Acute Coronary Syndromes In Australia Research Articles

Sex differences in the intention and decision to use emergency medical services for acute coronary syndrome in Australia: a retrospective study

BackgroundSex-based disparities in acute coronary syndrome (ACS) presentations exist and women often have worse outcomes after an ACS event. Calling the emergency medical services (EMS) initiates prehospital diagnosis and treatment...

The Rise of Transradial Artery Access for Percutaneous Coronary Intervention in Patients with Acute Coronary Syndromes in Australia.

Objectives The aim of this study was to evaluate the outcomes of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) via transradial artery access (TRA) or transfemoral artery access (TFA). Background Over the last decade, evidence for the benefit of TRA for PCI has grown, leading to a steady uptake of TRA around the world. Despite this, the topic remains controversial with contrary evidence to suggest no significant benefit over TFA. Methods A retrospective study of consecutive ACS patients from 2011 to 2017 who underwent PCI via TRA or TFA. The primary outcome was Major Adverse Cardiovascular Events (MACE), a composite of death, myocardial infarction (MI), target lesion revascularisation (TLR), or coronary artery bypass graft surgery (CABG) at 12 months. Secondary outcomes included Bleeding Academic Research Consortium (BARC) bleeding events scored 2 or higher, haematoma formation, and stent thrombosis, in addition to all individual components of MACE. Results We treated 3624 patients (77% male), with PCI via TFA (n = 2391) or TRA (n = 1233). Transradial artery access was associated with a reduction in mortality (3% vs 6.3%; p < 0.0001), MI (1.8% vs 3.9%; p=0.0004), CABG (0.6% vs 1.5%; p=0.0205), TLR (1% vs 2.9%; p < 0.0001), large haematoma (0.4% vs 1.8%; p=0.0003), BARC 2 (0.2% vs 1.1%; p=0.0029), and BARC 3 events (0.4% vs 1.0%; p=0.0426). On multivariate Cox regression analysis, TFA, age ≥ 75, prior PCI, use of bare metal stents, cardiogenic shock, cardiac arrest, and multivessel coronary artery disease were associated with an increased risk of MACE. Conclusion Despite the limitations secondary to the observational nature of our study and multiple confounders, our results are in line with results of major trials and, as such, we feel that our results support the use of TRA as the preferred access site in patients undergoing PCI for ACS to improve patient outcomes.

The impact of socioeconomic status on secondary prevention of the acute coronary syndrome

Abstract Background Although socioeconomic status (SES) has been reported to be associated with health inequities, there are limited studies exploring the association between SES and secondary prevention of acute coronary syndrome (ACS) in countries with universal health cover. Purpose The aim is to examine whether SES has an impact on the secondary prevention of ACS in Australia. Methods Australian SNAPSHOT ACS data (2012) and its 18-month follow-up data were linked to admissions data from 6 jurisdictions covering all states and territories, national death index and Medicare Pharmaceutical Benefits Scheme data covering up to 3 years post-discharge. The five SES groups (lowest in Group 1 and highest in Group 5) were derived from the Australian Bureau of Statistics Socio-Economic Indexes for Areas (SEIFA) using the residential postcode at baseline. Outcomes were cardiac rehabilitation (CR) participation and smoking rate at 18 months post discharge as well as the use of ≥3 of the 4 indicated medications, all-cause death and cardiovascular disease (CVD) rates by 36 months of discharge. Outcomes were compared between the groups using the multilevel logistic regression with covariates of SES (5 groups), sex, GRACE risk score (4 groups), ACS diagnosis (STEMI/NSTEMI/UA) and the jurisdictions where the admissions data were linked. Results Of 1655 patients with ACS (mean age 68±13.5 yrs, 65% were male), who were discharged from hospital alive and had linked data available, 353 (21%) were in SES Group 1 (lowest SES), 369 (22%) in Group 2, 382 (23%) in Group 3, 296 (18%) in Group 4 and 255 (15%) in Group 5 (highest SES). Baseline clinical characteristics were comparable across the five SES groups. At 18-month after discharge, 1014 (61%) patients were followed-up with comparable loss to follow-up in each group. After adjustment, fewer patients in the lower SES groups (Groups 1 and 2) had participated in CR than those in the highest SES group (Group 5) (OR (95% CI): 0.60 (0.36, 0.99) and 0.56 (0.35, 0.91), respectively). Moreover, the odds of smoking was greater in Group 3 than Group 5 (2.60 (1.15, 5.89)) but no trend was found across the groups. By 36 months of discharge after adjustment, there was no difference in the odds of using ≥3 out of 4 medications between the SES groups. Despite this, patients in Groups 1 and 2 were significantly more likely to die than those in the highest SES group (1.96 (1.19, 3.21) and 1.91 (1.19, 3.07), respectively). The odds of CVD readmission did not differ across SES groups. Conclusion This study suggests that patients with low SES were less likely to participate in CR programs and more likely to die than those with high SES. Smoking rates varied between patients with intermediate and high SES but no trend was found across the groups. Despite the universal health cover available, inequity between the SES groups still exist. Future research is needed to further explore strategies to help close the evidence-practice gaps. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Australian National Heart Foundation Postdoctoral Fellowship

