All New Zealand Acute Coronary Syndrome Quality Improvement Research Articles

Safety of Cardiac Computed Tomography to Exclude Left Atrial Appendage Thrombus Prior to Direct Current Cardioversion in Patients With Atrial Arrhythmias

Cardiac computed tomography (CCT) is a feasible imaging modality to exclude left atrial appendage (LAA) thrombus prior to pulmonary vein isolation procedures but has not been routinely used prior to direct current cardioversion (DCCV) for atrial arrhythmias until piloted during the COVID-19 pandemic. The safety of CCT to exclude LAA thrombus is evaluated in this study. All patients with atrial arrhythmias requiring DCCV as inpatients at Middlemore Hospital between 1 September 2020 to 31 December 2022, and who underwent CCT to exclude LAA thrombus were prospectively collected using the All New Zealand Acute Coronary Syndrome-Quality Improvement (ANZACS-QI) linked cardiac CT registry database. Patients’ clinical records were reviewed for the combined primary outcome of periprocedural and 60-day death, and thromboembolic events including cerebrovascular accidents. A total of 217 patients (64.5% male, mean age 57.8±14 years) underwent CCT during the study period. The majority (37%) were European, 19.8% were Māori, 30.4% were Pasifika, and 7% were other ethnicity. The mean body mass index was 34.8±8 kg/m2. Severe left ventricular systolic dysfunction was present in 70 (32.2%) patients. No LAA thrombus or slow flow was seen in 192 (88.4%) CCT scans. Transoesophageal echocardiography (TOE) was performed in 17 patients with LAA thrombus or slow flow on CCT, of which six had LAA thrombus. Direct current cardioversion was performed in 180 patients with no periprocedural or 60-day stroke. No deaths were recorded. Cardiac CT appears to be a safe alternative to TOE for excluding LAA thrombus prior to DCCV.

Can You Reliably Achieve Diagnostic Image Quality in Morbidly Obese Patients Undergoing Computed Tomography Coronary Angiography?

There is concern about computed tomography coronary angiography (CTCA) image quality with the increasing numbers of obese and morbidly obese patients presenting with chest pain syndrome. This study evaluated the CTCA image quality in obese and morbidly obese patients in Counties Manukau, using a dual source scanner. Scan reports were prospectively collected using the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) CT database between 1 January 2022 and 31 December 2022. Image quality was subjectively graded by the reporting cardiologist as good, average, or suboptimal at the time of scan. Coronary Artery Disease Reporting and Data System (CAD-RADS) score N (non-diagnostic) due to suboptimal image quality was collected. Patients were divided into three body mass index groups: 1) normal/overweight <30 kg/m2; 2) obese 30–40 kg/m2; 3) morbidly obese > 40 kg/m2. A total of 1,137 CTCA were performed. A total of 575 patients were normal/overweight and image quality was suboptimal in 10 (1.7%), average in 78 (13.6%), and good in 487 patients (84.7%); two patients had CAD-RADS-N due to suboptimal image quality. A total of 544 patients were obese and image quality was suboptimal in 16 (3.6%), average in 106 (23.9%), and good in 321 patients (72.5%); three patients had CAD-RADS-N due to suboptimal image quality. A total of 119 patients were morbidly obese and image quality was suboptimal in 10 (8.4%), average in 57 (47.9%), and good in 52 patients (43.7%); three patients had CAD-RADS-N due to suboptimal image quality. Although proportionately more morbidly obese patients were likely to have suboptimal CTCA image quality, diagnostic scans were obtained in almost all patients.

Uptake of Cardiac Rehabilitation in Te Whatu Ora – Counties Manukau During the Pandemic

Cardiac rehabilitation (CR) is an evidence-based range of interventions to support people with several cardiac issues. The impact of the COVID-19 pandemic created many challenges for health services and communities. Using the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZAC-QI) CR database this study tracked referral, mode, and level of engagement from 2013 to 2023. Over 10 years, 9,134 referrals were identified, with a steadily decreasing number every year (1,040 in 2023 vs 672 in 2022; 35% decrease). The majority (70%) was male; mean age for males was 66 years, for females 67 years; and ethnicity was Māori 12%, Pacific 25%, Indian 12%, others 51%. Attendance of any program was 71%, with a 600% increase in clinics vs group interventions. The average uptake of the exercise program was 24%; Māori compared with Pacific and Euro/others (61% vs 71% vs 73%, p>0.001); and younger people (<60 years, 66% vs older >61 years, 73%, p>0.001) were least likely to attend, with no gender differences (male 71% vs Female 69%, p=NS). There has been a significant decline in CR referrals over the last 10 years, with a shift from group-based education to individualised clinic contacts. Uptake of exercise programs remains low. Novel interventions to support Māori and younger patients have been implemented.

