Background: Mobile health interventions may support risk factor management and are readily scalable in healthcare systems. We aim to evaluate the efficacy of a text messaging–based intervention to improve glycemic control in patients with coronary heart disease and diabetes mellitus in China. Methods and Results: The CHAT-DM study (Cardiovascular Health and Texting-Diabetes Mellitus) was a parallel-group, single-blind, randomized clinical trial that included 502 patients with both coronary heart disease and diabetes mellitus from 34 hospitals in China. The intervention group (n=251) received 6 text messages per week for 6 months in addition to usual care. Messages were theory driven and culturally tailored to provide educational and motivational information on glucose monitoring, blood pressure control, medication adherence, physical activity, and lifestyle. The control group (n=251) received usual care and 2 thank you messages per month. The primary outcome was change in glycated hemoglobin (HbA 1C [hemoglobin A 1C ]) from baseline to 6 months. Secondary outcomes were change in proportion of patients achieving HbA 1C <7%, fasting blood glucose, systolic blood pressure, LDL (low-density lipoprotein) cholesterol, body mass index, and physical activity from baseline to 6 months. The end points were assessed using analyses of covariance. The follow-up rate was 99%. When compared with control group at 6 months, the intervention group had a greater reduction in HbA 1C (−0.2% versus 0.1%; P =0.003) and a greater proportion of participants who achieved HbA 1C <7% (69.3% versus 52.6%; P =0.004). Change in fasting blood glucose was larger in the intervention group (between-group difference: −0.6 mmol/L; 95% CI, −1.1 to −0.2; P =0.011), but no other outcome differences were observed. Nearly all participants reported that messages were easy to understand (97.1%) and useful (94.1%). Conclusions: A text message intervention resulted in better glycemic control in patients with diabetes mellitus and coronary heart disease. While the mechanism of this benefit remains to be determined, the results suggest that a simple, culturally sensitive mobile text messaging program may provide an effective and feasible way to improve disease self-management. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02883842.

Background: Mobile health technologies are low cost, scalable interventions with the potential to promote patient engagement and behavior change. We aimed to test whether a culturally sensitive text messaging intervention supporting secondary prevention improves the control of risk factors in patients with coronary heart disease in China. Methods and Results: In this multicenter, single-blinded randomized controlled trial, 822 patients (mean age, 56.4 [SD, 9.5] years; 14.1% women) with coronary heart disease and without diabetes mellitus from 37 hospitals in China were enrolled between August 2016 and March 2017. In addition to usual care, the control group (n=411) received 2 thank you messages/month; the intervention group (n=411) received 6 text messages/week for 6 months delivered by an automated computerized system. The messages provided educational and motivational information related to disease-specific knowledge, risk factor control, physical activity, and medication adherence. The primary end point was change in systolic blood pressure from baseline to 6 months. Secondary end points included the proportion with systolic blood pressure <140 mm Hg, smoking status, and change in body mass index, LDL-C (low-density lipoprotein cholesterol), and physical activity (assessed using the International Physical Activity Questionnaire). The end points were assessed using analyses of covariance. Follow-up was 99.6%. At 6 months, systolic blood pressure was not significantly lower in the intervention group compared with the control group, with a mean change (SD) of 3.2 (14.3) mm Hg and 2.0 (15.0) mm Hg ( P >0.05) from baseline, respectively (mean net change, −1.3 mm Hg [95% CI, −3.3 to 0.8]; P =0.221). There were no significant differences in the change in LDL-C level, physical activity, body mass index, or smoking status between the 2 groups. Nearly all patients in the intervention group reported the text messages to be useful (96.1%), easy to understand (98.8%), appropriate in frequency (93.8%), and reported being willing to receive future text messages (94.8%). Conclusions: Text messages supporting secondary prevention among patients with coronary heart disease did not lead to a greater reduction in blood pressure at 6 months. Mobile phone text messaging for secondary prevention was feasible and highly acceptable to patients. Clinical Trial Registration: URL: https://clinicaltrials.gov . Unique identifier: NCT02888769.

