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Discrepancies in post-ST-elevation myocardial infarction care in women compared with men: evaluating for implicit bias-a single-centre study. Ir J Med Sci 2021; 191:169-173. [PMID: 33580859 DOI: 10.1007/s11845-021-02528-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Recent research has demonstrated discrepancies in care post-ST-elevation myocardial infarction (STEMI), showing that women often have delays in time to percutaneous coronary intervention (PCI) and are less often prescribed evidence-based medications for secondary prevention. This single-centre study evaluated gender differences in management and local prescribing patterns of STEMI patients on discharge consistent with implicit bias, benchmarked against Australian clinical guidelines. METHOD AND RESULT A retrospective, consecutive study of 318 patients admitted with a STEMI was conducted at a large tertiary hospital from January 2018 until October 2019. Data was collected from medical records including patient demographics, door-to-balloon (DTB) time, and pharmacological management. The mean age of women with a STEMI was higher (67.90 years in women; 64.17 in men, p = 0.013). DTB times were unaffected by gender with 88% of both men and women receiving PCI in less than 90 min (1.04 95% CI (0.44-2.46). Women were less likely to be prescribed an angiotensin-converting enzyme (ACE)-inhibitor/angiotensin receptor blocker (ARB) on discharge (p = 0.003). However, all other medications prescribed were appropriate between genders based on recommended guidelines. CONCLUSIONS Our study identified excellent adherence with recommended guidelines, challenging recent data both internationally and from the Victorian Cardiac Outcomes Registry (VCOR). Pharmacological and revascularisation management post-STEMI for both male and female patients was equal, suggesting implicit bias is not universal and may be institutional. Health services should evaluate their practices to identify sources of implicit bias, which may influence their management of women presenting with a STEMI.
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102
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Barnes C, Fatovich DM, Macdonald SPJ, Alcock RF, Spiro JR, Briffa TG, Schultz CJ, Hillis GS. Single high-sensitivity troponin levels to assess patients with potential acute coronary syndromes. Heart 2021; 107:721-727. [PMID: 33436490 DOI: 10.1136/heartjnl-2020-317997] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We tested the hypothesis that patients with a potential acute coronary syndrome (ACS) and very low levels of high-sensitivity cardiac troponin I can be efficiently and safely discharged from the emergency department after a single troponin measurement. METHODS This prospective cohort study recruited 2255 consecutive patients aged ≥18 years presenting to the Emergency Department, Royal Perth Hospital, Western Australia, with chest pain without high-risk features but requiring the exclusion of ACS. Patients were managed using a guideline-recommended pathway or our novel Single Troponin Accelerated Triage (STAT) pathway. The primary outcome was the percentage of patients discharged in <3 hours. Secondary outcomes included the duration of observation and death or acute myocardial infarction in the next 30 days. RESULTS The study enrolled 1131 patients to the standard cohort and 1124 to the STAT cohort. Thirty-eight per cent of the standard cohort were discharged directly from emergency department compared with 63% of the STAT cohort (p<0.001). The median duration of observation was 4.3 (IQR 3.3-7.1) hours in the standard cohort and 3.6 (2.6-5.4) hours in the STAT cohort (p<0.001), with 21% and 38% discharged in <3 hours, respectively (p<0.001). No patients discharged directly from the emergency department died or suffered an acute myocardial infarction within 30 days in either cohort. CONCLUSIONS Among low-risk patients with a potential ACS, a pathway which incorporates early discharge based on a single very low level of high-sensitivity cardiac troponin increases the proportion of patients discharged directly from the emergency department, reduces length of stay and is safe. TRIAL REGISTRATION NUMBER ACTRN12618000797279.
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Affiliation(s)
- Cara Barnes
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Daniel M Fatovich
- Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Stephen P J Macdonald
- Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Richard F Alcock
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Jon R Spiro
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Tom G Briffa
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Carl J Schultz
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Graham S Hillis
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia .,Medical School, The University of Western Australia, Perth, Western Australia, Australia
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103
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Alyasin N, Teate A, Strickland K. The experience of women following first acute coronary syndrome: An integrative literature review. J Adv Nurs 2021; 77:2228-2247. [PMID: 33393122 DOI: 10.1111/jan.14677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/28/2020] [Accepted: 11/06/2020] [Indexed: 11/30/2022]
Abstract
AIM There is lack of evidence and research understanding among women's lived experiences following first acute coronary syndrome, thus their recovery process remains poorly understood. To date research has largely focused on men's experience of acute coronary syndrome while this area of health care and recovery has considerable impact on women's health and quality of life. Our aim was to review the literature exploring lived experience of women following first acute coronary syndrome. DESIGN Integrative review of the literature. DATA SOURCE We searched PubMed, MEDLINE, EMBASE, CINAHL and Scopus from 2008-2018 for articles published in English. REVIEW METHOD Of 1675 publications identified, 18 qualitative, quantitative, and mixed method studies met our inclusion criteria. Quality of included studies was assessed using Joanna Briggs Institute quality assessment tools. Findings were integrated using thematic synthesis. RESULTS Experiencing acute coronary syndrome was reported to have significant impacts on women's lives. The most common issues reported were physical limitations, fear, and uncertainties about the future, sexual dissatisfaction, and social isolation. Women also reported to have higher short- and long-term mortality rate, stroke, recurrent, and hospital readmissions compared with men. CONCLUSION This review identified current knowledge and gaps about lived experience of women following first acute coronary syndrome. It is anticipated that the information gained from this literature review will support new research aimed at improving the care women receive following acute coronary syndrome and therefore enhance their recovery and quality of life. IMPACT This review contributes to the current body of knowledge by addressing women's physical, psychosocial, and sexual state following acute coronary syndrome. Improvement in women's quality of life after acute coronary syndrome necessitates further research which ultimately results in better management and treatment of women and their recovery following first acute coronary syndrome.