What is the Statin Possession Ratio Cut-Off Which Identifies Those at Increased Risk Following Acute Coronary Syndrome (ANZACS-QI 68)?

More optimal dispensing of statins is associated with greater cholesterol lowering; however, it is not known whether this translates to improved outcomes following acute coronary syndrome (ACS). The aim of this study was to assess the association between various levels of statin adherence and outcomes following ACS. Patients hospitalised with ACS who underwent coronary angiography between 2014-2018 were identified from the All New Zealand ACS Quality Improvement (ANZACS-QI) registry. Medication possession ratio (MPR) was used to assess statin adherence and calculated over 1 year post-discharge using linked pharmaceutical dispensing datasets. Optimal, adequate and suboptimal adherence was defined as an MPR of ≥1.0, 0.8-0.99 and 0-0.79, respectively. A combined outcome of all-cause mortality and rehospitalisation for atherosclerotic disease was identified from 1 year post-discharge through September 2021. Cox proportional hazard models were used to adjust for confounding variables. Of the 30,452 patients, 68% had optimal adherence, 15% adequate adherence and 16% had suboptimal adherence to statins. Mean follow-up was 3.6 years. Those with suboptimal adherence had a higher adjusted risk of the combined outcome compared with those with optimal adherence (HR 1.18, 95% CI 1.11-1.26). There was no significant difference in adjusted outcome between those with optimal and adequate adherence (HR 0.99, 95% CI 0.92-1.06). Suboptimal statin adherence following ACS is associated with an increased risk of mortality and rehospitalisation. An MPR cut-off of 0.8 seems reasonable to identify those at higher risk of cardiovascular events that could benefit the most from interventions to improve statin adherence and is appropriate as a target for quality improvement programs.

Clinically Acquired High Sensitivity Cardiac Troponin T is a Poor Predictor of Reduced Left Ventricular Ejection Fraction After ST Elevation Myocardial Infarction: A National Cohort Study-ANZACS-QI 65.

Cardiac troponins (cTn) have been used historically to estimate infarct size in ST elevation myocardial infarction (STEMI). Within a resource constrained health care environment, cTn could therefore be used for prioritisation of patients for cardiac imaging, in particular echocardiography. We aimed to determine how useful routinely collected cTn would be in predicting significant left ventricular (LV) impairment. All patients in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry with their first episode of STEMI between January 2013 and November 2018, who had high sensitivity troponin T measured, were included. We excluded patients with no left ventricular ejection fraction (LVEF) assessment, known LV dysfunction, or prior myocardial infarction. In total,3,698 patients were included in the analysis. A higher mean hsTnT (admission and peak) was seen in patients with more severely impaired LV function but there was significant overlap in the range of hsTnT between the different LVEF categories. Cardiac troponins demonstrated poor discriminative ability to either predict or exclude significant LV impairment (LVEF <40%). At an optimal cutpoint of 3,405 ng/L, peak hsTnT had a sensitivity of 56.5% (95% confidence interval [CI] 42-62%), a specificity of 65.3% (95% CI 62-79%) and an area under the receiver operating curve of 0.62 (95% CI 0.60-0.64). This is the largest study comparing clinically measured troponin levels and LV function in patients presenting with STEMI. A definite, but weak, association was seen between peak troponin and the degree of LV dysfunction, with significant overlap in troponin levels between levels of myocardial dysfunction. Routinely acquired troponin is not suitable for clinical use as a method of prioritising patients for cardiac imaging.

Revascularisation and outcomes after acute coronary syndromes in patients with prior coronary artery bypass grafting-ANZACS-QI 67.

