OBJECTIVES:To evaluate the efficacy of dual antiplatelet therapy (DAPT) for three months versus 12 months in saphenous vein graft occlusion while reducing bleeding risk. DESIGN:Multicentre, non-inferiority, double blind, randomised controlled trial. SETTING:13 cardiac surgery centres in China, with enrolment between February 2023 and July 2024. PARTICIPANTS:2300 participants aged 18 to 80 years who underwent elective primary coronary artery bypass grafting with ≥1 saphenous vein graft. INTERVENTIONS:Participants were randomly assigned (1:1) to receive DAPT (ticagrelor 90 mg twice daily plus aspirin 100 mg once daily) for 12 months or the same dual antiplatelet regimen for the first three months, followed by placebo plus aspirin for nine months. MAIN OUTCOME MEASURES:The primary outcomes were saphenous vein graft occlusion at one year (non-inferiority) and Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding (superiority). Secondary outcomes were major adverse cardiovascular events (MACCE), saphenous vein graft failure, venous or arterial graft stenosis, and venous or arterial graft occlusion. RESULTS:2290 patients (mean age 61.5 (standard deviation (SD) 8.4) years, 20.6% (n=472) women) were included in the modified intention-to-treat set. The mean number of saphenous vein graft segments was 2.5 (SD 0.8). 2070 patients (90.4%) with a total of 5125 saphenous vein graft segments were assessed at one year. Saphenous vein graft occlusion occurred in 280 of 2596 (10.8%) in the three month DAPT group and 283 of 2529 (11.2%) in the 12 month DAPT group (absolute difference -0.31%, 95% confidence interval (CI) -3.13% to 2.52%; P=0.008 for non-inferiority). During a median follow-up of 368 (interquartile range 358-382) days, BARC type 2, 3, or 5 bleeding occurred in 95 patients (8.3%) in the three month DAPT group and 149 patients (13.2%) in the 12 month DAPT group (absolute difference -4.67%, 95% CI -7.18% to -2.16%; P<0.001). The number needed to treat to prevent one bleeding event was 21 (95% CI 13 to 46). MACCE occurred in 26 (2.3%) patients in the three month DAPT group and 27 (2.7%) in the 12 month DAPT group (absolute difference -0.11%, 95% CI -1.48% to 1.26%). The findings for other secondary outcomes were also similar between the two groups. CONCLUSIONS:A three month DAPT strategy was non-inferior to the 12 month DAPT strategy in saphenous vein graft occlusion and was superior in reducing bleeding risk. TRIAL REGISTRATION:ClinicalTrials.gov NCT05380063.

BACKGROUND:Patients with coronavirus disease 2019 (COVID-19) infection prior to cardiac surgery are at a higher risk of contracting the virus and worse outcomes. Administration of ursodeoxycholic acid (UDCA) may be effective in reducing the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, it remains unclear whether prophylactic use of UDCA could prevent complications in cardiac surgical patients with previous COVID-19 infection. METHODS:In one comparison from a 2 × 2 factorial trial, we randomly assigned patients with COVID-19 infection prior to cardiac surgery to UDCA or control in a 1:1 ratio. The randomization process was initiated 2 days before surgery by a central randomization system. The participants in the UDCA group received UDCA (15 mg/kg of body weight) on the day of randomization, administered orally twice a day during breakfast and dinner for 5 days. The primary outcome was a composite endpoint of all-cause death, myocardial infarction, stroke, moderate or severe acute kidney injury, and COVID-19 pneumonia within 30 days after surgery. RESULTS:From January 2023 through March 2023, a total of 500 participants were randomized, and all the participants (UDCA: 250 and control: 250; mean [standard deviation] age, 57.1 [11.5] years; 25.4% female) were included in the primary analysis. The primary outcome event occurred in 37 (14.8%) participants in the UDCA group and 35 (14.0%) participants in the control group (risk difference, 0.8% [97.5% confidence interval [CI], - 6.2% to 7.8%]; risk ratio, 1.08 [97.5% CI, 0.63 to 1.85]). The results were consistent in subgroups. Additionally, the incidence of COVID-19 pneumonia within 30 days was similar between the UDCA group and the control group (10.4% vs. 7.6%; risk difference, 2.8 [95% CI -2.2 to 7.8]; risk ratio, 1.35 [95% CI 0.75 to 2.44]). Serious adverse events occurred in 94 (37.6%) participants in the UDCA group and 94 (37.6%) participants in the control group (P>0.05). There were also no significant between-group differences in the incidence of the other secondary outcomes. CONCLUSION:Among patients who underwent cardiac surgery following a recent COVID-19 infection, prophylactic use of UDCA for a 5-day course was not associated with better postoperative outcomes, including major complications and COVID-19 reinfection.