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Affiliation(s)
- Najmeh Alyasin
- School of Nursing, Midwifery and Public Health, Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Alison Teate
- School of Nursing, Midwifery and Public Health, Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Karen Strickland
- School of Nursing, Midwifery and Public Health, Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
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104
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Aria S, Clugston R. Re-Thrombolysis of a Reoccluded STEMI in a Remote Patient. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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105
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Forsyth R, Sun Z, Reid C, Moorin R. Rates and Patterns of First-Time Admissions for Acute Coronary Syndromes across Western Australia Using Linked Administrative Health Data 2007-2015. J Clin Med 2020; 10:jcm10010049. [PMID: 33375744 PMCID: PMC7794922 DOI: 10.3390/jcm10010049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 11/16/2022] Open
Abstract
Acute coronary syndrome (ACS) is globally recognised as a significant health burden, for which the reduction in total ischemic times by way of the most suitable reperfusion strategy has been the focus of national and international initiatives. In a setting such as Western Australia, characterised by 79% of the population dwelling in the greater capital region, transfers to hospitals capable of percutaneous coronary intervention (PCI) is often a necessary but time-consuming reality for outer-metropolitan and rural patients. Methods: Hospital separations, emergency department admissions and death registration data between 1 January 2007 and 31 December 2015 were linked by the Western Australian Data Linkage Unit, identifying patients with a confirmed first-time diagnosis of ACS, who were either a direct admission or experienced an inter-hospital transfer. Results: Although the presentation rates of ACS remained stable over the nine years evaluated, the rates of first-time admissions for ACS were more than double in the rural residential cohort, including higher rates of ST-segment elevation myocardial infarction, the most time-critical manifestation of ACS. Consequently, rural patients were more likely to undergo an inter-hospital transfer. However, 42% of metropolitan admissions for a first-time ACS also experienced a transfer. Conclusion: While the time burden of inter-hospital transfers for rural patients is a reality in health care systems where it is not feasible to have advanced facilities and workforce skills outside of large population centres, there is a concerning trend of inter-hospital transfers within the metropolitan region highlighting the need for further initiatives to streamline pre-hospital triage to ensure patients with symptoms indicative of ACS present to PCI-equipped hospitals.
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Affiliation(s)
- René Forsyth
- Discipline of Medical Radiation Sciences, Curtin University, Perth, WA 6102, Australia;
| | - Zhonghua Sun
- Discipline of Medical Radiation Sciences, Curtin University, Perth, WA 6102, Australia;
- Correspondence: ; Tel.: +61-8-9266-7509
| | - Christopher Reid
- School of Public Health, NHMRC Centre of Research Excellence in Cardiovascular Outcomes Improvement, Perth, WA 6102, Australia;
- Centre of Research Excellence in Therapeutics, Monash University, Melbourne, VIC 3800, Australia
| | - Rachael Moorin
- School of Public Health, Curtin University, Perth, WA 6102, Australia;
- School of Population and Global Health, the University of Western Australia, Crawley, WA 6009, Australia
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106
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Sanfilippo FM, Hillis GS, Rankin JM, Latchem D, Schultz CJ, Yong J, Li IW, Briffa TG. Invasive Coronary Angiography after Chest Pain Presentations to Emergency Departments. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17249502. [PMID: 33352982 PMCID: PMC7766965 DOI: 10.3390/ijerph17249502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 01/06/2023]
Abstract
We investigated patients presenting to emergency departments (EDs) with chest pain to identify factors that influence the use of invasive coronary angiography (ICA). Using linked ED, hospitalisations, death and cardiac biomarker data, we identified people aged 20 years and over who presented with chest pain to tertiary public hospital EDs in Western Australia from 1 January 2016 to 31 March 2017 (ED chest pain cohort). We report patient characteristics, ED discharge diagnosis, pathways to ICA, ICA within 90 days, troponin test results, and gender differences. Associations were examined with the Pearson Chi-squared test and multivariate logistic regression. There were 16,974 people in the ED chest pain cohort, with a mean age of 55.6 years and 50.7% males, accounting for 20,131 ED presentations. Acute coronary syndrome was the ED discharge diagnosis in 10.4% of presentations. ED pathways were: discharged home (57.5%); hospitalisation (41.7%); interhospital transfer (0.4%); and died in ED (0.03%)/inpatients (0.3%). There were 1546 (9.1%) ICAs performed within 90 days of the first ED chest pain visit, of which 59 visits (3.8%) had no troponin tests and 565 visits (36.6%) had normal troponin. ICAs were performed in more men than women (12.3% vs. 6.1%, p < 0.0001; adjusted OR 1.89, 95% CI 1.65, 2.18), and mostly within 7 days. Equal numbers of males and females present with chest pain to tertiary hospital EDs, but men are twice as likely to get ICA. Over one-third of ICAs occur in those with normal troponin levels, indicating that further investigation is required to determine risk profile, outcomes and cost effectiveness.
