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Dongfeng Gu and colleagues review community based cohort studies in China, finding strategies to improve the quality and scale of these studies in China and beyond

AbstractObjectiveTo study the effect of long term exposure to ambient fine particulate matter of diameter ≤2.5 μm (PM2.5) on the incidence of total, ischemic, and hemorrhagic stroke among Chinese adults.DesignPopulation based prospective cohort study.SettingPrediction for Atherosclerotic Cardiovascular Disease Risk in China (China-PAR) project carried out in 15 provinces across China.Participants117 575 Chinese men and women without stroke at baseline in the China-PAR project.Main outcome measuresIncidence of total, ischemic, and hemorrhagic stroke.ResultsThe long term average PM2.5 level from 2000 to 2015 at participants’ residential addresses was 64.9 μg/m3, ranging from 31.2 μg/m3 to 97.0 μg/m3. During 900 214 person years of follow-up, 3540 cases of incident stroke were identified, of which 63.0% (n=2230) were ischemic and 27.5% (n=973) were hemorrhagic. Compared with the first quarter of exposure to PM2.5 (<54.5 μg/m3), participants in the highest quarter (>78.2 μg/m3) had an increased risk of incident stroke (hazard ratio 1.53, 95% confidence interval 1.34 to 1.74), ischemic stroke (1.82, 1.55 to 2.14), and hemorrhagic stroke (1.50, 1.16 to 1.93). For each increase of 10 μg/m3 in PM2.5 concentration, the increased risks of incident stroke, ischemic stroke, and hemorrhagic stroke were 13% (1.13, 1.09 to 1.17), 20% (1.20, 1.15 to 1.25), and 12% (1.12, 1.05 to 1.20), respectively. Almost linear exposure-response relations between long term exposure to PM2.5 and incident stroke, overall and by its subtypes, were observed.ConclusionsThis study provides evidence from China that long term exposure to ambient PM2.5 at relatively high concentrations is positively associated with incident stroke and its major subtypes. These findings are meaningful for both environmental and health policy development related to air pollution and stroke prevention, not only in China, but also in other low and middle income countries.

Although the dynamic zero-COVID policy has effectively controlled virus spread in China, China has to face challenges in balancing social-economic burdens, vaccine protection, and the management of long COVID symptoms. This study proposed a fine-grained agent-based model to simulate various strategies for transitioning from a dynamic zero-COVID policy with a case study in Shenzhen. The results indicate that a gradual transition, maintaining some restrictions, can mitigate infection outbreaks. However, the severity and duration of epidemics vary based on the strictness of the measures. In contrast, a more direct transition to reopening may lead to rapid herd immunity but necessitate preparedness for potential sequelae and reinfections. Policymakers should assess healthcare capacity for severe cases and potential long-COVID symptoms and determine the most suitable approach tailored to local conditions.

Cardiovascular disease (CVD) remains the leading cause of deaths nationwide. However, little is understood about its temporal trend and corresponding influence on longevity improvements. We aimed to describe the updated tendency in CVD mortality and to quantify its impact on life expectancy (LE) increase in China. All-cause mortality rates were calculated with population sizes from the National Bureau of Statistics and death counts from the National Health Commission. We estimated CVD mortality rates by allocating age- and sex-based mortality envelopes to each CVD subtype based on its proportion derived from the Disease Surveillance Points system. The probability of CVD premature deaths and LE were calculated with life tables and we adopted Arriaga's method to quantitate age- and cause-specific contributions to LE gains. During 2013 to 2018, the age-standardized mortality rate of CVD decreased from 289.69 (95% confidence interval [CI]: 289.03, 290.35)/100,000 to 272.37 (95%CI: 271.81, 272.94)/100,000, along with a decline in probability of CVD premature deaths from 9.05% (95%CI: 9.02%, 9.09%) to 8.13% (95%CI: 8.10%, 8.16%). The gap in CVD mortality across sexes expanded with more remarkable declines in females, especially for those aged 15 to 64 years. Among major subtypes, the probability of premature deaths from hemorrhage stroke declined fastest, while improvements of ischemic stroke and ischemic heart disease were limited, and there was an increase in stroke sequelae. LE in China reached 77.04 (95%CI: 76.96, 77.12) years in 2018 with an increase of 1.38 years from 2013. Of the total LE gains, 21.15% (0.29 years) were attributed to reductions of CVD mortality in the overall population, mostly driven by those aged >65 years. The general process in reducing CVD mortality has contributed to longevity improvements in China. More attention should be paid to prevention and control of atherosclerotic CVD and stroke sequelae, especially for the elderly. Working-age males also deserve additional attention due to inadequate improvements.