BACKGROUND:Non-vitamin K antagonist anticoagulant (NOAC) is considered the first-line treatment for atrial fibrillation (AF) patients to reduce the risk of stroke, especially in the elderly. However, robust clinical evidence is lacking regarding the appropriateness of low-dose NOAC. DESIGN:The SAFE-AF trial is an investigator-initiated, multicenter, open-label, randomized controlled, blind endpoint evaluation, non-inferiority designed trial comparing the efficacy and safety of low-dose rivaroxaban with standard-dose rivaroxaban in patients aged ≥70 years with AF. Participants (N = 4,374) will be randomized 1:1 to receive either standard-dose rivaroxaban (20 mg once daily) or low-dose rivaroxaban (15 mg once daily). The primary efficacy endpoint is the composite endpoint of clinical events including cardiovascular death, myocardial infarction, stroke, and systemic embolic events (SEE). The primary safety endpoint is the composite endpoint of major bleeding events and clinically relevant non-major bleeding events. CONCLUSIONS:The SAFE-AF trial is intended to provide valid evidence concerning low-dose rivaroxaban for anticoagulant therapy in older patients with AF. TRIAL REGISTRATION:ClinicalTrials.gov, identifier NCT06108414.

Background The Enhanced Recovery After Cardiac Surgery (ERACS) programs are comprehensive multidisciplinary interventions to improve patients’ recovery. The application of the ERAS principle in pediatric patients has not been identified completely. Methods This study is a multicenter, stepwise design, cluster randomized controlled trial. 3030 patients presenting during control and intervention periods are eligible if they are aged from 28 days to 6 years old and awaiting elective correction surgery of congenital heart disease with cardiopulmonary bypass. 5 centers are randomly assigned to staggered start dates for one-way crossover from the control phase to the intervention phase. In the intervention periods, patients will receive a bundle strategy including preoperative, intraoperative, and postoperative approaches. During the control phase, patients receive the usual care. The primary outcome consists of major adverse cardiac and cerebrovascular events (MACCEs), postoperative pulmonary complications (PPCs), and acute kidney injury (AKI). Discussion This study aims to explore whether the bundle of ERAS measurements could improve patients’ recovery in congenital heart surgery. Trial registration http://www.clinicaltrials.gov . (NCT05914103).

Background and Objectives: Gastric varices (GV) with spontaneous portosystemic shunt (SPSS) are associated with ectopic embolism in endoscopic cyanoacrylate. This study targeted to assess the efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration (BRTO) for GV with high-risk ectopic embolism. Materials and Methods: We retrospectively analyzed six tertiary hospitals' 104 patients with GV at high-risk ectopic embolism (the narrowest diameter of SPSS was greater than or equal to 5 mm and the maximum diameter usually > 8 mm) who underwent EUS-guided coil embolization combined with endoscopic cyanoacrylate injection or BRTO from January 2014 to December 2020. The outcomes included rebleeding, survival, and complications. Results: The EUS group and BRTO group contained 59 and 45 patients, respectively. The technical success rate between the two groups was similar (96.6% vs. 95.6%, P = 1.000). During the follow-up, both groups' 5-day rebleeding rate and 6-week mortality rate were 0%. One-year all-cause rebleeding rate (20.0% vs. 18.9%, P = 0.900) and 1-year mortality rate (2.0% vs. 0%, P = 1.000) in the EUS group were similar to the BRTO group. One patient experienced ectopic embolism in the EUS group, while the BRTO group did not. Both groups had similar mean days (16.0 [interquartile range (IQR), 12.0-19.0] vs. 16.5 [IQR, 11.8-26.0], P = 0.165) and cost of hospitalization ( yen 45950.6 [IQR, 39330.2-55768.2] vs. yen 51205.8 [IQR, 31628.8-74251.5], P = 0.680). Multivariate analysis showed that the narrowest diameter of the shunt (odds ratio [OR] = 1.86; 95% confidence interval [CI]: 1.062-3.258; P = 0.03) and content of hemoglobin (OR = 0.941; 95% CI: 0.892-0.992; P = 0.025) were the prognostic factors for survival. Conclusions: The efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection for GV with high-risk ectopic embolism are comparable to BRTO.