490 Factors Influencing Catheterisation Rates following Acute Coronary Syndromes in Australia

490 Factors Influencing Catheterisation Rates following Acute Coronary Syndromes in Australia

495 Gender Differences in Management and Outcomes in Non-ST-Elevation Acute Coronary Syndromes in Australia

To assess differences in management and outcomes in men and women with non-ST-elevation acute coronary syndromes (NSTEACS). Prospective cohort study of 7783 patients (2422 women, 5361 men) diagnosed with NSTEACS from the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE) registry between 2009 and 2019. Baseline data were collected via electronic case report form from 43 Australian hospitals with telephone follow-up at 6 months. Women were older (67.9 v 65.3, p<0.0001) with higher GRACE risk scores (105.6 v 100.8, p<0.0001). They were less likely to undergo cardiac catheterisation (71% v 77%, p<0.0001) and had longer median wait times for this (53 v 47.2 hours, p<0.0001). Women were more likely to have non-obstructive disease (35% v 14%, p<0.0001). At discharge, women were less likely to be prescribed aspirin (83% v 89%, p<0.0001), a second antiplatelet (58% v 67%, p<0.0001), beta-blockers (69% v 74%, p=0.0004), statins (84% v 91%, p<0.0001), or be referred for cardiac rehabilitation (53% v 62%, p<0.0001). Adjusted mortality rates in hospital (aOR, 0.98; 95% CI, 0.66-1.44) and at 6-months (aOR, 0.91; 95% CI, 0.65-1.28) were comparable between men and women, as were MACE rates in hospital (aOR, 0.96; 95% CI, 0.77-1.19) and at 6-months (aOR, 0.97; 95% CI, 0.79-1.20). Women with NSTEACS received less thorough investigation and therapy compared to men, however mortality and MACE rates were not different.

Intensive lipid-lowering therapy in the 12 months after an acute coronary syndrome in Australia: an observational analysis.

To determine the prevalence and identify predictors of people hospitalised with acute coronary syndrome (ACS) receiving intensive lipid-lowering therapy during the 12 months after their discharge from hospital. Retrospective observational analysis. Data were extracted from CONCORDANCE, a prospective, Australian investigator-initiated ACS registry. Patients enrolled in CONCORDANCE during January 2015 - May 2016 who survived to hospital discharge, for whom information on lipid-lowering therapy 6 or 12 months after discharge from hospital were available. Not receiving intensive lipid-lowering therapy (with or without ezetimibe) at the most recent follow-up (6 or 12 months); predictors of not receiving intensive lipid-lowering therapy. 1876 of 3441 patients (55%) were receiving intensive lipid-lowering therapy 6 or 12 months after their hospitalisation with an ACS. Predictors of not receiving intensive lipid-lowering therapy included not been prescribed this treatment prior to their hospital admission (odds ratio [OR], 1.53; 95% CI, 1.26-1.85) or at hospital discharge (aOR, 7.24; 95% CI, 4.37-12.0), being a woman (aOR, 1.20; 95% CI, 1.02-1.41), and not being referred for cardiac rehabilitation (aOR 1.39; 95% CI, 1.09-1.78). Patients who were managed medically in hospital (not revascularised; aOR, 1.54; 95% CI, 1.25-1.91) or underwent coronary artery bypass grafting (aOR 1.55; 95% CI, 1.26-1.92) were less likely to be receiving intensive lipid-lowering therapy at follow-up than those with a percutaneous coronary intervention. Unmeasured hospital factors accounted for 17% of the variation in the likelihood of intensive lipid-lowering therapy. 45% of patients in Australia are not receiving intensive lipid-lowering therapy in the 12 months after their ACS. Optimising oral lipid-lowering therapy would reduce the recurrence of coronary events in this high risk group.