Lipid-lowering drugs and antihypertensive drugs are commonly combined for cardiovascular disease (CVD). However, the relationship of combined medications with CVD remains controversial. We aimed to explore the associations of genetically proxied medications of lipid-lowering and antihypertensive drugs, either alone or both, with risk of CVD, other clinical and safety outcomes. We divided 423,821 individuals in the UK Biobank into 4 groups via median genetic scores for targets of lipid-lowering drugs and antihypertensive drugs: lower low-density lipoprotein cholesterol (LDL-C) mediated by targets of statins or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, lower systolic blood pressure (SBP) mediated by targets of β-blockers (BBs) or calcium channel blockers (CCBs), combined genetically lower LDL-C and SBP, and reference (genetically both higher LDL-C and SBP). Associations with risk of CVD and other clinical outcomes were explored among each group in factorial Mendelian randomization. Independent and additive effects were observed between genetically proxied medications of lipid-lowering and antihypertensive drugs with CVD (including coronary artery disease, stroke, and peripheral artery diseases) and other clinical outcomes (ischemic stroke, hemorrhagic stroke, heart failure, diabetes mellitus, chronic kidney disease, and dementia) (P > 0.05 for interaction in all outcomes). Take the effect of PCSK9 inhibitors and BBs on CVD for instance: compared with the reference, PCSK9 group had a 4% lower risk of CVD (odds ratio [OR], 0.96; 95%CI, 0.94-0.99), and a 3% lower risk was observed in BBs group (OR, 0.97; 95%CI, 0.94-0.99), while combined both were associated with a 6% additively lower risk (OR, 0.94; 95%CI, 0.92-0.97; P = 0.87 for interaction). Genetically proxied medications of combined lipid-lowering and antihypertensive drugs have an independent and additive effects on CVD, other clinical and safety outcomes, with implications for CVD clinical practice, subsequent trials as well as drug development of polypills.

Existing evidence on the relationship between cardiovascular health (CVH) metrics and cardiovascular disease (CVD) was primarily derived from western populations. We aimed to evaluate the benefits of ideal CVH metrics on preventing incident atherosclerotic CVD (ASCVD) in Chinese population. This study was conducted among 93,987 adults from the China-PAR project (Prediction for ASCVD Risk in China) who were followed up until 2015. Cox proportional hazard regression models were used to estimate the hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) of CVH metrics for the risk of ASCVD, including coronary heart disease (CHD), stroke and ASCVD death. We further estimated the population-attributable risk percentage (PAR%) of these metrics in relation to each outcome. We observed gradient inverse associations between the number of ideal CVH metrics and ASCVD incidence. Compared with participants having ≤2 ideal CVH metrics, the multivariable-adjusted HRs (95% CIs) of ASCVD for those with 3, 4, 5, 6 and 7 ideal CVH metrics were 0.83 (0.74–0.93), 0.66 (0.59–0.74), 0.55 (0.48–0.61), 0.44 (0.38–0.50) and 0.24 (0.18–0.31), respectively (P for trend <0.0001). Approximately 62.1% of total ASCVD, 38.7% of CHD, 66.4% of stroke, and 60.5% of ASCVD death were attributable to not achieving all the seven ideal CVH metrics. After adjusting effects of ideal health factors, having four ideal health behaviors could independently bring adults health benefits in preventing 17.4% of ASCVD, 18.0% of CHD, 16.7% of stroke, and 10.1% of ASCVD death. Among all the seven CVH metrics, to keep with ideal blood pressure (BP) implied the largest public health gains against various ASCVD events (PAR% between 33.0% and 47.2%), while ideal diet was the metric most difficult to be achieved in the long term. Our study indicates that the more ideal CVH metrics adults have, the less ASCVD burden there is in China. Special efforts of health education and behavior modification should be made on keeping ideal BP and dietary habits in general Chinese population to prevent the epidemic of ASCVD.

Despite the recent development of using satellite remote sensing to predict surface NO2 levels in China, methods for estimating reliable historical NO2 exposure, especially before the establishment of NO2 monitoring network in 2013, are still rare. A gap‐filling model was first adopted to impute the missing NO2 column densities from satellite, then an ensemble machine learning model incorporating three base learners was developed to estimate the spatiotemporal pattern of monthly mean NO2 concentrations at 0.05° spatial resolution from 2005 to 2020 in China. Further, we applied the exposure data set with epidemiologically derived exposure response relations to estimate the annual NO2 associated mortality burdens in China. The coverage of satellite NO2 column densities increased from 46.9% to 100% after gap‐filling. The ensemble model predictions had good agreement with observations, and the sample‐based, temporal and spatial cross‐validation (CV) R2 were 0.88, 0.82, and 0.73, respectively. In addition, our model can provide accurate historical NO2 concentrations, with both by‐year CV R2 and external separate year validation R2 achieving 0.80. The estimated national NO2 levels showed a increasing trend during 2005–2011, then decreased gradually until 2020, especially in 2012–2015. The estimated annual mortality burden attributable to long‐term NO2 exposure ranged from 305 thousand to 416 thousand, and varied considerably across provinces in China. This satellite‐based ensemble model could provide reliable long‐term NO2 predictions at a high spatial resolution with complete coverage for environmental and epidemiological studies in China. Our results also highlighted the heavy disease burden by NO2 and call for more targeted policies to reduce the emission of nitrogen oxides in China. Plain Language Summary This study developed a satellite‐based ensemble machine learning model to predict 16‐year NO2 levels and identified high mortality burden attributed to NO2 in China with great implications for environmental policy making. Key Points We developed an ensemble machine learning model on NO2 levels using column densities from Ozone Monitoring Instrument satellite as main predictors Our model obtained sample‐based, temporal and spatial cross‐validation R2 of 0.88, 0.82, and 0.73, respectively The estimated annual mortality burden attributable to chronic NO2 exposure ranged from 305 thousand to 416 thousand in China

