studies with extended follow-up. Funding:The National High Level Hospital Clinical Research Funding, the Capital's Funds for Health Improvement and Research, the Chinese Academy of Medical Sciences, the Noncommunicable Chronic Diseases National Science and Technology Major Project, Shanghai Municipal Health Commission "Top Priority Research Centre", and Shanghai Shenkang Hospital Development Centre.

OBJECTIVES:A lack of standardization in heart team implementation potentially leads to suboptimal decision-making quality, and we previously established a modified heart team protocol to improve the decision-making quality. The present trial was to validate the effect of the modified heart team implementation protocol on improving the decision-making quality versus the conventional protocol in complex coronary artery disease (CAD). METHODS:Eligible interventional cardiologists, cardiac surgeons and non-interventional cardiologists were randomly allocated to the intervention or control arm and established 12 heart teams in each arm. The 12 heart teams in each arm were randomly divided into 6 pairs, and 480 historic cases with complex CAD into 6 sets of 80 cases. In each arm, each set of 80 cases was discussed independently by one pair of heart teams, with each case finally receiving two heart team decisions ('pairwise decisions'). The intervention arm conducted heart team decision-making according to the previously established protocol and the control arm based on guideline recommendations. The primary outcome was the overall percent agreement of the inter-team pairwise decisions. Decision-making appropriateness was further analysed. RESULTS:A total of 36 cardiac surgeons, 36 interventional cardiologists and 12 non-interventional cardiologists from 26 centres were enrolled. The overall percent agreement was significantly higher in the intervention arm than the control arm (72.1% vs 65.8%, P = 0.04; kappa 0.51 vs 0.37). Both team-level (19.4% vs 33.0%; P < 0.001) and specialist-level (interventional cardiologists, 19.8% vs 37.7%, P < 0.001; cardiac surgeons, 19.8% vs 28.7%, P < 0.001) inappropriateness rate of decision-making was significantly lower in the intervention arm than the control arm. CONCLUSIONS:The modified heart team implementation protocol improved the decision-making quality and appropriateness compared with the guideline-based protocol.