N. Cox

Managing the Femoral Artery in Coronary Angiography

Vascular access and subsequent methods to obtain haemostasis are commonly overlooked components of coronary angiography, yet most complications related to diagnostic coronary angiography and percutaneous coronary interventions come from groin bleeds. Most of these complications are minor, leading to bruising and patient discomfort. However, major vascular complications such as retroperitoneal bleeding are life threatening. A number of devices are now available to ensure the arteriotomy can be closed immediately at the end of the procedure. These devices have advantages but are in themselves the source of additional complications, which are not seen without them. The mechanisms related to the use of these devices and the potential complications that they may cause should be understood by all cardiologists performing coronary angiography.

What is the impact of systems of care for heart failure on patients diagnosed with heart failure: a systematic review

BackgroundHospital admissions for heart failure are predicted to rise substantially over the next decade placing increasing pressure on the health care system. There is an urgent need to redesign systems of care for heart failure to improve evidence-based practice and create seamless transitions through the continuum of care. The aim of the review was to examine systems of care for heart failure that reduce hospital readmissions and/or mortality.MethodElectronic databases searched were: Ovid MEDLINE, EMBASE, CINAHL, grey literature, reviewed bibliographies and Cochrane Central Register of Controlled Trials for randomised controlled trials, non-randomised trials and cohort studies from 1st January 2008 to 4th August 2015. Inclusion criteria for studies were: English language, randomised controlled trials, non-randomised trials and cohort studies of systems of care for patients diagnosed with heart failure and aimed at reducing hospital readmissions and/or mortality.Three reviewer authors independently assessed articles for eligibility based on title and abstract and then full-text. Quality of evidence was assessed using Newcastle-Ottawa Scale for non-randomised trials and GRADE rating tool for randomised controlled trials.ResultsWe included 29 articles reporting on systems of care in the workforce, primary care, in-hospital, transitional care, outpatients and telemonitoring. Several studies found that access to a specialist heart failure team/service reduced hospital readmissions and mortality. In primary care, a collaborative model of care where the primary physician shared the care with a cardiologist, improved patient outcomes compared to a primary physician only. During hospitalisation, quality improvement programs improved the quality of inpatient care resulting in reduced hospital readmissions and mortality. In the transitional care phase, heart failure programs, nurse-led clinics, and early outpatient follow-up reduced hospital readmissions. There was a lack of evidence as to the efficacy of telemonitoring with many studies finding conflicting evidence.ConclusionRedesigning systems of care aimed at improving the translation of evidence into clinical practice and transitional care can potentially improve patient outcomes in a cohort of patients known for high readmission rates and mortality.

Practicality, safety and accuracy of computed tomography coronary angiography in the evaluation of low TIMI-risk score chest pain patients: A pilot study

Objectives:  The present pilot study aimed to assess the practicality, safety and accuracy of performing CT coronary angiography (CT‐CA) in the evaluation of acute chest pain of patients with low thrombolysis in myocardial infarction (TIMI) risk scores.

Non‐invasive multislice computed tomography coronary angiography for imaging coronary arteries, stents and bypass grafts

Multislice computed tomography (MSCT) is evolving rapidly and available data suggest that MSCT coronary angiography may be a reliable and accurate non‐invasive imaging modality of coronary arteries. Current generations of MSCT scanners have high sensitivity and specificity for diagnosing native coronary artery disease and coronary bypass graft occlusion. The performance of MSCT in the evaluation of stent patency is still being assessed. In comparison with conventional selective coronary angiography (SCA), MSCT is non‐invasive, cheaper and it has the advantages of imaging plaque compositions as well as assessment of luminal patency. Nevertheless, the role of MSCT in the management of coronary artery disease is yet to be fully defined.

