C. Hammett

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.

Validation of NICE diagnostic guidance for rule out of myocardial infarction using high-sensitivity troponin tests

Objective To validate the National Institute for Health and Care Excellence (NICE) recommended algorithms for high-sensitivity troponin (hsTn) assays in adults presenting with chest pain. Methods International post hoc analysis of three prospective, observational studies from tertiary hospital emergency departments. The primary endpoint was cardiac death or acute myocardial infarction (AMI) within 24 hours of presentation, and the secondary endpoint was major adverse cardiac events (MACE) at 30 days. Results 15% of patients were diagnosed with non-ST elevation myocardial infarction (MI) on admission. The hsTnI algorithm classified 2506/3128 (80.1%) of patients as ‘ruled out’ with 50 (2.0%) missed MI. 943/3128 (30.1%) of patients had a troponin I level below the limit of detection on admission with 2 (0.2%) missed MI. For the hsTnT algorithm, 1794/3374 (53.1%) of patients were ‘ruled out’ with 7 (0.4%) missed MI. 490/3374 (14.5%) of patients had a troponin T below the limit of blank on admission with no MI. MACE at 30 days occurred in 10.7% and 8.5% of patients ‘ruled out’ defined by the hsTnI and hsTnT algorithms, respectively. Conclusions The NICE algorithms could identify patients with low probability of AMI within 2 hours; however, neither strategy performed as predicted by the NICE diagnostic guidance model. Additionally, the rate of MACE at 30 days was sufficiently high that the algorithms should only be used as one component of a more extensive model of risk stratification. Trial registration number ACTRN12611001069943, NCT00470587; post-results.

The demographic profile of young patients (<45 years-old) with acute coronary syndromes in Queensland.

BACKGROUND There is little data regarding the demographic profile of young (<45 years) Australian acute coronary syndrome patients. The aim of this study was to compare baseline characteristics, risk factor profile and outcomes of young patients compared with their older counterparts referred to two metropolitan Queensland hospitals. METHODS Over a four-year period, data on acute coronary syndrome patients referred to The Prince Charles and Royal Brisbane Hospitals were retrospectively analysed. Three major groups were identified: <45 years, 45-60 years and those >60 years. Age, sex, body mass index, risk factor profile, degree of coronary disease, left ventricular dysfunction, mode of presentation, initial pharmacological therapy and mortality data were compared between the three groups. RESULTS 4549 patients were analysed of whom, 277 were less than 45 years old. Younger patients tended to be male, more overweight and present more commonly with ST segment elevation myocardial infarction compared to their older counterparts. Smoking, family history and dyslipidaemia tended to occur more frequently in younger patients as compared to those >45 years. Those patients >45 years tended to present with non-ST segment elevation myocardial infarction and have a higher degree of ischaemic burden and left ventricular dysfunction. No patients <45 years died in their index admission at 30 days or at one year. CONCLUSIONS Although young patients <45 years make up the minority (6.1%) of patients presenting with acute coronary syndrome and generally have a favourable prognosis, this paper highlights the need for aggressive risk factor modification, with particular attention to smoking and dyslipidaemia, before the onset of overt clinical disease.

Improved Assessment of Chest pain Trial (IMPACT): assessing patients with possible acute coronary syndromes

Objective: To examine the safety and efficacy of the Improved Assessment of Chest pain Trial (IMPACT) protocol, a strategy for accelerated assessment of patients presenting to emergency departments (EDs) with chest pain.

Lack of association between baseline plasma homocysteine concentrations and restenosis rates after a first elective percutaneous coronary intervention without stenting