INTRODUCTION:Dual antiplatelet therapy (DAPT), referred to as the combination of aspirin and P2Y12 receptor antagonist (clopidogrel or ticagrelor), potentially improves patency of saphenous vein grafts (SVG) after coronary artery bypass grafting (CABG), while it is further proposed that DAPT potentially increases bleeding risk. Compared with DAPT, de-escalated DAPT (De-DAPT) is an effective antiplatelet strategy for acute coronary syndrome treatment, which significantly reduces the risk of bleeding without increasing the incidence of major adverse cardiovascular events. However, insufficient evidence is available to determine the timing of DAPT after CABG. METHODS AND ANALYSIS:ETHICS AND DISSEMINATION: The Ethics Committee in Fuwai hospital approved this study (2022-1774). Fifteen centres agreed to participate the TOP-CABG trial, and the study has been approved in these 15 centres by whose ethics committee. The results of the trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER:NCT05380063.

Abstract Background Sex differences present in the blood management of patients after coronary artery bypass grafts (CABG) surgeries. Tranexamic acid (TXA) performed well in maintaining hemostasis during and after surgeries. However, the impact of sex differences on blood control after CABG in patients who received TXA was not investigated. Methods Overall, 29,536 patients undergoing CABG with TXA administration from 2009 to 2019 in our hospital were included. Propensity score matching was performed. Finally, 6808 males and 6808 females were matched based on 23 covariates. Results Female patients had a 0.36-fold lower incidence of reoperations due to major hemorrhage or cardiac tamponade compared to males (1.3% vs. 2.0%, p = 0.001, OR = 0.64, 95%CI = 0.49–0.84). Females had a median of 100 ml less blood loss in 24 h (median 360 vs. 460 ml, p < 0.0001), 150 ml less in 48 h (median 580 vs. 730 ml, p < 0.0001), and 180 ml less in total (median 760 vs. 940 ml, p < 0.0001) than male patients. The red blood cell (RBC) transfusion rate in female was 1.53-fold higher than that in male (33.0% vs. 21.6%, OR = 1.53, 95% CI = 1.43–1.63, p < 0.0001). Females also had higher morbidities than males after CABGs. Conclusions Females had less blood loss than males after CABG with the TXA treatment. Females still had a higher RBC transfusion rate after surgery. Morbidities in women were also higher than that in men.

Background Tranexamic acid (TXA) administered during off-pump coronary artery bypass (OPCAB) surgeries has achieved good blood control in small cohorts. We aimed to investigate the safety issues and hemostasis associated with TXA administration during OPCAB in a large retrospective cohort study. Methods This study included 19,687 patients with OPCAB from 2009 to 2019. A total of 1,307 patients were excluded because they were younger than 18 years or certain values were missing. Among the remaining 18,380 patients, 10,969 were in the TXA group and 7,411 patients were in the no-TXA group. There were 4,889 patients whose TXA dose was ≥50 mg/kg, and the remaining 6,080 patients had a TXA dose of <50 mg/kg. Propensity score matching (PSM) was performed between the TXA and no-TXA groups and between the high-dose and low-dose groups, and statistical analysis was performed. Results Tranexamic acid administration did not increase the risk of hospital death or thromboembolic events. Patients who administered TXA had less blood loss at 24 h (478.32 ± 276.41 vs. 641.28 ± 295.09, p < 0.001) and 48 h (730.59 ± 358.55 vs. 915.24 ± 390.13, p < 0.001) and total blood loss (989.00 ± 680.43 vs. 1,220.01 ± 720.68, p < 0.001) after OPCAB than the patients with non-TXA. Therefore, the risk of total blood exposure [odds ratio (OR) = 0.50, 95% CI 0.47–0.54, p < 0.001] or blood component exposure (p < 0.001) was decreased significantly in the patients who administered TXA. The TXA dosage did not impact the patient survival, thromboembolic events, or blood management. Conclusions The application of TXA was safe and provided blood control in patients with OPCAB, and the dosage did not affect these parameters.

