B. Aliprandi-Costa

Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study.

Objectives: To characterise management of suspected acute coronary syndrome (ACS) in Australia and New Zealand, and to assess the application of recommended therapies according to published guidelines.

Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand

Objective To evaluate the proportion of patients hospitalised with acute coronary syndrome (ACS) in Australia and New Zealand who received optimal inpatient preventive care and to identify factors associated with preventive care. Methods All patients hospitalised bi-nationally with ACS were identified between 14–27 May 2012. Optimal in-hospital preventive care was defined as having received lifestyle advice, referral to rehabilitation, and prescription of secondary prevention pharmacotherapies. Multilevel multivariable logistic regression was used to determine factors associated with receipt of optimal preventive care. Results For the 2299 ACS survivors, mean (SD) age was 69 (13) years, 46% were referred to rehabilitation, 65% were discharged on sufficient preventive medications, and 27% received optimal preventive care. Diagnosis of ST elevation myocardial infarction (OR: 2.64 [95% CI: 1.88–3.71]; p<0.001) and non-ST elevation myocardial infarction (OR: 1.99 [95% CI: 1.52–2.61]; p<0.001) compared with a diagnosis of unstable angina, having a percutaneous coronary intervention (PCI) (OR: 4.71 [95% CI: 3.67–6.11]; p<0.001) or coronary bypass (OR: 2.10 [95% CI: 1.21–3.60]; p=0.011) during the admission or history of hypertension (OR:1.36 [95% CI: 1.06–1.75]; p=0.017) were associated with greater exposure to preventive care. Age over 70 years (OR:0.53 [95% CI: 0.35–0.79]; p=0.002) or admission to a private hospital (OR:0.59 [95% CI: 0.42–0.84]; p=0.003) were associated with lower exposure to preventive care. Conclusions Only one-quarter of ACS patients received optimal secondary prevention in-hospital. Patients with UA, who did not have PCI, were over 70 years or were admitted to a private hospital, were less likely to receive optimal care.

Acute coronary syndrome and stable coronary artery disease: Are they so different? Long-term outcomes in a contemporary PCI cohort

BACKGROUND Patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) are known to have poorer short-term prognosis compared to stable coronary artery (CAD) patients undergoing elective PCI. Few studies have made direct comparison of long-term mortality between ACS and stable CAD patients undergoing PCI. The aim of our study was to compare the long-term mortality following PCI between patients with ACS and those with stable CAD. METHODS We examined consecutive patients undergoing PCI with stenting at a tertiary referral hospital. Clinical, angiographic and biochemical data were collected and analysed. The primary outcome was all-cause mortality retrieved from the Statewide Death Registry database. RESULTS Included were 1923 consecutive PCI patients (970 stable CAD and 953 ACS). The mean follow-up time was 4.1 years ± 1.8 years. In-hospital mortality was 1.4% overall, seen exclusively in patients with ACS (n=28, 2.9%). Post-discharge mortality was 6.7% among patients with stable CAD and 10.5% for ACS (P<0.01). Multivariate predictors of post-discharge deaths for both groups included age (HR 1.08 per year, P<0.001) and impaired renal function (HR 2.49, P<0.001). Following adjustment for these factors, an ACS indication for PCI was not associated with greater post-discharge mortality (adjusted HR 1.18: 0.85-1.64, P=0.32). CONCLUSIONS Patients undergoing PCI following an ACS have higher long-term mortality to those with stable CAD, which is potentially explained by a greater prevalence of comorbidities. This suggests that for the ACS population, contemporary interventional and medical management strategies may effectively and specifically counter the adverse prognostic impact of coronary instability and myocardial damage.

Survival after an acute coronary syndrome: 18-month outcomes from the Australian and New Zealand SNAPSHOT ACS study

Objectives: To assess the impact of the availability of a catheterisation laboratory and evidence‐based care on the 18‐month mortality rate in patients with suspected acute coronary syndromes (ACS).

Management and outcomes following an acute coronary event in patients with chronic heart failure 1999-2007

The outcome of patients with chronic heart failure (CHF) following an ischaemic event is poorly understood. We evaluated the management and outcomes of CHF patients presenting with an acute coronary syndrome (ACS) and explored changes in outcomes over time.