Implementing Sustainable Data Collection for a Cardiac Outcomes Registry in an Australian Public Hospital

BACKGROUND Clinical outcome registries are an increasingly vital component of ensuring quality and safety of patient care. However, Australian hospitals rarely have additional resources or the capacity to fund the additional staff time to complete the task of data collection and entry. At the same time, registry funding models do not support staff for the collection of data at the site but are directed towards the central registry tasks of data reporting, managing and quality monitoring. The sustainability of a registry is contingent on building efficiencies into data management and collection. METHODS We describe the methods used in a large Victorian public hospital to develop a sustainable data collection system for the Victorian Cardiac Outcomes Registry (VCOR), using existing staff and resources common to many public hospitals. We describe the features of the registry and the hospital specific strategies that allowed us to do this as part of our routine business of providing good quality cardiac care. RESULTS All clinical staff involved in patient care were given some data collection task with the entry of these data embedded into the staffs daily workflow. A senior cardiology registrar was empowered to allocate data entry tasks to colleagues when data were found to be incomplete. The task of 30-day follow-up proved the most onerous part of data collection. Cath-lab nursing staff were allocated this role. CONCLUSION With hospital accreditation and funding models moving towards performance based quality indicators, collection of accurate and reliable information is crucial. Our experience demonstrates the successful implementation of clinical outcome registry data collection in a financially constrained public hospital environment utilising existing resources.

Prevalence and outcomes of trans-radial access for percutaneous coronary intervention in contemporary practise

BACKGROUND Trans-radial access for percutaneous coronary intervention (PCI) has been associated with lower vascular complication rates and improved outcomes. We assessed the current uptake of trans-radial PCI in Victoria, Australia, and evaluated if patients were selected according to baseline bleeding risk in contemporary clinical practise, and compared selected clinical outcomes. METHODS PCI data of all patients between 1st January 2013 and 31st December 2014 were analysed using The Victorian Cardiac Outcomes Registry (VCOR). Propensity-matched analysis was performed to compare the clinical outcomes. RESULTS 11,711 procedures were analysed. The femoral route was the predominant access site (66%). Patients undergoing trans-radial access PCI were younger (63.9±11.6 vs. 67.2±11.8; p<0.001), had a higher BMI (28.9±5.5 vs. 28.5±5.2; p<0.001), more likely to be male (80.0 vs. 74.9%;p<0.001), less likely to have presented with cardiogenic shock (0.9 vs. 2.8%; p<0.001) or have the following comorbidities: diabetes (19.8 vs. 23.1%; p<0.001), peripheral vascular disease (2.9 vs. 4.3%; p=0.005) or renal impairment (13.6 vs. 22.1%; p<0.001). The radial group had less bleeding events (3.2 vs. 4.6%; p<0.001) and shorter hospital length of stay (3.1±4.7 vs. 3.3±3.9; p=0.006). There was no significant difference in mortality (1.0 vs. 1.4%; p=0.095). CONCLUSIONS Trans-femoral approach remains the dominant access site for PCI in Victoria. The choice of route does not appear to be selected by consideration of bleeding risk. The radial route is associated with improved clinical outcomes of reduced bleeding and length of stay consistent with previous findings, and this supports the efficacy and safety of trans-radial PCI in real-world clinical practise.

Changes in Statin Prescription Patterns in Patients Admitted to an Australian Geriatric Subacute Unit

BACKGROUND Assessment of demographic and clinical factors influencing the decision of statin discontinuation in the elderly population admitted to subacute geriatric unit. The aim of this study is to assess the clinical factors impacting the decision-making process of statin discontinuation in the elderly. METHODS We retrospectively assessed changes in statin discontinuation and prescription among patients (≥60 years old) discharged from a geriatric evaluation and management unit by reviewing hospital digital medical records at Western Health - The Williamstown Hospital over a 12-month period from 4 February 2012 until 4 February 2013 inclusive. The main outcome of the study was to determine the independent predictors of statin discontinuation using logistic regression analysis. RESULTS Of the studied population, 46% were already prescribed statins prior to their admission. Statins were discontinued in 17.5% of patients at discharge. Predictors of statin de-prescription included octogenarian status, primary prevention indication, poor functional recovery, residential care facility discharge destination and lower cognitive function. The presence of previous cardiovascular disease history and the burden of comorbidities were not predictors of statin discontinuation. CONCLUSIONS We observed that factors that conveyed poor prognosis such as advanced age, poor functional recovery, worse cognitive function, being discharged to a residential care facility as well as primary prevention indication for statin prescription are predictors of statin discontinuation in the geriatric unit.

