Marcus Ilton

The Design and Rationale of the Australian Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events (CONCORDANCE)

BACKGROUND Cardiovascular observational registries characterise patients and describe the manner and use of therapeutic strategies. They facilitate analyses on the quality of care among participating institutions and document variations in clinical practice which can be benchmarked against best practice recommendations. The Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events (CONCORDANCE) is an Australian observational registry that describes management and outcomes in patients with acute coronary syndromes (ACS) and feeds back both performance and outcome measures to participating hospitals. METHODS The CONCORDANCE registry has been designed within a comparative effectiveness research (CER) framework to collect and report data from hospitals located in geographically diverse regions of Australia. Information including patient demographics, presenting characteristics, past medical history, in-hospital management and outcomes at six months and two years are entered into a web-based database using an electronic clinical record form (eCRF). Individual hospital information is returned to the sites in a real time confidential report detailing information on key performance indicator (KPI) process measures and outcomes benchmarked against the aggregated study cohort. Governance rules ensure data security and protect patient and clinician confidentiality. Consistent with a CER framework, additional characteristics of the registry include: (a) the capacity to evaluate associations between the inter and intra hospital systems and the provision of evidence based care and outcomes, (b) ongoing data collection from representative hospitals which allow spatial and temporal analysis of change in practice and the application of treatment modalities in the real world setting and (c) the provision of a data spine for quality improvement strategies and practical clinical trials. CONCLUSION The CONCORDANCE registry is a clinician-driven initiative describing clinical care for ACS patients admitted to Australian hospitals. The registry generates high quality data which is fed back to clinicians, and key stakeholders in ACS care. Using a CER approach, the registry describes the translation of randomised trial evidence into practice, and provides insights into strategies that could improve care and ultimately patient outcomes.

A framework for overcoming disparities in management of acute coronary syndromes in the Australian Aboriginal and Torres Strait Islander population. A consensus statement from the National Heart Foundation of Australia

Aboriginal and Torres Strait Islander patients with acute coronary syndromes (ACS) experience lower intervention rates and poorer outcomes compared with non‐Indigenous patients. A broad range of geographical, cultural and systemic factors contribute to delays and suboptimal treatment for ACS. Every Indigenous ACS patient, regardless of where they live, should be able to expect a coordinated, patient‐centred pathway of care provided by designated provider clinical networks and supported by Indigenous cardiac coordinators, Aboriginal liaison officers (ALOs) and health workers. These designated provider clinical networks provide: ➢appropriate prehospital and inhospital treatment ➢an individualised patient care plan developed jointly with the patient and his or her family ➢culturally appropriate education initiated within the hospital setting and involving families with support from ALOs ➢effective follow‐up care and access to relevant secondary prevention programs. We outline generic pathways to provide policymakers, health planners and health care providers with a framework for ACS diagnosis and management that can be implemented across the diverse settings in which Aboriginal and Torres Strait Islander people reside and their care is delivered, in order to optimise care and assertively address the current disparities in outcomes.

Rheumatic heart disease in Indigenous children in northern Australia: differences in prevalence and the challenges of screening

Objectives: To compare regional differences in the prevalence of rheumatic heart disease (RHD) detected by echocardiographic screening in high‐risk Indigenous Australian children, and to describe the logistical and other practical challenges of RHD screening.

Impact of medical consultation frequency on risk factors and medications 6 months after acute coronary syndrome.