Coronary angiography in patients with previous coronary artery bypass grafts (CABG) is technically more difficult with increased procedure time, radiation exposure and in-hospital complications. In a contemporary national registry of acute coronary syndrome (ACS) patients undergoing an invasive strategy, we compared the management and outcomes of patients with and without prior CABG. The All New Zealand ACS Quality Improvement (ANZACS-QI) registry was used to identify patients admitted to New Zealand public hospitals with an ACS who underwent invasive coronary angiography (2014-2018). Outcomes were ascertained by anonymised linkage to national datasets. Of 26,869 patients, 1,791 (6.7%) had prior CABG and 25,078 (93.3%) had no prior CABG. Prior CABG patients were older (mean age 71 years vs 65 years), more comorbid and less likely to be revascularised than those without CABG (49.8% vs 73.0%). Compared to patients without CABG, at a mean follow-up of 2.1 years, patients with prior CABG had higher all-cause mortality (HR 2.03 (1.80-2.29)), and were more likely to have recurrent myocardial infarction (HR 2.70 (2.40-3.04)), rehospitalisation with congestive cardiac failure (HR 2.36 (2.10-2.66)) and stroke (HR 1.82 (1.41-2.34)). In contemporary real-world practice, despite half of the patients with ACS and prior CABG receiving PCI, the outcomes remain poor compared with those without prior CABG.

The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS): Design and Methodology

Background. Each year, approximately 5000 New Zealanders are admitted to hospital with first-time acute coronary syndrome (ACS). The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) is a prospective longitudinal cohort study embedded within the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry in six hospitals. The objective of MENZACS is to examine the relationship between clinical, genomic, and cardiometabolic markers in relation to presentation and outcomes post-ACS. Methods. Patients with first-time ACS are enrolled and study-specific research data is collected alongside the ANZACS-QI registry. The research blood samples are stored for future genetic/biomarker assays. Dietary information is collected with a food frequency questionnaire and information about physical activity, smoking, and stress is also collected via questionnaire. Detailed family history, ancestry, and ethnicity data are recorded on all participants. Results. During the period between 2015 and 2019, there were 2015 patients enrolled. The mean age was 61 years, with 60% of patients aged &lt;65 years and 21% were female. Ethnicity and cardiovascular (CV) risk factor distribution was similar to ANZACS-QI: 13% Māori, 5% Pacific, 5% Indian, and 74% NZ European. In terms of CV risk factors, 56% were ex-/current smokers, 42% had hypertension, and 19% had diabetes. ACS subtype was ST elevation myocardial infarction (STEMI) in 41%, non-ST elevation myocardial infarction (NSTEM) in 54%, and unstable angina in 5%. Ninety-nine percent of MENZACS participants underwent coronary angiography and 90% had revascularization; there were high rates of prescription of secondary prevention medications upon discharge from hospital. Conclusion. MENZACS represents a cohort with optimal contemporary management and will be a significant epidemiological bioresource for the study of environmental and genetic factors contributing to ACS in New Zealand’s multi-ethnic environment. The study will utilise clinical, nutritional, lifestyle, genomic, and biomarker analyses to explore factors influencing the progression of coronary disease and develop risk prediction models for health outcomes.

Obesity and All Cause Mortality Following Acute Coronary Syndrome (ANZACS-QI 53)

Some studies have suggested a lower mortality in obese subjects with cardiovascular disease. The aim of this study was to evaluate the relationship between body mass index (BMI) and outcomes in patients with acute coronary syndrome (ACS). The study included 13,742 patients undergoing coronary angiography for ACS between 2012 and 2016 from the All New Zealand Acute Coronary Syndrome-Quality Improvement (ANZACS-QI) registry. Patients were categorised by BMI (kg/m2) as: underweight <18.5, normal 18.5 to <25, overweight 25 to <30, mildly obese 30 to <35, moderately obese 35 to <40, and severely obese ≥40. The primary endpoint of the study was all cause mortality with secondary endpoints of cardiovascular disease (CVD) and non-CVD mortality within 4 years of discharge. Unadjusted all cause mortality was lowest in the mildly obese but no different to normal or overweight after adjustment for multiple confounders. Adjusted all cause mortality was higher in the moderately (hazard ratio [HR] 1.39, 95% CI: 1.10-1.75) and severely obese (2.06, 95% CI: 1.57-2.70) compared to the mildly obese. Non-CVD mortality (HR 1.58, 95% CI: 1.12-2.23) was the major contributor to higher all cause mortality in moderately obese patients. Both CVD mortality (HR 2.36, 95% CI: 1.67-3.32) and non-CVD mortality (HR 1.67, 95% CI: 1.07-2.61) contributed to higher all cause mortality in the severely obese. Moderate and severe obesity is associated with worse survival post ACS influenced by higher non-CVD mortality in moderate/severe obesity and higher CVD mortality in severe obesity.

