C. Astley

Prognostic impact of types of atrial fibrillation in acute coronary syndromes

Atrial fibrillation (AF) has been established as an independent predictor of long-term mortality after acute myocardial infarction. However, this is less well defined across the whole spectrum of acute coronary syndromes (ACSs). The Acute Coronary Syndrome Prospective Audit is a prospective multicenter registry with 12-month outcome data for 3,393 patients (755 with ST-segment elevation myocardial infarction, 1942 with high-risk non-ST-segment elevation ACS [NSTE-ACS], and 696 with intermediate-risk NSTE-ACS). A total of 149 patients (4.4%) had new-onset AF and 387 (11.4%) had previous AF. New-onset AF was more, and previous AF was less frequent in those with ST-segment elevation myocardial infarction than in those with high-risk NSTE-ACS or intermediate-risk NSTE-ACS (p <0.001). Compared to patients without arrhythmia, patients with new-onset AF and previous AF were significantly older and had more high-risk features at presentation (p <0.004). Patients with new-onset AF more often had left main coronary artery disease, resulting in a greater rate of surgical revascularization (p <0.001). Only new-onset AF resulted in adverse in-hospital outcomes (p <0.001). Only patients with previous AF had greater long-term mortality (hazard ratio 1.42, p <0.05). New-onset AF was only associated with a worse long-term composite outcome (hazard ratio 1.66, p = 0.004). However, the odds ratio for the composite outcome was greatest for patients with new-onset AF with intermediate-risk NSTE-ACS (odds ratio 3.9, p = 0.02) than for those with high-risk NSTE-ACS (odds ratio 2.0, p = 0.01) or ST-segment elevation myocardial infarction (odds ratio 1.4, p = 0.4). In conclusion, new-onset AF was associated with worse short-term outcomes and previous AF was associated with greater mortality even at long-term follow-up. The prognostic burden of new-onset AF differed with the type of ACS presentation.

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.

Current management of acute coronary syndromes in Australia: observations from the acute coronary syndromes prospective audit.

Background: Acute coronary syndromes (ACS) management is now well informed by guidelines extrapolated from clinical trials. However, most of these data have been acquired outside the local context. We sought to describe the current patterns of ACS care in Australia.

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.

Potential survival gains in the treatment of myocardial infarction.

Objectives: To evaluate the potential impact of complete implementation of guideline recommendations in myocardial infarction (MI) care, and contrast this with new innovations. Design: Modelling of potential events prevented from literature-based treatment effects and observed guideline recommendation utilisation rates. Setting: Hospital-based care. Participants: Nationwide registry of 1630 patients with MI adjusted for age, gender and GRACE score extrapolated to a population of 10 000 patients. Interventions: Literature-based efficacy estimates associated with guideline-recommended treatments and a putative treatment providing a 10–30% 12-month event reduction. Main outcome measures: Mortality and recurrent MI or stroke by 30 days and 30 days to 12 months. Results: Adjusted-mortality rates for optimally managed patients with ST-segment MI (STEMI) and non-ST-segment MI (NSTEMI) to 30 days were 0.6% and 2.5%, respectively. Adjusted mortality from 30 days to 12 months was 1.8% among optimally managed patients. No reperfusion occurred in 31% of patients with STEMI. Fewer than four guideline treatments were prescribed in 26% of patients at discharge. Compared with in-hospital care, better application of secondary prevention treatments provided the greater absolute gains (STEMI 23 lives/10 000 patients by 30 days, NSTEMI 43 lives/10 000 by 30 days and secondary prevention 104 lives/10 000 by 12 months). A putative novel treatment reducing mortality by 30% among optimally managed patients would save a further 4 lives/10 000 by 12 months. Conclusions: Potential gains from improved clinical effectiveness in MI care are likely to compare favourably with benefits achieved though innovations, and should inform priorities in research and implementation strategies for improving MI outcomes.

Morbidity, mortality and economic burden of renal impairment in cardiac intensive care

Background: Moderate to severe impairment of renal function has emerged as a potent risk factor for adverse short‐ and long‐term outcomes among patients presenting with cardiac disease.