This study presents pooled analyses of the associations between BMI and risk of death in more than 1.1 million people from 19 cohorts in Asia after a mean follow-up of 9.2 years. Underweight was associated with a substantially increased risk of death in all Asian populations. Over the past few decades, there has been a dramatic increase in the prevalence of obesity in many countries. The World Health Organization (WHO) estimates that more than 1 billion adults worldwide are overweight; of these, at least 300 million are obese. 1 A large number of epidemiologic studies have evaluated the associations between body weight and, more often, the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) and a wide range of health outcomes. Obesity is associated with multiple chronic diseases, including type 2 diabetes, hypertension, coronary heart disease, stroke, and several . . .

His-Purkinje system pacing (HPSP), including his-bundle pacing (HBP) and left bundle branch area pacing (LBBaP), imitates the natural conduction of the heart as an alternative to biventricular pacing (BVP) in cardiac resynchronization therapy (CRT). However, the feasibility and efficacy of HPSP were currently only evidenced by studies with a limited sample size, so this study aimed to provide a comprehensive assessment through a systematic review and meta-analysis. In order to compare the clinical outcomes associated with HPSP and BVP in patients for CRT, PubMed, EMBASE, Cochrane Library and Web of Science database were searched from inception to April 10, 2023. Clinical outcomes of interest including QRS duration (QRSd), left ventricular (LV) function and New York Heart Association (NYHA) functional classification, pacing threshold, echocardiographic and clinical response, hospitalization rate of HF and all-cause mortality were also extracted and summarized for meta-analysis. A total of 13 studies (ten observational studies and three randomized studies) involving 1,121 patients were finally included. The patients were followed up for 6-27 months. Compared with BVP, CRT patients treated by HPSP presented shorter QRSd [mean difference (MD): -26.23 ms, 95% confidence interval (CI): -34.54 to -17.92, P < 0.001, I  = 91%], greater LV functional improvement with increased left ventricular ejection fraction (LVEF) (MD: 6.01, 95% CI: 4.81 to 7.22, P < 0.001, I  = 0%), decreased left ventricular end-diastolic dimension (LVEDD) (MD: -2.91, 95% CI: -4.86 to -0.95, P = 0.004, I  = 35%), and more improved NYHA functional classification (MD: -0.45, 95% CI: -0.67 to -0.23, P < 0.001, I  = 70%). In addition, HPSP was more likely to have higher echocardiographic [odds ratio (OR): 2.76, 95% CI: 1.74 to 4.39, P < 0.001, I  = 0%], clinical (OR: 2.10, 95% CI: 1.16 to 3.80, P = 0.01, I  = 0%) and super clinical (OR: 3.17, 95% CI: 2.09 to 4.79, P < 0.001, I  = 0%) responses than BVP, and a lower hospitalization rate of HF (OR: 0.34, 95% CI: 0.22 to 0.51, P < 0.001, I  = 0%), while presented no difference (OR: 0.68, 95% CI: 0.44 to 1.06, P = 0.09, I  = 0%) in all-cause mortality compared with BVP. With threshold change taking into account, BVP was less stable than LBBaP (MD: -0.12 V, 95% CI: -0.22 to -0.03, P = 0.01, I  = 57%), but had no difference with HBP (MD: 0.11 V, 95% CI: -0.09 to 0.31, P = 0.28, I  = 0%). The present findings suggested that HPSP was associated with greater improvement of cardiac function in patients with indication for CRT and was a potential alternative to BVP to achieve physiological pacing through native his-purkinje system.

Dongfeng Gu and colleagues report a genome-wide association study for coronary artery disease in Han Chinese individuals. They identify four loci newly associated with coronary artery disease. We performed a meta-analysis of 2 genome-wide association studies of coronary artery disease comprising 1,515 cases and 5,019 controls followed by replication studies in 15,460 cases and 11,472 controls, all of Chinese Han ancestry. We identify four new loci for coronary artery disease that reached the threshold of genome-wide significance ( P < 5 × 10 −8 ). These loci mapped in or near TTC32 - WDR35 , GUCY1A3 , C6orf10-BTNL2 and ATP2B1 . We also replicated four loci previously identified in European populations (in or near PHACTR1 , TCF21 , CDKN2A-CDKN2B and C12orf51 ). These findings provide new insights into pathways contributing to the susceptibility for coronary artery disease in the Chinese Han population.