Background: The safety and blood management effects of Tranexamic acid (TXA) and its dose effects in coronary artery bypass graft (CABG) were still ambiguous. This study aimed to analyze these TXA effects. Methods: Overall, 42,010 patients undergoing CABG were enrolled in this retrospective cohort study. Patients were assigned to the TXA group (n = 29,536) and the no-TXA group (n = 12,474). Furthermore, the TXA group was divided into the high-dose (>= 50 mg/kg) (16,488) and the low-dose (<50 mg/kg) (13,048) subgroup. Propensity score matching was performed in both groups respectively. The primary endpoint after CABG was composed of hospital death, perioperative myocardial infarction (PMI), stroke, acute kidney injury (AKI), and pulmonary embolism. The secondary endpoint included blood loss and blood transfusion after surgery. Results: TXA led to a 1.40-fold risk of PMI (p < 0.001). Patients in the TXA group had fewer re-operations for bleeding or tamponade [Odd ratio (OR) = 0.82, p = 0.044], less blood loss after surgery (p < 0.001), and a lower risk for blood transfusion exposure (OR = 0.45, p < 0.001) than those in the no-TXA group. The high-dose TXA reduced blood loss after cardiac surgery compared to the low-dose TXA (p < 0.001) with no associations with blood exposure or adverse events. Conclusions: The use of TXA during CABG increased the risk of PMI despite better blood control after surgery. The high dose of TXA acquired better bleeding management. Meanwhile, it did not increase the risk of primary endpoint.

Background: Previous cluster-randomized controlled trials evaluating the impact of implementing evidence-based guidelines for nutrition therapy in critical illness do not consistently demonstrate patient benefits. A large-scale, sufficiently powered study is therefore warranted to ascertain the effects of guideline implementation on patient-centered outcomes. Methods: We conducted a multicenter, cluster-randomized, parallel-controlled trial in intensive care units (ICUs) across China. We developed an evidence-based feeding guideline. ICUs randomly allocated to the guideline group formed a local "intervention team", which actively implemented the guideline using standardized materials, a graphical feeding protocol, and live online education outreach meetings conducted by members of the study management committee. ICUs assigned to the control group remained unaware of the guideline content. All ICUs enrolled patients who were expected to stay in the ICU longer than seven days. The primary outcome was allcause mortality within 28 days of enrollment. Results: Forty-eight ICUs were randomized to the guideline group and 49 to the control group. From March 2018 to July 2019, the guideline ICUs enrolled 1399 patients, and the control ICUs enrolled 1373 patients. Implementation of the guideline resulted in significantly earlier EN initiation (1.20 vs. 1.55 mean days to initiation of EN; difference -0.40 [95% CI -0.71 to - 0.09]; P= 0.01) and delayed PN initiation (1.29 vs. 0.80 mean days to start of PN; difference 1.06 [95% CI 0.44 to 1.67]; P= 0.001). There was no significant difference in 28-day mortality (14.2% vs. 15.2%; difference - 1.6% [95% CI - 4.3% to 1.2%]; P=0.42) between groups. Conclusions: In this large-scale, multicenter trial, active implementation of an evidence-based feeding guideline reduced the time to commencement of EN and overall PN use but did not translate to a reduction in mortality from critical illness.