Lost in Translation Health Resource Variability in the Achievement of Optimal Performance and Clinical Outcome

Background— An evidence-practice gap in acute coronary syndromes (ACS) is commonly recognized. System, provider, and patient factors can influence guideline adherence. Through using guideline facilitators in the clinical setting, the uptake of evidence-based recommendations may be increased. We hypothesized that facilitators of guideline recommendations (systems, tools, and workforce) in acute cardiac care were associated with increased guideline adherence and decreased adverse outcome. Methods and Results— A cross-sectional evaluation of guideline facilitators was conducted in Australian hospitals. The population was derived from the Acute Coronary Syndrome Prospective Audit (ACACIA) and assessed performance, death, and recurrent myocardial infarction (death/re-MI) at 30 days and 12 months. Thirty-five hospitals and 2392 patients participated. Significant associations with decreased death/re-MI were observed with hospital strategies to facilitate primary percutaneous coronary intervention for ST-elevation MI patients (38/428 [8.9%] versus 30/154 [19.5%], P<0.001) and after adjustment (odds ratio [OR], 0.47 [95% confidence interval (CI), 0.24 to 0.90], P<0.023), electronic discharge checklists (none: 233/1956 [11.9%], integrated; 43/251[17.1%], P=0.069, electronic; 6/124 [4.8%], P<0.001) and after adjustment (integrated versus none: OR, 1.66 [95% CI, 0.98 to 2.80], P=0.057 and electronic versus none: OR, 0.49 [95% CI, 0.35 to 0.68], P<0.001), and intensive cardiac care unit (ICCU) staff-to-patient ratios (neither: 200/1257 (15.9%), CCU: 135/1051 (12.8%), ICCU: 8/84 (9.5%), P=0.049 and after adjustment (CCU versus neither: OR, 0.74 [95% CI, 0.47 to 1.14], P=0.172 and ICCU versus neither: OR, 0.55; [95% CI, 0.38 to 0.81] P=0.003). Conclusions— Facilitating uptake of evidence in clinical practice may need to consider quality improvement systems, tools and workforce to achieve optimal ACS outcomes.

Randomized Comparison of High-Sensitivity Troponin Reporting in Undifferentiated Chest Pain Assessment

Background—High-sensitivity troponin T (hs-TnT) assays promise greater discrimination of evolving myocardial infarction, but the impact of unguided implementation on the effectiveness of care is uncertain. Methods and Results—We evaluated the impact of hs-TnT reporting on care and outcome among chest pain patients presenting to 5 emergency departments within a multicenter randomized trial. Patients were allocated to hs-TnT reporting (hs-report) or standard reporting (std-report; Roche Elecys). The primary end point was death and new or recurrent acute coronary syndrome by 12 months. A total of 1937 patients without ST-segment elevation were enrolled between July 2011 and March 2013. The median age was 61 (interquartile range, 48–74) years, and 46.3% were women. During the index hospitalization, 1466 patients (75.7%) had maximal troponin <30 ng/L within 24 hours. Randomization to hs-report format did not alter the admission rate (hs-report: 57.7% versus std-report: 58.0%; P=0.069). There was no difference in angiography (hs-report: 11.9% versus std-report: 10.9%; P=0.479). The hs-reporting did not reduce 12-month death or new/recurrent acute coronary syndrome in the overall population (hs-report: 9.7% versus std-report: 7.2% [hazard ratio, 0.83 (0.57–1.22); P=0.362]). However, among those with troponin levels <30 ng/L, a modest reduction in the primary end point was observed (hs-report: 2.6% versus std-report: 4.4%, [hazard ratio, 0.58; 95% confidence interval, 0.34–0.1.00; P=0.050). Conclusions—High-sensitivity troponin reporting alone is associated with only modest changes in practice. Clinical effectiveness in the adoption of high-sensitivity troponin may require close coupling with protocols that guide interpretation and care. Clinical Trial Registration—URL: http://www.ANZCTR.org.au. Unique identifier: ACTRN12611000879965.

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).

Availability of highly sensitive troponin assays and acute coronary syndrome care: insights from the SNAPSHOT registry.

Objectives: To examine differences in care and inhospital course of patients with possible acute coronary syndrome (ACS) in Australia and New Zealand based on whether a highly sensitive (hs) troponin assay was used at the hospital to which they presented.