Objective: To evaluate the association between baseline homocysteine concentrations and restenosis rates in patients electively undergoing their first percutaneous coronary intervention (PCI) without stenting. Design: Prospective, single centre, observational study. Setting and patients: Patients electively undergoing their first PCI without stenting at a tertiary referral centre between 1990 and 1998. Methods: Blood samples were collected from all patients at baseline and assayed to determine the patients’ homocysteine concentrations. Patients whose PCI was successful underwent repeat angiography at a median of 6.4 (interquartile range 6–6.8) months. Their baseline and follow up angiograms were compared by quantitative coronary angiography to assess the incidence of restenosis. For the analysis, the patients were divided into two groups based on whether their baseline homocysteine concentrations were above or below the median value. These two groups were compared to determine whether there was any association between their baseline homocysteine concentrations and the incidence of restenosis at six months. Results: 134 patients had a successful first PCI without stenting (involving 200 lesions). At six month angiography, restenosis was observed in 33 patients (49.3%) with baseline homocysteine concentrations above the median value and in 31 patients (46.3%) with concentrations below the median value (p  =  0.74). There was no difference in the percentage of lesions developing restenosis (38 (39.6%) v 40 (38.5%), respectively, p  =  0.87) or late lumen loss (0.40 mm v 0.31 mm, respectively, p  =  0.24). On multivariable analysis, there was no association between homocysteine concentrations and late lumen loss (r  =  −0.11, p  =  0.11) or the percentage diameter stenosis at follow up (r  =  −0.07, p  =  0.32). Conclusion: Baseline homocysteine concentrations were not associated with six month restenosis rates in patients electively undergoing their first PCI without stenting.

Use of clinical risk stratification in non-ST elevation acute coronary syndromes: an analysis from the CONCORDANCE registry

Aims There is little information on clinical risk stratification (CRS) compared to objective risk tools in patients with non-ST elevation acute coronary syndromes (NSTEACS). We quantified CRS use, its agreement with Global Registry of Acute Coronary Events (GRACE) risk scores (GRS), and association with outcomes. Methods and results Data were extracted from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE), a multi-centre NSTEACS registry. From February 2009 to December 2015, 4512 patients from 41 sites were included. Predictors of CRS use and association with treatment were identified, CRS-GRS agreement determined and prediction of in-hospital and 6-month mortality compared. Clinical risk stratification was documented in 21% of patients. Family history of coronary disease was the only independent predictor of CRS use [odds ratio (OR) 1.23, 95% confidence interval (95% CI) 1.04-1.45]; electrocardiogram changes (OR 0.8, 95% CI 0.68-0.96), elevated biomarkers (OR 0.59, 95% CI 0.48-0.73), dementia (OR 0.56, 95% CI 0.36-0.84), and an urban hospital setting (OR 0.41, 95% CI 0.19-0.89) were independent negative predictors. A treatment-risk paradox was observed: high CRS risk patients received less anticoagulation (79% vs. 88%, P = 0.001) and angiography (83% vs. 71%, P < 0.001). CRS-GRS agreement was poor (kappa coefficient = 0.034) and CRS less predictive for in-hospital (c-statistic 0.54 vs. 0.87, P < 0.001) and 6-month (c-statistic 0.55 vs. 0.74, P < 0.01) mortality. Conclusion In Australia, CRS does not guide treatment, correlate with GRS or predict outcomes. This study suggests the need for greater awareness and integration of validated tools such as the GRACE score to optimally direct treatment and potentially improve outcomes.

A Comparison of Radial and Femoral Coronary Angiography in Patients From SNAPSHOT ACS, a Prospective Acute Coronary Syndrome Audit in Australia and New Zealand.

BACKGROUND There is wide variation in the use of radial over femoral access for patients with ACS. This study evaluates the factors associated with the selection of radial versus femoral angiography in Australia and New Zealand and the effect of access site on clinical events in acute coronary syndrome (ACS) patients. METHODS An analysis of the SNAPSHOT ACS audit was conducted during May 2012 across 286 hospitals in Australia and New Zealand. Data collected included baseline patient characteristics, hospital site details, treatment received, clinical events in-hospital and mortality at 18 months. Univariate and multivariable analyses were performed. RESULTS Of the 1621 patients undergoing coronary angiography, access was through the femoral artery in 1043 (63%), and the radial in 578 (36%) patients. Radial access dominated in New Zealand (241 out of 327, 73.7%), compared to Australia (337 out of 1293, 26.1%, p=<0.001), with interstate variation (6% to 54%, p=<0.001). Independent predictors of access site included country of admission (Odds of radial, Aus v NZ OR 0.14, 95% CI 0.08-0.24, p=<0.0001), prior CABG surgery (OR 0.16, 95% CI 0.09-0.31, p=<0.0001), high GRACE score (90th decile) (OR 0.44, 95% CI 0.21-0.91, p=0.026) and admission to a centre with high annual PCI volume (>209 cases per year) (OR 1.86, 95% CI 1.06-3.26, p=0.03). After adjustment, there was no difference in clinical events in-hospital or mortality at 18 months CONCLUSION: Coronary angiography in New Zealand rather than Australia is the strongest predictor of radial access in ACS patients. There was no difference in outcomes according to access site in this population based cohort study.