A Contemporary Presentation of the Incidence and Management of Spontaneous Coronary Artery Dissection (SCAD) in New Zealand: An ANZACS-QI Study

Spontaneous coronary artery dissection (SCAD) is an underdiagnosed and poorly understood condition that frequently affects younger women without cardiovascular risk factors. In this project we aimed to describe the present landscape of SCAD in New Zealand (NZ). All patients in NZ who were admitted to hospital with a diagnosis of Acute Coronary Syndrome (ACS) from July 2019 to December 2020 and who underwent coronary angiography were identified from the All NZ Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. Of 12,053 patients admitted to hospital with an ACS, 122 had SCAD (1.0%). 80% of those with SCAD were female, with mean age of 57 years, and fewer traditional cardiovascular risk factors. Non-ST elevation myocardial infarction was the most common presentation (82.0%), while 16.4% presented with ST-elevation myocardial infarction. The majority of patients were managed conservatively (91.8%) while 8.2% underwent percutaneous coronary intervention (PCI). 56.6% of SCAD patients had normal left ventricular function. Nearly 80% of patients were discharged on aspirin therapy, while 60.7% had a P2Y12 inhibitor. Beta blockers, statins and ACEI/ARB were part of the management strategy in 62.5%, 59.8% and 42.6% of patients, respectively, while 47.5% had a combination of all 3. Amongst 122 patients, only 1 in-hospital death and 1 inpatient recurrent MI occurred, with 3 patients having bleeding of any kind. In NZ, incidence of SCAD is approximately 1%. Most patients affected in NZ are female with fewer traditional cardiovascular risk factors. Management is predominantly conservative, and there is a low rate of early adverse outcomes.

Recovery of Left Ventricular Ejection Fraction Post-Acute Coronary Syndrome

A reduction in left ventricular ejection fraction (LVEF) after acute myocardial infarction (MI) is associated with increased mortality. Recovery of LVEF correlates with an improved prognosis. There is little data about whether LVEF is being investigated post-MI in local practice and which factors are associated with the improvement of LVEF. Using the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) Registry and patient notes, retrospective analysis of admissions to the Auckland City Hospital Coronary Care Unit between January 2015 and December 2016 for MI with reduced LVEF (<50%) or unknown LVEF was performed. Of the 824 patients with reduced or unknown LVEF, 414 (50.2%) received both initial and follow-up investigations of LVEF at any time. Patients with initial LVEFs between 40%–49.9%, 30%–39.9% and <30% had follow up investigation rates of 54.0%, 73.1% and 66.7%, respectively.186 (22.6%) patients were deceased by December 2020. The median initial LVEF of patients that received both initial and follow-up studies was 37.5% (32.5–44.0). At follow-up, median LVEF was 42.5% (35.0–50.0). 165 (39.9%) patients in this group experienced an increase of >10% in LVEF between initial and follow-up assessments. Patients with reduced LVEF post-MI suffer from high mortality, and the local practice of assessing LVEF is deficient. Encouragingly, a significant proportion of patients that received follow-up experienced an increase in LVEF. Further evaluation may establish which patient factors and medical treatments influence this recovery.

Outcomes for working age patients after first-time acute coronary syndrome – ANZACS-QI 35

BackgroundAcute coronary syndrome (ACS) events and the ongoing burden of disease can have a significant impact on the subsequent life-course of working age people. MethodsWe report 12-month clinical outcomes for 10,822 patients hospitalized with first-time ACS between 2015-2016 and enrolled in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry, with a focus on people of working age (defined as <65 years). ResultsNearly half (48%) of first-time ACS occurred in people of working age. Compared to those >65 years, these patients had a high burden of cardiovascular risk factors, and were more likely to be male (75% vs 60%), to be of non-European ethnicity (36% vs 15%), and to be living in areas of high deprivation. Subsequent clinical events were common in the younger patients, with 15% dying or being readmitted for cardiovascular causes within 12 months despite high rates of angiography (96%), revascularization (74%) and evidence-based medical therapy at the time of the index ACS event. ConclusionsThe high risk factor burden and subsequent high rate of clinical events in working age patients reinforces the need for a longer-term focus on strategies to improve clinical outcomes following first-time ACS.