The peri-operative management of anti-platelet therapy in elective, non-cardiac surgery

BACKGROUND Cardiovascular complications are important causes of morbidity and mortality in patients undergoing elective non-cardiac surgery, with adverse cardiac outcomes estimated to occur in approximately 4% of all patients. Anti-platelet therapy withdrawal may precede up to 10% of acute cardiovascular syndromes, with withdrawal in the peri-operative setting incompletely appraised. OBJECTIVES The aims of our study were to determine the proportion of patients undergoing elective non-cardiac surgery currently prescribed anti-platelet therapy, and identify current practice in peri-operative management. In addition, the relationship between management of anti-platelet therapy and peri-operative cardiac risk was assessed. METHODS We evaluated consecutive patients attending elective non-cardiac surgery at a major tertiary referral centre. Clinical and biochemical data were collected and analysed on patients currently prescribed anti-platelet therapy. Peri-operative management of anti-platelet therapy was compared with estimated peri-operative cardiac risk. RESULTS Included were 2950 consecutive patients, with 516 (17%) prescribed anti-platelet therapy, primarily for ischaemic heart disease. Two hundred and eighty nine (56%) patients had all anti-platelet therapy ceased in the peri-operative period, including 49% of patients with ischaemic heart disease and 46% of patients with previous coronary stenting. Peri-operative cardiac risk score did not influence anti-platelet therapy management. CONCLUSIONS Approximately 17% of patients undergoing elective non-cardiac surgery are prescribed anti-platelet therapy, the predominant indication being for ischaemic heart disease. Almost half of all patients with previous coronary stenting had no anti-platelet therapy during the peri-operative period. The decision to cease anti-platelet therapy, which occurred commonly, did not appear to be guided by peri-operative cardiac risk stratification.

The contribution of the composite of clinical process indicators as a measure of hospital performance in the management of acute coronary syndromes—insights from the CONCORDANCE registry

Aims Acute coronary syndrome (ACS) is a costly condition for health service provision yet variation in the delivery of care between hospitals persists. A composite measure of adherence with evidence-based clinical-process indicators (CPIs) could better inform hospital performance reporting and clinical outcomes in the management of ACS. Methods Data on 7444 ACS patients from 39 Australian hospitals were used to derive a hospital-specific composite quality score by calculating mean adherence to 14 evidence-based CPIs. Using the generalized estimating equation to account for clustering of patients within hospitals and the GRACE risk score to adjust for differences in presenting risk, we evaluated associations between the hospital-specific composite quality score, in-hospital major adverse events, in-hospital mortality and mortality and readmission for ACS at 6 months. Results Hospitals had a mean adherence of 68.3% (SD 21.7) with the composite quality score. There was significant variation between hospital adherence tertile 1 (79%) and tertile 3 (56%), P < 0.0001. With risk adjustment, there was an association between hospitals with a higher composite quality score and reduced in-hospital adverse events (OR: 0.85, CI: 0.71–0.99) and survival at hospital discharge (OR: 0.47; 95% CI: 0.28–0.77). There was trending improvement in survival at 6 months (OR 0.48; CI: 0.20–1.16) and fewer readmissions to hospital for ACS at 6 months (OR 0.79; CI 0.60–1.05). Conclusion The association between the quality composite score and reduced in-hospital events and survival at hospital discharge supports the utility of reporting CPIs in routine hospital performance reporting on the management of ACS. Australia and New Zealand Clinical Trial Registration (ANZCTR) CONCORDANCE Registry ACTRN12614000887673.

Developments in procedural and disease registries: a focus on coronary artery disease

Purpose of review Registries are becoming an increasingly important component of clinical practice through the collection of clinical data including outcomes on representative populations of patients. An understanding of registry structure and function is important for practicing cardiovascular clinicians. Clinical populations may be identified on the basis of procedures they undergo (procedural registries), or their clinical condition (disease registries). Registries provide opportunities to document and improve quality of care. They also provide insights into the nature of disease and the benefit of treatments in subgroups of patients, and poorly resourced environments, that are not well represented in randomized clinical trials. Recent findings To maximize the value of registries, minimum quality criteria must be met. These include clear definitions of the included populations, an unbiased inclusive patient sampling strategy, high quality data with processes to ensure this, a clear governance structure, and adherence to relevant ethical and privacy guidelines. Statistical techniques adjusting for the nonrandomized nature of treatment allocations continue to evolve. There is increasing potential for randomized controlled trials to be conducted within registry cohorts. By using the same clinical data for both the registry and the trial, and enrolling unselected patients, this cost-effective approach provides information on the effectiveness of care in the pragmatic clinical environment. Summary The potential of these rich clinical data sources is yet to be realized. Future developments that will enhance their value include improved efficiencies by integration with the electronic medical record, more widespread crosstalk between high quality registries facilitated by data linkage, simplification of ethical processes, and development of sustainable funding models.

HbA1c Assessment in Diabetic Patients with Acute Coronary Syndromes

Guidelines for the management of acute coronary syndromes (ACS) advocate for maintaining adequate long‐term glycaemic control in diabetic patients. Glycosylated haemoglobin (HbA1c) measurement is commonly used to monitor long‐term glycaemic control in diabetes.

Glycosylated haemoglobin assessment in diabetic patients with acute coronary syndromes.

Guidelines for the management of acute coronary syndromes (ACS) advocate for maintaining adequate long‐term glycaemic control in diabetic patients. Glycosylated haemoglobin (HbA1c) measurement is commonly used to monitor long‐term glycaemic control in diabetes.