Background: Mobile health technologies are low-cost, scalable interventions with the potential to promote patient engagement and behavior change. We designed and tested a tailored culturally-sensitive text messaging intervention to support secondary prevention in patients with coronary heart disease. Methods: In this multi-center, single-blinded randomized controlled trial, we enrolled 822 patients (mean age, 56.4 [SD, 9.5] years; 16.1% [132 of 822] women) with a history of AMI or PCI and without diabetes from 37 hospitals in China from August 2016 to March 2017. In addition to usual care, the control group (n=411) received 2 thank-you messages/month; the intervention group (n=411) received 6 text messages/week for 6 months delivered by an automated computerized system. The messages provided educational and motivational information related to disease-specific knowledge, risk factor control, physical activity and medication adherence. The primary endpoint was change in systolic blood pressure (SBP) from baseline to 6 months. Secondary end points included the proportion with SBP<140mmHg, smoking status, and change in BMI, LDL-C, and physical activity. The endpoints were assessed using analyses of covariance. Results: Follow up was 99.6% (819 of 822). The mean baseline SBP (SD) for the intervention and control groups were 130.9 (15.1) mmHg and 131.4 (17.5) mmHg, respectively. At 6 months, SBP was not significantly lower in the intervention group compared to the control group (mean SBP 127.8 vs. 129.4mmHg, p=0.089), with a mean change (SD) of 3.2 (14.3) mmHg and 2.0 (15.0) mmHg from baseline, respectively (mean net change -1.3mmHg [95%CI -3.3 to 0.8]; P=0.221). There were no significant differences in the change in LDL-C level, physical activity, BMI or smoking status between two groups. Nearly all patients in the intervention group reported the text messages to be useful (96.1%[389 of 405]), easy to understand (98.8%[400 of 405]), appropriate in frequency (93.8%[380 of 405]), and reported being willing to receive future text messages (94.8%[384 of 405]). Conclusions: Text messages supporting secondary prevention among patients with CHD did not lead to a greater reduction in blood pressure at 6 months. However, it was feasible and highly acceptable to patients.

ObjectiveTo assess the association between educational attainment and acute myocardial infarction (AMI) outcomes in China to inform future healthcare interventions.MethodsWe used data from the China Patient-centred Evaluative Assessment of Cardiac Events-Prospective AMI study of 3369 consecutive patients hospitalised with AMI from 53 hospitals. Educational attainment was categorised as: high (senior high school, college or postgraduate degree), intermediate (junior high school) or low (primary school or illiterate). We used survival models to assess the relationship between education and 1-year major adverse cardiovascular events (MACE), all-cause mortality, both unadjusted and after adjustment for demographic characteristics and cardiovascular risk factors.ResultsThe median participant age was 61 (52, 69) years, 23.2% were women, and 33.3% had high, 32.4% intermediate and 34.3% low educational attainment. In unadjusted analysis, compared with high educational attainment, low educational attainment was associated with a higher 1-year risk of MACE (HR 2.41, 95% CI 1.72 to 3.37) and death (HR for low vs high education 3.09, 95% CI 1.69 to 5.65). In risk-adjusted analyses, the association between education and death was attenuated and no longer statistically significant (adjusted HR 1.41, 95% CI 0.74 to 2.69, p=0.30). However, the risk of 1-year MACE (adjusted HR 1.68, 95% CI 1.18 to 2.41, p=0.004) remained significantly greaterin low educational attainment group.ConclusionsIn a national Chinese cohort of patients hospitalised with AMI, low educational attainment was associated with a higher risk of adverse events in the year following discharge. This association highlights the need to consider interventions to improve AMI outcomes in adults with low levels of education.Clinical trial registrationNCT01624909; Results.

IntroductionMobile health interventions have the potential to promote risk factor management and lifestyle modification, and are a particularly attractive approach for scaling across healthcare systems with limited resources. We are conducting two randomised trials to evaluate the efficacy of text message-based health messages in improving secondary coronary heart disease (CHD) prevention among patients with or without diabetes.Methods and analysisThe Cardiovascular Health And Text Messaging (CHAT) Study and the CHAT-Diabetes Mellitus (CHAT-DM) Study are multicentre, single-blind, randomised controlled trials of text messaging versus standard treatment with 6 months of follow-up conducted in 37 hospitals throughout 17 provinces in China. The intervention group receives six text messages per week which target blood pressure control, medication adherence, physical activity, smoking cessation (when appropriate), glucose monitoring and lifestyle recommendations including diet (in CHAT-DM). The text messages were developed based on behavioural change techniques, using models such as the information-motivation-behavioural skills model, goal setting and provision of social support. A total sample size of 800 patients would be adequate for CHAT Study and sample size of 500 patients would be adequate for the CHAT-DM Study. In CHAT, the primary outcome is the change in systolic blood pressure (SBP) at 6 months. Secondary outcomes include a change in proportion of patients achieving a SBP <140 mm Hg, low-density lipoprotein cholesterol (LDL-C), physical activity, medication adherence, body mass index (BMI) and smoking cessation. In CHAT-DM, the primary outcome is the change in glycaemic haemoglobin (HbA1C) at 6 months. Secondary outcomes include a change in the proportion of patients achieving HbA1C<7%, fasting blood glucose, SBP, LDL-C, BMI, physical activity and medication adherence.Ethics and disseminationThe central ethics committee at the China National Center for Cardiovascular Disease and the Yale University Institutional Review Board approved the CHAT and CHAT-DM studies. Results will be disseminated via usual scientific forums including peer-reviewed publications.Trial registration numberCHAT (NCT02888769) and CHAT-DM (NCT02883842); Pre-results.