Target Doses of Secondary Prevention Medications Are Not Being Achieved in Patients With Reduced Left Ventricular Ejection Fraction After Acute Coronary Syndrome (ANZACS-QI 34)

Patients with reduced left ventricular ejection fraction (EF<40%) are at high risk for adverse outcomes and benefit from evidence based doses of angiotensin converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB) and beta blockers. Our aim was to investigate the dispensing and uptitration of these medications following acute coronary syndrome (ACS), according to left ventricular ejection fraction. Patients presenting with ACS who underwent coronary angiography during 2015 were recorded in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. Medication dispensing data on discharge and at 1-year follow-up were obtained using anonymised linkage to the national pharmaceutical dataset. Doses of medications dispensed were compared to target doses recommended in clinical guidelines. 4,082 patients were included in the study, of whom 602 (15%) had reduced ejection fraction (rEF). More patients with rEF were prescribed ACEi/ARB on discharge compared to those with preserved ejection fraction (pEF) (89% vs. 68%). Beta blocker dispensing on discharge was also higher in the rEF group (94% vs. 83%). In the rEF subgroup, 76% were maintained on ACEi/ARB and 85% on beta blockers by 1 year of follow-up. However, at discharge only 31% and 29% were on ≥50% of target doses of ACEi/ARB and beta blocker doses respectively, and by 1 year this increased only slightly to 34% and 35% respectively. There is suboptimal dispensing of evidence-based medications in the year following ACS. Further intervention is required to improve medication uptitration and adherence, particularly of beta blockers and ACEI/ARBs in those with reduced ejection fraction.

Impact of chronic kidney disease on mortality and cardiovascular outcomes after acute coronary syndrome: A nationwide data linkage study (ANZACS-QI 44).

Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular disease (CVD). We examined the characteristics, management and outcomes of patients with CKD in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) national registry. The cohort comprised New Zealand (NZ) patients with an acute coronary syndrome undergoing coronary angiography between January 2013 and December 2016. Patients were categorized according to their stage of CKD. Outcomes included all-cause and cause-specific mortality and hospitalization with myocardial infarction (MI), stroke and major bleeding. Of the 20 604 patients, 20.3% had normal renal function, with 53.3%, 23.3%, 1.7% and 1.4% having CKD stages 2, 3, 4 and 5 CKD, respectively. Patients with severe CKD were more likely to be Māori or Pacific and live in an area with greater socioeconomic deprivation. Death, recurrent MI or stroke, and major bleeding all increased incrementally with each worsening stage of CKD severity. Compared with those with normal renal function, patients with stage 5 CKD had a much higher all-cause (hazard ratio [HR] 16.41, 95% CI 13.06-20.61), cardiovascular (HR 16.38, 95% CI 12.17-22.04) and non-cardiovascular mortality (HR 13.66 9, 95% CI.56-19.51). In addition, patients with stage 5 CKD were at a higher risk of recurrent MI or stroke (HR 4.73, 95% CI 3.86-5.80) and bleeding (HR 5.84, 95% CI 4.39-7.76). CKD was associated with increased mortality and a high incidence of morbidity in patients undergoing coronary angiography in New Zealand. Initiatives to understand and improve outcomes in this group of patients are urgently needed.

Diagnostic coronary angiography and percutaneous coronary intervention practices in New Zealand: The All New Zealand Acute Coronary Syndrome-Quality Improvement CathPCI registry 3-year study (ANZACS-QI 37)