BACKGROUND: Vein graft occlusion is deemed a major challenge in coronary artery bypass grafting. Previous studies implied that the no-touch technique for vein graft harvesting could reduce occlusion rate compared with the conventional approach; however, evidence on the clinical benefit and generalizability of the no-touch technique is scare. METHODS: From April 2017 to June 2019, we randomly assigned 2655 patients undergoing coronary artery bypass grafting at 7 hospitals in a 1:1 ratio to receive no-touch technique or conventional approach for vein harvesting. The primary outcome was vein graft occlusion on computed tomography angiography at 3 months and the secondary outcomes included 12-month vein graft occlusion, recurrence of angina, and major adverse cardiac and cerebrovascular events. The generalized estimate equation model was used to account for the cluster effect of grafts from the same patient. RESULTS: During the follow-up, 2533 (96.0%) participants received computed tomography angiography at 3 months after coronary artery bypass grafting and 2434 (92.2%) received it at 12 months. The no-touch group had significantly lower rates of vein graft occlusion than the conventional group both at 3 months (2.8% versus 4.8%; odds ratio, 0.57 [95% CI, 0.41-0.80]; P<0.001) and 12 months (3.7% versus 6.5%; odds ratio, 0.56 [95% CI, 0.41-0.76]; P<0.001). Recurrence of angina was also less common in the no-touch group at 12 months (2.3% versus 4.1%; odds ratio, 0.55 [95% CI, 0.35-0.85]; P<0.01). Rates of major adverse cardiac and cerebrovascular events were of no significant difference between the 2 groups. The no-touch technique was associated with higher rates of leg wound surgical interventions at 3-month follow-up (10.3% versus 4.3%; odds ratio, 2.55 [95% CI, 1.85-3.52]; P<0.001). CONCLUSIONS: Compared with the conventional vein harvesting approach in coronary artery bypass grafting, the no-touch technique significantly reduced the risk of vein graft occlusion and improved patient prognosis.

Background Acute decompensated heart failure (ADHF) contributes millions of emergency department (ED) visits and it is associated with high in-hospital mortality. The aim of this study was to develop and validate a multiparametric score for critically-ill ADHF patients. Methods In this single-center, retrospective study, a total of 1268 ADHF patients in China were enrolled and divided into derivation (n = 1014) and validation (n = 254) cohorts. The primary endpoint was any in-hospital death, cardiac arrest or utilization of mechanical support devices. Logistic regression model was preformed to identify risk factors and build the new scoring system. The assigning point of each parameter was determined according to its β coefficient. The discrimination was validated internally using C statistic and calibration was evaluated by the Hosmer-Lemeshow goodness-of-fit test. Results We constructed a predictive score based on six significant risk factors [systolic blood pressure (SBP), white blood cell (WBC) count, hematocrit (HCT), total bilirubin (TBIL), estimated glomerular filtration rate (eGFR) and NT-proBNP]. This new model was computed as (1 × SBP < 90 mmHg) + (2 × WBC > 9.2 × 10 9 /L) + (1 × HCT ≤ 0.407) + (2 × TBIL > 34.2 μmol/L) + (2 × eGFR < 15 ml/min/1.73 m 2 ) + (1 × NTproBNP ≥ 10728.9 ng/ml). The C statistic for the new score was 0.758 (95% CI 0.667–0.838) higher than APACHE II, AHEAD and ADHERE score. It also demonstrated good calibration for detecting high-risk patients in the validation cohort (χ 2 = 6.681, p = 0.463). Conclusions The new score including SBP, WBC, HCT, TBIL, eGFR and NT-proBNP might be used to predict short-term prognosis of Chinese critically-ill ADHF patients.

Tranexamic acid (TxA) reduces perioperative blood transfusion in cardiac surgery; however, the optimal dose of TxA remains unknown. METHODS AND RESULTS: This large-scale, double-blind, randomized controlled trial with a 1-year follow-up enrolls patients undergoing elective cardiac surgery with cardiopulmonary bypass. Patients are randomly assigned 1:1 into either the high-dose TxA group (intravenous bolus [30 mg/kg] after anesthesia followed by intravenous maintenance [16 mg/kg/h] throughout the operation, and a pump prime dose of 2 mg/kg) or the low-dose TxA group (intravenous bolus and maintenance are 10 mg/kg and 2 mg/kg/h, respectively, and a pump prime dose of 1 mg/kg). The primary efficacy end point is the rate of perioperative allogeneic red blood cell (RBC) transfusion defined as the number (%) of patients who will receive at least 1 RBC unit from operation day to discharge. The primary safety end point is the 30-day rate of the composite of perioperative seizures, renal dysfunction, myocardial infarction, ischemic stroke, deep vein thrombosis, pulmonary embolism, and all-cause mortality. The secondary end points are perioperative allogeneic RBC transfusion volume, the non-RBC blood transfusion rate, postoperative bleeding, reoperation rate, mechanical ventilation duration, intensive care unit stay, hospital length of stay, total hospitalization cost, each component of composite primary safety end point, and the 6-month/1-year follow-up mortality and morbidity. We estimated a sample size of 3,008 participants. CONCLUSIONS: The study is designed to identify a TxA dose with maximal efficacy and minimal complications. We hypothesize that the high dose has superior efficacy and noninferior safety to the low dose.