A prerandomization run-in is a period between screening a potential trial participant and their being randomized. In a 2019 article in JAMA Network Open, Fukuoka et al 1 evaluated whether a mobile phone education application and in-person counseling could increase physical activity in 210 study participants. A prerandomization run-in was used to improve adherence and determine baseline physical activity levels of the participants. In this article, the advantages and limitations of run-in periods are reviewed.

ObjectivesPatients admitted to hospital with acute myocardial infarction (AMI) have considerable variability in in-hospital risks, resulting in higher demands on healthcare resources. Simple risk-assessment tools are important for the identification of patients with higher risk to inform clinical decisions. However, few risk assessment tools have been built that are suitable for populations with AMI in China. We aim to develop and validate a risk prediction model, and further build a risk scoring system.DesignData from a nationally representative retrospective study was used to develop the model. Patients from a prospective study and another nationally representative retrospective study were both used for external validation.Setting161 nationally representative hospitals, and 53 and 157 other hospitals were involved in the above three studies, respectively.Participants8010 patients hospitalised for AMI were included as development sample, and 4485 and 11 223 other patients were included as validation samples in their corresponding studies.Primary and secondary outcome measuresThe in-hospital major adverse cardiovascular events (MACE) was defined as death from any cause, recurrent AMI, or ischaemic stroke.ResultsThe proportion of in-hospital MACE was 11.7%, 8.8% and 11.4% among the development sample and two external-validation samples, respectively. Nine predictors (ie, age, sex, left ventricular ejection fraction, Killip class, systolic blood pressure, creatinine, white blood cell count, heart rate and blood glucose) were independently associated with in-hospital MACE. The model performed well on both discrimination and calibration capability, with areas under the Receiver Operating Characteristic Curve (ROC) curve of 0.85, 0.74 and 0.80, and calibration slopes of 0.98, 0.84 and 0.97 in the development sample and two external validation samples, respectively. A point-based risk scoring system was built with good discrimination and reclassification ability.ConclusionsA prediction model using readily available clinical parameters was developed and externally validated to estimate risks of in-hospital MACE among patients with AMI, thereby better informing decision-making in improving clinical care.

Background Improving health status is one of the major goals in the management of heart failure (HF). However, little is known about the long‐term individual trajectories of health status in patients with acute HF after discharge. Methods and Results We enrolled 2328 patients hospitalized for HF from 51 hospitals prospectively and measured their health status via the Kansas City Cardiomyopathy Questionnaire–12 at admission and 1, 6, and 12 months after discharge, respectively. The median age of the patients included was 66 years, and 63.3% were men. Six patterns of Kansas City Cardiomyopathy Questionnaire–12 trajectories were identified by a latent class trajectory model: persistently good (34.0%), rapidly improving (35.5%), slowly improving (10.4%), moderately regressing (7.4%), severely regressing (7.5%), and persistently poor (5.3%). Advanced age, decompensated chronic HF, HF with mildly reduced ejection fraction, HF with preserved ejection fraction, depression symptoms, cognitive impairment, and each additional HF rehospitalization within 1 year of discharge were associated with unfavorable health status (moderately regressing, severely regressing, and persistently poor) ( P <0.05). Compared with the pattern of persistently good, slowly improving (hazard ratio [HR], 1.50 [95% CI, 1.06–2.12]), moderately regressing (HR, 1.92 [1.43–2.58]), severely regressing (HR, 2.26 [1.54–3.31]), and persistently poor (HR, 2.34 [1.55–3.53]) were associated with increased risks of all‐cause death. Conclusions One‐fifth of 1‐year survivors after hospitalization for HF experienced unfavorable health status trajectories and had a substantially increased risk of death during the following years. Our findings help inform the understanding of disease progression from a patient perception perspective and its relationship with long‐term survival. Registration URL: https://www.clinicaltrials.gov ; unique identifier: NCT02878811.