BackgroundCoronary heart disease remains one of the leading causes of mortality and morbidity in New Zealand (NZ) and globally. The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) programme includes the CathPCI registry which records all those referred for diagnostic coronary angiography (DCA) and percutaneous coronary intervention (PCI) in NZ. We present the methods and three-years of data from the ANZACS-QI CathPCI registry. MethodsThe data was extracted from the ANZACS QI CathPCI registry from 01/09/2014 to 24/09/2017. The ANZACS-QI data dictionary defines all the clinical, procedural and outcomes variables collected, and standard statistical analyses were applied. Results40,870 patients underwent cardiac catheterisation, with a mean age of 65 years, and males making up 67% of the cohort. Indications included acute coronary syndrome 55%, angina with suspected stable coronary disease 28%, valve surgery workup 8%, planned PCI 3%, heart failure/cardiomyopathy 3%, arrhythmia 1% and other 2%. For those undergoing DCA alone, radial access was used in 85% and two-thirds had at least one major artery with >50% stenosis. PCI was performed in 39% of patients. Drug-eluting stents were used in 97%. ConclusionThe CathPCI registry records the characteristics and outcomes of all patients undergoing DCA and PCI in NZ hospitals. As part of the ANZACS-QI programme the registry provides an important platform for quality improvement, research and to inform clinical practice.

A028 The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS): Baseline Characteristics of Patients With First-time ACS

Each year, approximately 5000 New Zealanders are admitted to hospital with a first-time acute coronary syndrome (ACS). The aim of the Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) is to examine the relationship of clinical, genomic and cardiometabolic markers in relation to presentation and outcomes post-ACS. MENZACS is a prospective, longitudinal cohort study embedded within the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) programme in 6 hospitals. Patients with first-time ACS were enrolled and study-specific research data collected alongside the ANZACS-QI registry. Research blood samples were stored for future genetic/biomarker assays. We report here the baseline characteristics of the MENZACS cohort and compare to the ANZACS-QI registry (first-time ACS). Between 2015-2019, 2026 patients were enrolled, mean age 61yrs, 21% were female. Ethnicity and CV risk factor distribution was similar to ANZACS-QI: 13% Māori, 5% Pacific, 5% Indian and 74% NZ European. CV risk factors included 56% ex-/current smoker, 42% hypertension, 18% diabetes. 60% of the patients were aged < 65 years. ACS subtype for MENZACS vs ANZACS-QI: STEMI 40% vs 31%, NSTEMI 52% vs 59%. 99% had coronary angiography and 90% had revascularisation; there were high rates of secondary prevention medications (table).Tabled 1Discharge MedicationAspirin1927 (98%)Dual antiplatelet therapy1611 (82%)Statin1922 (97%)Beta-blocker1652 (84%)ACEi/ARB1550 (79%) Open table in a new tab MENZACS represents a cohort with optimal contemporary management and will be a significant epidemiological bioresource for the study of environmental and genetic factors contributing to ACS in New Zealand's multi-ethnic environment. The study will utilise clinical, nutritional, lifestyle, genomic and biomarker analyses to explore aetiological factors and develop risk prediction models for outcome.

A022 In-hospital Outcomes Following Cardiac Catheterisation in New Zealand (NZ): An All NZ Acute Coronary Syndrome Quality Improvement (ANZACS-QI) Analysis

There is limited contemporary short-term outcome data relating to diagnostic coronary angiography (DCA) and percutaneous coronary intervention (PCI) in NZ. This retrospective analysis aims to determine in-hospital outcomes in patients undergoing DCA and PCI in NZ and identify predictors of poor outcome. This ANZACS-QI Cath/PCI registry-based study included 40870 patients who underwent a total of 46283 procedures over 45169 episodes of care between 01/09/2014 to 24/09/2017. Each episode of care was used to determine the in-hospital outcomes. A stepwise logistic regression was used for multivariate analysis to identify predictors of outcome. Mean age 65 (standard deviation 12) years, male 67%, NZ European 76%, previous CABG 7%. ACS indication 55%. Of the total 46283 procedures performed, 85% were radial access, 28258 were DCA and 18025 were PCI. The table below lists the number of adverse in-hospital outcomes by indication and procedure. Other procedural indications (n=6245) included valvular heart disease, heart failure and ventricular arrhythmia. The independent predictors of death were age (OR 1.55/10y, p<0.0001), STEMI (OR 6.6, p<0.0001), cardiogenic shock (OR 16.9, p<0.0001) and femoral access (OR 3.4, p<0.0001). This study demonstrates low rates of adverse short-term outcomes in NZ patients undergoing DCA and PCI. The rates of death, recurrent MI and stroke compare favourably to international registries, and the independent predictors of death identified are also similar.