The Establishment of the Victorian Cardiac Outcomes Registry (VCOR): Monitoring and Optimising Outcomes for Cardiac Patients in Victoria

BACKGROUND The Victorian Cardiac Outcomes Registry (VCOR) was established in 2012 to ensure the safety and quality of cardiac based therapies across Victoria. As a clinical quality registry, VCOR monitors the performance of health services in both the public and private sectors, by measuring and reporting on trends in the quality of patient care over time, within individual hospitals, comparatively with other hospitals, and aggregated at the state level. The current paper describes the VCOR registry aims, methods, governance structure and progress to date. METHODS Primary management of the registry is undertaken at Monash University in association with the Victorian Cardiac Clinical Network, Department of Health and Human Services Victoria. RESULTS The Victorian Cardiac Outcomes Registry has currently collected data on more than 33,000 cardiac patients across three separate areas of interest in 35 hospitals. These include percutaneous coronary intervention (PCI), the early treatment of acute myocardial infarction in rural and regional settings, and data relating to in-hospital management of heart failure. CONCLUSIONS The Victorian Cardiac Outcomes Registry is a clinical cardiac registry that commenced data collection in 2013, providing a detailed description of selected aspects of contemporary cardiology clinical practice in a majority of Victorian hospitals. This information enables hospitals and cardiac units to benchmark their practice, clinical outcomes and quality of care to other similar units and hospitals across the state. If replicated by other states in Australia, there will be the potential for important national comparisons, with the goal to foster continuous improvement in patient care and outcomes across the entire Australian health system.

Impact of limited English proficiency on presentation and outcomes of patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

Doctor–patient language discordance has been shown to lead to worse clinical outcomes. In this study of patients undergoing primary percutaneous coronary intervention for ST‐elevation myocardial infarction at an Australian health service, we demonstrated that limited English proficiency (LEP) is an independent predictor of prolonged symptom‐to‐door time, but does not lead to worse 30‐day mortality compared with English‐proficient patients. More effort needs to be placed in providing public health education in varied languages to encourage early presentation to hospital for patients with LEP.

Prevalence of Asymptomatic Coronary Heart Disease in the Siblings of Young Myocardial Infarction Patients as Detected by Coronary Computer Tomography Angiography: A Pilot Study

BACKGROUND There is little data on the prevalence of coronary heart disease (CHD) in the young. The study aimed to estimate the prevalence of asymptomatic CHD in siblings of young patients with myocardial infarction (MI) using coronary computed tomography angiography (CCTA). METHODS Prospective observational data was collected on siblings of patients aged ≤55 years presenting with acute MI and having coronary stenosis ≥50% on invasive coronary angiography in at least one epicardial coronary artery. Inclusion criteria included ages 30-55 and 30-60 years for males and females respectively. Outcome of interest was obstructive CHD by coronary computer tomography angiography (CCTA), which was defined by either moderate (50-69% stenosis) and/or severe (≥70% stenosis). RESULTS Fifty participants were studied of whom 20 (40%) were male. Thirty (60%) were current or ex-smokers, 4 (8%) had diabetes, 8 (16%) had hypertension and 26 (52%) had dyslipidaemia. Obstructive CHD by CCTA was detected in 9 (18%, 95% CI 9%-31%) participants and 3 (6%, 95% CI 1%-17%) participants were found to have severe luminal stenosis. The median radiation dose was 3.9 (IQR 0.9) mSv. CONCLUSIONS Approximately a fifth of siblings of young MI patients were found to have asymptomatic but obstructive CHD detected on CCTA of which one third was severe. This is a group in whom screening for CHD warrants further investigation.