OBJECTIVE Initiatives that support primary care to better enable delivery of optimal prevention services are of great importance. The purpose of this study was to examine the frequency of medical consultations by patients with acute coronary syndrome (ACS) in the 6 months after hospital discharge and to determine whether the frequency of visits was associated with differences in lifestyle, clinical measures and medication prescription. METHODS We conducted a retrospective subgroup analysis of data collected in the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE), which is an ongoing (prospective) clinical initiative providing continuous real-time reporting on the clinical characteristics, management and outcomes of patients admitted to Australian hospitals with ACS. We compared clinical measures, medications, smoking status and receipt of cardiac rehabilitation with frequency of medical consultations 6 months after hospital discharge. RESULTS Patients with ACS visited their general practitioner (GP) a mean of 4.4 (± 3.8) times and their cardiologist 1.2 (± 0.9) times in the 6-month period after their index admission. Patients who saw a GP in the 6-month period had significantly higher rates of participation in cardiac rehabilitation, receipt of dietary advice and prescription of cardioprotective medications. Factors associated with increased frequency of GP visits were older age groups (oldest fourth vs youngest fourth incidence rate ratio (IRR) 1.08; 95% CI 1.01, 1.14), being female (male vs female IRR 0.83; 95% CI 0.80, 0.86), diagnosis of ST-segment elevation myocardial infarction (STEMI) (STEMI vs non-STEMI IRR 1.08; 95% CI 1.04, 1.13; STEMI vs unstable angina IRR 1.01; 95% CI 0.95, 1.06), being a current smoker (IRR 1.09; 95% CI 1.05, 1.15), history of cardiovascular disease (IRR 1.06; 95% CI 1.01, 1.12), history of diabetes (IRR 1.25; 95% CI 1.21, 1.31), inpatient revascularisation (IRR 0.95; 95% CI 0.91, 0.99), receipt of cardiac rehabilitation referral (IRR 0.93; 95% CI 0.89, 0.97), and discharged on four or more out of five indicated medications (IRR 1.04; 95% CI 1.00, 1.08). CONCLUSION The majority of ACS survivors in this study saw their GP frequently and their cardiologist at least once during the 6 months after index admission. Seizing these opportunities to engage, manage and support patients is important for strengthening prevention in primary care.

Northern Territory Heart Failure Initiative-Clinical Audit (NTHFI-CA)-a prospective database on the quality of care and outcomes for acute decompensated heart failure admission in the Northern Territory: study design and rationale.

Introduction Congestive heart failure is a significant cause of morbidity and mortality in Australia. Accurate data for the Northern Territory and Indigenous Australians are not presently available. The economic burden of this chronic cardiovascular disease is felt by all funding bodies and it still remains unclear what impact current measures have on preventing the ongoing disease burden and how much of this filters down to more remote areas. Clear differentials also exist in rural areas including a larger Indigenous community, greater disease burden, differing aetiologies for heart failure as well as service and infrastructure discrepancies. It is becoming increasingly clear that urban solutions will not affect regional outcomes. To understand regional issues relevant to heart failure management, an understanding of the key performance indicators in that setting is critical. Methods and analysis The Northern Territory Heart Failure Initiative—Clinical Audit (NTHFI-CA) is a prospective registry of acute heart failure admissions over a 12-month period across the two main Northern Territory tertiary hospitals. The study collects information across six domains and five dimensions of healthcare. The study aims to set in place an evidenced and reproducible audit system for heart failure and inform the developing heart failure disease management programme. The findings, is believed, will assist the development of solutions to narrow the outcomes divide between remote and urban Australia and between Indigenous and Non-Indigenous Australians, in case they exist. A combination of descriptive statistics and mixed effects modelling will be used to analyse the data. Ethics and dissemination This study has been approved by respective ethics committees of both the admitting institutions. All participants will be provided a written informed consent which will be completed prior to enrolment in the study. The study results will be disseminated through local and international health conferences and peer reviewed manuscripts.

Why it Remains Difficult for Remote Cardiologist to Obtain the Locus ofControl for Ambulatory Health Care Conditions Such as Congestive HeartFailure

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Northern Territory Perspectives on Heart Failure with Comorbidities – Understanding Trial Validity and Exploring Collaborative Opportunities to Broaden the Evidence Base

Congestive Heart Failure (CHF) is an ambulatory care sensitive condition, associated with significant morbidity and mortality, rarely with cure. Outpatient based pharmacological management represents the main and most important aspect of care, and is usually lifelong. This narrative styled opinion review looks at the pharmacological agents recommended in the guidelines in context of the Northern Territory (NT) of Australia. We explore the concept of validity, a term used to describe the basis of standardising a particular trial or study and the population to which it is applicable. We aim to highlight the problems of the current guidelines based approach. We also present alternatives that could utilise the core principles from major trials, while incorporating regional considerations, which could benefit clients living in the NT and remote Australia.