A014 Governance of Research to Achieve Equity in Cardiovascular Health Outcomes: MENZACS

A marked equity gap is acknowledged in almost all health outcomes for Māori and Pacific people in Aotearoa. In CV health, the gap is across all major markers of CVD risk and morbidity and CVD is the largest contributor to the difference in life expectancy between Māori, Pacific and non-Māori, non-Pacific people. All CV research performed in Aotearoa should therefore progress equity for Māori and Pacific people. Achieving equity within any piece of work however requires leadership, and a strategic approach at all stages of the project, guided by an active and effective governance structure that guides and supports the operational research team. The multi-ethnic NZ study of acute coronary syndromes (MENZACS) study is a prospective, longitudinal cohort study embedded within the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) programme in 6 hospitals. Patients with first-time ACS were enrolled and study-specific research data collected alongside the ANZACS-QI registry. The project has a focus for Māori and Pacific people and has had a governance group from inception that has worked closely with the research team through methodological development, results analysis and in problem solving culturally specific concerns. This presentation will walk through the process of set-up and operationalisation of the governance group with a view to outlining a best practice approach. There will also be case examples – including specifically the collection of genetic information - where the governance group and research team worked in an integrative manner to ensure the correct process was established and then implemented.

A036 Prescription and Early Dispensing of Statin Therapy Following Acute Coronary Syndrome in Non surgically Revascularised Patients- Nationwide Perspective

Early initiation and long-term adherence to statin therapy improves outcomes in patients following acute coronary syndrome (ACS). Previous New Zealand national analysis showed only two thirds of these patients were maintained on long-term statin therapy. It is unclear if suboptimal prescription and/or initial dispensation is a causative factor. Cohort (N=16557) was identified from All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry data for consecutive New Zealand residents (1 January 2015 to 31 December 2017) who underwent coronary angiogram without surgical revascularisation following ACS. These were linked to national data sets through encrypted patient identifiers to derive medication data. We looked at statin prescription at discharge, early dispensing (3 months) and calculated medication possession ratio (MPR) at one year. 15431 (93%) patients in the cohort were prescribed statin therapy at discharge with similar early dispensing rate. There is high rate of initial prescription and dispensing across various demographics with high rate for male sex and Indian ethnicity. Adequate statin maintenance (MPR ≥ 0.8) at one year is suboptimal (n=13219, 80%) particularly in the younger patients, female sex, Māori/Pacific ethnicity, and lower income population. Higher initial prescribing and early dispensing rates across various demographics suggests minimal barriers to early statin use post myocardial infarction. However, statin maintenance at one year remains suboptimal which suggests a more robust follow up or outpatient strategy is required.

Nationwide trends in acute coronary syndrome by subtype in New Zealand 2006–2016

ObjectivesRecent studies in acute coronary syndrome (ACS) have reported mixed results for trends in ACS subtypes. The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) 31 study evaluated trends...

An Economic Evaluation of the All New Zealand Acute Coronary Syndrome Quality Improvement Registry Program (ANZACS-QI 28)

The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) program comprises a clinical quality registry of acute coronary syndrome patients admitted to hospitals across New Zealand. Its primary purpose is to improve quality of care by promoting evidence- and guidelines-based practice, and benchmarking against performance targets. Few studies have examined the cost-effectiveness attributed to clinical quality registries. We aimed to evaluate the clinical and cost impacts of the ANZACS-QI program in New Zealand from both a societal and health care system perspective. Using decision analytic Markov models, we estimated the effectiveness and costs of the ANZACS-QI program in each year over 4 years (2013-2016), against a hypothetical scenario where the registry did not exist. We assumed that the ANZACS-QI contributed to 15% of the temporal changes to patient mortality and hospital readmissions for myocardial infarction observed in the study period. Marginal costs of the registry and years of life saved were estimated. Over a one-year period, the return on investment (ROI) ratio for the ANZACS-QI program was 1.53; thus, every dollar spent on the program resulted in a return of NZD $1.53. (All dollars are in 2017 New Zealand dollars [NZD] unless otherwise stated). The estimated incremental cost-effectiveness ratio (ICER) was $113,327 per year of life saved (YoLS). Extending the time horizon to 5 years, reduced the ICER to $19,684 per YoLS. The ANZACS-QI program represents a sound investment for New Zealand. Even based on highly conservative assumptions, the program is cost saving for society, at a ROI ratio of about 1.5 each year.