A Gender-Based Comparison of Management, In-Hospital and Late Outcomes for Patients with Acute Coronary Syndrome in Australia and New Zealand: Results from the SNAPSHOT ACS Audit

Background: Death from acute coronary syndrome (ACS) may be prevented using evidence-based guidelines which are equally applicable to women and men. Prospective local studies comparing ACS care and outcomes between women and men are lacking. Aim: To identify and compare current management and outcomes of ACS in Australia and New Zealand for women and men. Methods: We investigated comprehensive data from the prospective binational ACS SNAPSHOT audit for individual women and men hospitalised in Australia and New Zealand between 14.5.2012 - 27.5.2012. Results: There were 4387 ACS patient admissions to 478 sites, including 1767 women (40%) and 2620 men. Women were older (68.5 vs 65.3 years: p < 0.0001), with similar GRACE scores (100.72 ± 35.6 vs 100.27 ± 34.7: p = 0.623). Women received angiography for ACS (OR 0.78, 95% CI: 0.65–0.90: p = 0.001), guideline based medications (OR 0.63, 95% CI: 0.55-0.72: p < 0.0001) and cardiac rehabilitation referral (OR 0.78, 95% CI 0.67-0.91: p = 0.002) less often than men. Proportionately less women experienced cardiac arrest (0.7 vs 2.5%: p < 0.0001) and major adverse events (8.7 vs 11%: p = 0.009). After adjustment for GRACE score, there were no differences in death at 18 months (OR 0.94, 95% CI 0.74-1.2: p = 0.63). Conclusions: Australian and New Zealand women and men experience treatment differences not explained by GRACE risk scores; women receive fewer discharge medications, investigations and rehabilitation. Yet outcomes are similar. Thus, further research is required to determine if treatment differences are warranted. Optimal guideline delivery needs to be identified in both genders to reduce inequity and maximise outcomes.

Acute coronary syndrome in Australia

Acute coronary syndrome in Australia

Evidence-based interventions in primary care following acute coronary syndrome in Australia and New Zealand: a systematic scoping review.

BackgroundCoronary artery disease has a significant disease burden, but there are many known barriers to management of acute coronary syndrome (ACS). General practitioners (GPs) bear considerable responsibility for post-discharge management of ACS in Australia and New Zealand (NZ), but knowledge about the extent and efficacy of such management is limited. This systematic review summarises published evidence from Australia and New Zealand regarding management in primary care after discharge following ACS.MethodsA search of PubMed, Scopus, CINAHL-Plus and PSYCINFO databases in August 2015 was supplemented by citation screening and hand-searching. Literature was selected based on specified criteria, and assessed for quality using the Mixed Methods Appraisal Tool (MMAT). Extracted data was related to evidence-based interventions specified by published guidelines.ResultsThe search yielded 19 publications, most of which reported on quantitative and observational studies from Australia. The majority of studies scored at least 75 % on the MMAT. Diverse aspects of management by GPs are presented according to categories of evidence-based guidelines. Data suggests that GPs are more likely to prescribe ACS medications than to assist in lifestyle or psychological management. GP referral to cardiac rehabilitation varied, and one study showed an improvement in the number of ACS patients with documented ACS management plans. Few studies described successful interventions to improve GP management, though some quality improvement efforts through education and integration of care with hospitals were beneficial. Limited data was published about interventions effective in rural, minority, and Indigenous populations.ConclusionsResearch reflects room for improvement in GP post-discharge ACS management, but little is known about effective methods for improvement. Additional research, both observational and interventional, would assist GPs in improving the quality of post-discharge ACS care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12872-016-0388-y) contains supplementary material, which is available to authorized users.

Insights Into the Use of Interventional Management in Acute Coronary Syndromes in Australia Over the Last 15 years

Insights Into the Use of Interventional Management in Acute Coronary Syndromes in Australia Over the Last 15 years

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. To evaluate the frequency and clinical predictors of in-hospital HbA1c measurement in diabetic patients presenting with ACS and the relationship between HbA1c assessment and mortality following discharge. This registry-based cohort study included 1743 diabetic patients from 33 representative hospitals across Australia with a final diagnosis of ACS. Independent predictors of HbA1c assessment were evaluated using a multivariable logistic generalised estimating equations analysis. The association between HbA1c assessment and mortality following discharge was evaluated using Cox proportional hazard analysis. Seven hundred and fourteen (41%) patients had HbA1c assessment during admission. Frequency of assessment varied markedly between hospitals (7.7-87.6%). HbA1c assessment was significantly more frequent in hospitals with catheterisation laboratories. Frequency of assessment was not associated with location of hospital (rural vs urban) or hospital capacity. Independent clinical predictors of HbA1c assessment across participating hospitals were younger age, ST-Elevation Myocardial Infarction, cardiac catheterisation and coronary artery bypass surgery during admission. HbA1c assessment was associated with higher rates of coronary catheterisation, revascularisation and receipt of evidence-based medicines but not with mortality during 6 months following discharge (hazard ratio, 0.48; 95% confidence interval, 0.19-1.18). Frequency of HbA1c assessment varies markedly between hospitals, and most diabetic patients admitted for ACS in Australia do not receive assessment of pre-admission glycaemic control. HbA1c assessment was associated with better evidence driven medical care.