Contextualizing Genetics for Regional Heart Failure Care

Congestive heart failure (CHF) is a chronic and often devastating cardiovascular disorder with no cure. There has been much advancement in the last two decades that has seen improvements in morbidity and mortality. Clinicians have also noted variations in the responses to therapies. More detailed observations also point to clusters of diseases, phenotypic groupings, unusual severity and the rates at which CHF occurs. Medical genetics is playing an increasingly important role in answering some of these observations. This developing field in many respects provides more information than is currently clinically applicable. This includes making sense of the established single gene mutations or uncommon private mutations. In this thematic series which discusses the many factors that could be relevant for CHF care, once established treatments are available in the communities; this section addresses a contextual role for medical genetics.

Differences in management and outcomes for men and women with ST-elevation myocardial infarction

Objective: To examine whether there are sex differences in the characteristics, management, and clinical outcomes of patients with an ST‐elevation myocardial infarction (STEMI).

Mortality from Aortic Stenosis Across the Spectrum of Severity: Analysis of Big Data from the National Echo Database of Australia

Geoff Strange1, Simon Stewart2, David Celermajer3, Tom Marwick4, Greg Scalia5, David Prior6, Marcus Ilton7, David Playford1. 1University of Notre Dame, Fremantle, Australia; 2University of Adelaide, Adelaide, Australia; 3University of Sydney, Sydney, Australia; 4Baker IDI, Melbourne, Australia; 5University of Queensland, Queensland, Australia; 6University of Melbourne, Melbourne, Australia; 7Royal Darwin Hospital, Darwin, Australia Background: Echocardiography (echo) is pivotal in evaluation of aortic valve gradients. We evaluated prognostic implications of the full spectrum of aortic stenosis severity in a large patient cohort, matched with mortality data. Methods: NEDA is a vendor-agnostic cloud-based database, containing echo measurement data (1997 -2017) from laboratories (N=10) across Australia (currently >530,000 Echos). Data linkage to the National Death Index (NDI) provided survival status on each induvial from the last recorded echo to a census date in October 2017. Data were available from 352,844 individuals comprising 186,820 men (60.8±18.0 yrs) and 166,024 women (60.9±19.2 yrs) with a mean follow up of 5.4 years per person and 63,142 fatal events. Results: Overall, a peak aortic valve velocity (AVvel) was recorded in 278,955 patients, demonstrating a J-shaped mortality pattern with highest ageand sex-adjusted risk profi le in those individuals (n=52,010) in the upper quintile (> 1.8 m/s and mean aortic gradient of 13mmHg); HR=1.29 (95% CI 1.25-1.32, p<0.001) relative to the lowest quintile. 1and 5-year mortality was 5.0% and 14.9% in the lowest vs 9.2 and 28.1% in the highest (p<0.0001) quintile, respectively. Th ose cases in the upper quintile were then further examined for survival against increasing gradients (n=44,340). Aft er adjusting for age, gender and ejection fraction, the mortality risk plateaued at a threshold of a mean gradient ≥30.9±1.3mmHg (AVvel > 3.71±0.26m/s), with an adjusted HR=0.94(95% CI 0.82-1.08, p=0.4) compared with those in the upper quintile of that group (mean gradient 59.9±9.4mmHg, AVvel 4.96±0.47m/s). 1and 5-year mortality profi les were equivalent for those with mean aortic pressure gradients 20-30mmHg (10.9%, 32.6% respectively), 30-40mmHg (11.8%, 33.0%) and >40mmHg (13.7%, 34.5%). Conclusion: Aortic stenosis is associated with signifi cant mortality across the spectrum of severity, including mild disease. Th ere is no discernible diff erence in survival between “moderate” and “severe” aortic stenosis. P1-115