OBJECTIVES:This study was designed to investigate the impact of renin-angiotensin system blockade (RASB) therapy with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers on the outcomes of coronary artery ectasia (CAE). METHODS:The CAE patients identified by coronary angiography from our center were consecutively enrolled. We obtained the baseline discharge prescription of RASB from the medical records system and conducted follow-up through telephone interviews. Cox regression models, propensity score and subgroup analysis were used to assess the impact of RASB on all-cause mortality and non-fatal myocardial infarction. Both the unadjusted and adjusted Kaplan-Meier curves stratified by RASB therapy were plotted. RESULTS:There were 595 patients with CAE in total and 333 (56.0%) were prescribed RASB therapy. Over a 2 year follow-up time, 16 all-cause deaths and 10 non-fatal myocardial infarctions were identified. Those patients treated with RASB had a significantly lower all-cause mortality and non-fatal myocardial infarction rate with an adjusted hazard ratio of 0.32 (95% confidence interval: 0.13 to 0.77, p = .011). The outcome benefits of RASB therapy were further confirmed in the propensity score analysis and subgroup analysis. CONCLUSIONS:This observational study suggests that RASB therapy is associated with a lower risk of all-cause mortality and non-fatal myocardial infarction in patients with CAE.

The objective of this study is to evaluate the clinical feasibility of serum matrix metalloproteinase-9 (MMP-9) for screening plaque composition as assessed by coronary computed tomography angiography (CCTA) in outpatients with chest pain,and the effects of sex on this feasibility. Eight hundred and sixty-two consecutive outpatients with chest pain were divided into three groups according to the results of CCTA: non-plaque (NP, n = 474), calcified plaques (CPs, n = 179), non-calcified and mixed plaques (NCPs and MPs, n = 209). We found that serum MMP-9 levels were significantly higher in patients with NCPs and MPs compared to those with either NP or CPs, especially in women (649.7 ± 279.8 vs. 485.7 ± 231.6 ng/mL or 515.7 ± 274.5 ng/mL, P < 0.001). MMP-9 showed better identification of NCPs and MPs than other related factors and was an independent predictor for NCPs and MPs both in women and men. The receiver operating characteristic analysis indicated a substantial superiority in women with area under the curve of 0.75 (95% CI 0.69–0.82, P < 0.01), compared with men of 0.59 (95% CI 0.53–0.65, z = 3.71, P < 0.01). The diagnostic tests revealed a moderate risk of the presence of NCPs and MPs with MMP-9 ≥531.6 ng/mL in female patients.

The study aimed to explore the gap of prevalence of healthy lifestyle behaviors including smoking cessation, quitting drinking, physical activity and healthy eating between Chinese adults with and without cardiovascular diseases (CVDs).This study is a cross-sectional component of Prospective Urban Rural Epidemiology (PURE)-China study, which recruited ~46,000 participants from 70 rural and 45 urban communities between 2005 and 2009. Participants were divided into disease (with CVDs) and control (without any diseases) groups. The adjusted rates were estimated for different strata by the generalized, linear mixed-effects model, including community as a random effect with additional adjustment for age, sex, education and income.Among 40,490 participants, <10% had all four healthy lifestyle behaviors (disease group versus control group: urban areas: 7.8% versus 8.1%; rural areas: 3.4% versus 3.2%). The rates of smoking cessation and quitting drinking were significantly higher in disease group for both urban and rural residents (P<0.001). In urban areas, higher rates were observed in all other three healthy lifestyle behaviors except physical activity in low-income regions (P<0.05). Similarly, the higher trends were observed for stopping smoking and drinking while opposite trends for healthy eating among rural residents from low-income regions (P<0.05).Our study showed that the prevalence of adopting all four behaviors was low among Chinese adults. Individuals with CVDs were more likely to follow healthy lifestyle behaviors, but it still indicated a large gap between the actual and ideal adoption of healthy lifestyle behaviors, which called for the promotion of population-wide strategies to modify lifestyle behaviors in addition to individual health-care intervention strategies.