Acute coronary syndrome in Australia: Where are we now and where

Acute coronary syndrome (ACS) is a significant contributor to both morbidity and mortality in Australia. Generally speaking, sufferers of ACS who live in rural areas and are treated at rural hospitals have poorer outcomes than those living in metropolitan areas. To characterise the differences in the management and outcomes of rural and metropolitan populations in the context of ACS, as well as identify factors responsible for these differences and suggest how they may be addressed. A review of the current literature surrounding ACS in Australia was undertaken. Through the MEDLINE/PubMed database a thorough search using the terms "acute coronary syndrome" and "Australia" identified 460 papers for review, excluding abstracts and adding "rural", "metropolitan", "reperfusion", and "outcomes" to this search narrowed the results to 149 papers for review. Data was also extracted from the Australian Institute of Health and Welfare and other Australian government publications. The review draws on insights from both local and international resources and seeks to provide an understanding of the contemporary landscape of ACS in both rural and metropolitan Australia. The review is broken down into three key sections: An outline of the 2011 National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHF/CSANZ) guidelines and adjuvant tools used in the assessment and treatment of ACS, and to what extent these guidelines have been implemented clinically.An exploration of the current landscape of ACS in Australia and identification of the disparities facing rural populations compared to those in metropolitan areas.Discussion of the factors that are resulting in poorer outcomes for ACS sufferers and suggestions of novel approaches towards addressing these factors. Disparities exist between the management and outcomes of rural and metropolitan populations experiencing ACS. While the causes of these discrepancies are multifactorial; the onus is on the healthcare system to effectively reduce associated morbidity and mortality. Improvements in the management of ACS may be achieved through a continued reduction in call-to-needles time via the use of remote and mobile thrombolysis services as well as improvements in in-hospital risk assessment in order to flag and investigate those at risk of ACS.

Abstract 18319: Cardiac Services for Care of Suspected Acute Coronary Syndromes in Australia and New Zealand Hospitals

Background: Population-wide assessment of cardiac services recommended for optimal acute coronary syndromes (ACS) care has not been previously performed. We assessed the availability of ACS services among hospitals in Australia and New Zealand. Method: Services recommended for optimal ACS outcomes were identified from ACS guidelines and clinical consensus, and were collected from hospitals using a structured questionnaire. Thirty services reflecting acute care, investigations and procedures, management of complications, and preventative services were included. Data on consecutive ACS admissions over 2 weeks was simultaneously collected. Results: Of the 433 acute hospitals in both countries, 273(63%) provided service characteristics and 243(89%) provided patient data (n=2287 ACS patients). Figure shows the availability of selected services. Among hospitals, an emergency physician was available in 50%, cardiology consultation was available acutely in 35% and 22% provided primary PCI. Most investigations/procedures were available in &lt;50% of hospitals except exercise stress testing (58%) and echocardiography (56%). A CCU was present in 52%, 44% provided an inpatient cardiology service, 52% provided a follow-up clinic and &lt;40% provided an outpatient heart failure program or a readmissions reduction program. Service availability varied markedly among hospitals (median 14 services,IQR 7-30). Among hospitals that collected patient data, 25% of all patients presented to hospitals with &lt;50%(15/30) of services and only 40% were cared at hospitals with &gt;80%(24/30) services available. Service availability was not correlated with in-hospital outcomes although the study lacked sufficient power. Conclusion: The availability of cardiac services for optimal ACS care varies widely in Australian and New Zealand hospitals. Such inequalities resulting from uncoordinated dissemination of healthcare resources may contribute to variations in ACS outcomes

The predictors of discharge without clopidogrel following admission with acute coronary syndrome in australia - the concordance registry

The predictors of discharge without clopidogrel following admission with acute coronary syndrome in australia - the concordance registry

The Predictors of Discharge Without Clopidogrel Following Admission with Acute Coronary Syndrome in Australia – The CONCORDANCE Registry

The Predictors of Discharge Without Clopidogrel Following Admission with Acute Coronary Syndrome in Australia – The CONCORDANCE Registry