Expertise and infrastructure capacity impacts acute coronary syndrome outcomes

Objective Effective translation of evidence to practice may depend on systems of care characteristics within the health service. The present study evaluated associations between hospital expertise and infrastructure capacity and acute coronary syndrome (ACS) care as part of the SNAPSHOT ACS registry. Methods A survey collected hospital systems and process data and our analysis developed a score to assess hospital infrastructure and expertise capacity. Patient-level data from a registry of 4387 suspected ACS patients enrolled over a 2-week period were used and associations with guideline care and in-hospital and 6-, 12- and 18-month outcomes were measured. Results Of 375 participating hospitals, 348 (92.8%) were included in the analysis. Higher expertise was associated with increased coronary angiograms (440/1329; 33.1%), 580/1656 (35.0%) and 609/1402 (43.4%) for low, intermediate and high expertise capacity respectively; P<0.001) and the prescription of guideline therapies observed a tendency for an association with (531/1329 (40.0%), 733/1656 (44.3%) and 603/1402 (43.0%) for low, intermediate and high expertise capacity respectively; P=0.056), but not rehabilitation (474/1329 (35.7%), 603/1656 (36.4%) and 535/1402 (38.2%) for low, intermediate and high expertise capacity respectively; P=0.377). Higher expertise capacity was associated with a lower incidence of major adverse events (152/1329 (11.4%), 142/1656 (8.6%) and 149/149 (10.6%) for low, intermediate and high expertise capacity respectively; P=0.026), as well as adjusted mortality within 18 months (low vs intermediate expertise capacity: odds ratio (OR) 0.79, 95% confidence interval (CI) 0.58-1.08, P=0.153; intermediate vs high expertise capacity: OR 0.64, 95% CI 0.48-0.86, P=0.003). Conclusions Both higher-level expertise in decision making and infrastructure capacity are associated with improved evidence translation and survival over 18 months of an ACS event and have clear healthcare design and policy implications. What is known about the topic? There are comprehensive guidelines for treating ACS patients, but Australia and New Zealand registry data reveal substantial gaps in delivery of best practice care across metropolitan, regional, rural and remote health services, raising questions of equity of access and outcome. Greater mortality and morbidity gains can be achieved by increasing the application of current evidence-based therapies than by developing new therapy innovations. Health service system characteristics may be barriers or enablers to the delivery of best practice care and need to be identified and evaluated for correlations with performance indicators and outcomes in order to improve health service design. What does this paper add? This study measures two system characteristics, namely expertise and infrastructure, evaluating the relationship with ACS guideline application and clinical outcomes in a large and diverse cohort of Australian and New Zealand hospitals. The study identifies decision-making expertise and infrastructure capacity, to a lesser degree, as enabling characteristics to help improve patient outcomes. What are the implications for practitioners? In the design of health services to improve access and equity, expertise must be preserved. However, it is difficult to have experienced personnel at the bedside no matter where the health service, and engineering innovative systems and processes of care to facilitate delivery of expertise should be considered.

Intensive LDL Reduction Post Acute Coronary Syndromes: A Catalyst for Improved Outcomes

Intensive LDL Reductio n Post Acute Coronary Syndromes: A Catalyst for Improved Outcomes Karam Kostner, MD, PhD, FRACP, FCSANZ , Stephen Nicholls, MBBS, PhD, FRACP, FACC FESC, FAHA, FCSANZ, John Amerena, MBBS, FRACP, FCSANZ , Alex Brown, BMed, MPH, PhD, FRACP, FCSANZ, Mark Cooper, MBBS, PhD, FRACP , Chris Hammett, BHB, MBChB, MD, FRACP, FCSANZ , Richard O’Brien, MBBS, PhD, FRACP , Leonard Kritharides, MBBS PhD, FRACP, FAHA, FCSANZ, David L. Hare, MBBS, DPM, FRACP, FESC, FCSANZ , Gerald F. Watts, DSc, PhD, DM, FRCP, FRACP , Philip Aylward, MA (Oxon), BM, BCh, PhD, FRCP, FRACP, FACC A full list of authors’ institutional roles is printed at the end of this article.