Use of Secondary Prevention Medications in Patients Following Admission with Acute Coronary Syndrome in Australia—The CONCORDANCE Study

Use of Secondary PreventionMedications in Patients Following Admission with Acute Coronary Syndrome in Australia—The CONCORDANCE Study C. Chow1,2,∗, I. Ranasinghe1,3, A. Blenkhorn4, K. Alford5, M. Ilton6, A. Patel 1 1 The George Institute for Global Health, University of Sydney, Australia 2 Department of Cardiology, Westmead Hospital, Australia 3 Department of Cardiology, Concord Hospital, Australia 4 Lismore Base Hospital, Australia 5 Port Macquarie Base Hospital, Australia 6 Royal Darwin Hospital, Australia

Management and outcomes of patients with acute coronary syndromes in Australia and New Zealand, 2000–2007

To describe temporal trends in the use of evidence-based medical therapies and management of patients with acute coronary syndromes (ACS) in Australia and New Zealand. Our analysis of the Australian and New Zealand cohort of the Global Registry of Acute Coronary Events (GRACE) included patients with ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation ACS (NSTEACS) enrolled continuously between January 2000and December 2007from 11metropolitan and rural centres in Australia and New Zealand. 5615patients were included in this analysis (1723with STEMI; 3892with NSTEACS). During 2000-2007there was an increase in the use of statin therapy, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and thienopyridines (P< 0.0001for each). Among patients with STEMI, there was an increase in emergency revascularisation with PCI (from 11% to 27% [P<0.0001]), and inhospital coronary angiography (from 61% to 76% [P<0.0001]). Among patients with NSTEACS, there was an increase in revascularisation with PCI (from 20% to 25% [P=0.004]). Heart failure rates declined substantially among STEMI and NSTEACS patients (from 21% to 12% [P=0.0002], and from 13% to 4% [P<0.0001], respectively) as did rates of hospital readmission for ischaemic heart disease at 6months (from 23% to 9% [P=0.0001], and from 24% to 15% [P=0.0001], respectively). From 2000to 2007in Australia and New Zealand, there was a fall in inhospital events and 6-month readmissions among patients admitted with ACS. This showed an association with improved uptake of guideline-recommended medical and interventional therapies. These data suggest an overall improvement in the quality of care offered to contemporary ACS patients in Australia and New Zealand.

Treatment of Non-ST Elevation Acute Coronary Syndromes in Australia and New Zealand: Are We Targeting the Right Patients?

Treatment of Non-ST Elevation Acute Coronary Syndromes in Australia and New Zealand: Are We Targeting the Right Patients?

Management and Outcomes of Patients with Acute Coronary Syndromes in Australia and New Zealand 2000–2007

Management and Outcomes of Patients with Acute Coronary Syndromes in Australia and New Zealand 2000–2007

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

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. The Acute Coronary Syndrome Prospective Audit study is a prospective multi-centre registry of ST-segment elevation myocardial infarction (STEMI), high-risk non-ST-segment elevation ACS (NSTEACS-HR) and intermediate-risk non-ST-segment elevation ACS (NSTEACS-IR) patients, involving 39 metropolitan, regional and rural sites. Data included hospital characteristics, geographic and demographic factors, risk stratification, in-hospital management including invasive services, and clinical outcomes. A cohort of 3402 patients was enrolled; the median age was 65.5 years. Female and non-metropolitan patients comprised 35.5% and 23.9% of the population, respectively. At enrolment, 756 (22.2%) were STEMI patients, 1948 (57.3%) were high-risk NSTEACS patients and 698 (20.5%) were intermediate-risk NSTEACS patients. Evidence-based therapies and invasive management use were highest among suspected STEMI patients compared with other strata (angiography: STEMI 89%, NSTEACS-HR 54%, NSTEACS-IR 34%, P < 0.001) (percutaneous coronary intervention: STEMI 68.1%, NSTEACS-HR 22.2%, NSTEACS-IR 8.1%, P < 0.001). In hospital mortality was low (STEMI 4.0%, NSTEACS-HR 1.8%, NSTEACS-IR 0.1%, P < 0.001), as was recurrent MI (STEMI 2.4%, NSTEACS-HR: 2.8%, NSTEACS-IR 1.2%, P = 0.052). There appears to be an 'evidence-practice gap' in the management of ACS, but this is not matched by an increased risk of in-hospital clinical events. Objective evaluation of local clinical care is a key initial step in developing quality improvement initiatives and this study provides a basis for the improvement in ACS management in Australia.