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Affiliation(s)
- Frank M. Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth 6009, Australia; (I.W.L.); (T.G.B.)
- Correspondence:
| | - Graham S. Hillis
- Cardiology Department, Royal Perth Hospital, Perth 6000, Australia; (G.S.H.); (C.J.S.)
- Medical School, The University of Western Australia, Perth 6009, Australia
| | - Jamie M. Rankin
- Cardiology Department, Fiona Stanley Hospital, Murdoch 6150, Australia;
| | - Donald Latchem
- Department of Cardiovascular Medicine, Sir Charles Gairdner Hospital, Nedlands 6009, Australia;
| | - Carl J. Schultz
- Cardiology Department, Royal Perth Hospital, Perth 6000, Australia; (G.S.H.); (C.J.S.)
- Medical School, The University of Western Australia, Perth 6009, Australia
| | - Jongsay Yong
- Melbourne Institute of Applied Economic and Social Research, University of Melbourne, Melbourne 3010, Australia;
| | - Ian W. Li
- School of Population and Global Health, The University of Western Australia, Perth 6009, Australia; (I.W.L.); (T.G.B.)
| | - Tom G. Briffa
- School of Population and Global Health, The University of Western Australia, Perth 6009, Australia; (I.W.L.); (T.G.B.)
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107
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Brown RE, Welsh P, Logue J. Systematic review of clinical guidelines for lipid lowering in the secondary prevention of cardiovascular disease events. Open Heart 2020; 7:e001396. [PMID: 33443127 PMCID: PMC7751215 DOI: 10.1136/openhrt-2020-001396] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The WHO recommends that those with established cardiovascular disease should be treated with lipid-lowering therapy, but there is no specific guidance regarding lipid monitoring. Unnecessary general practitioner visits may be a burden for patients and increase healthcare costs. A systematic review of the current guidelines was performed to reveal gaps in the evidence base for optimal lipid monitoring approaches. METHODS For this systematic review, a search of Medline, Cumulative Index to Nursing and Allied Health Literature and Turning Research Into Practice databases was conducted for relevant guidelines published in the 10 years prior to 31 December 2019. Recommendations surrounding the frequency of testing, lipid-lowering therapies and target cholesterol values were compared qualitatively. Each guideline was assessed using the 2009 Appraisal of Guidelines for Research and Evaluation II tool. RESULTS Twenty-two guidelines were included. All recommended statins as the primary lipid-lowering therapy, with a high level of supporting evidence. Considerable variation was found in the recommendations for cholesterol targets. Seventeen guidelines provided at least one cholesterol target, which for low-density lipoprotein (LDL) cholesterol ranged between 1.0 and 2.6 mmol/L, although the most frequently recommended was <1.8 mmol/L (n=12). For long-term follow-up, many recommended reviewing patients annually (n=9), although there was some variation in recommendations for the interval of between 3 and 12 months. Supporting evidence for any approach was limited, often being derived from clinical opinion. CONCLUSIONS Further research is required to provide an evidence base for optimal lipid monitoring of the on-statin secondary prevention population.
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Affiliation(s)
- Rosemary Elisabeth Brown
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Paul Welsh
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Jennifer Logue
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
- Lancaster Medical School, Lancaster University, Lancaster, Lancashire, UK
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108
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Hay M, Stehli J, Martin C, Brennan A, Dinh DT, Lefkovits J, Zaman S. Sex differences in optimal medical therapy following myocardial infarction according to left ventricular ejection fraction. Eur J Prev Cardiol 2020; 27:2348-2350. [DOI: 10.1177/2047487319900875] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Michael Hay
- Monash Cardiovascular Research Centre, Monash University, Australia
- Monash Heart, Monash Medical Centre, Australia
| | - Julia Stehli
- Cardiology Department, The Alfred Hospital, Australia
| | | | - Angela Brennan
- Monash University, Centre of Cardiovascular Research and Education in Therapeutics, Australia
| | - Diem T Dinh
- Monash University, Centre of Cardiovascular Research and Education in Therapeutics, Australia
| | - Jeffrey Lefkovits
- Monash University, Centre of Cardiovascular Research and Education in Therapeutics, Australia
- Cardiology Department, Royal Melbourne Hospital, Australia
| | - Sarah Zaman
- Monash Cardiovascular Research Centre, Monash University, Australia
- Monash Heart, Monash Medical Centre, Australia
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109
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Curtis E, Fernandez R, Moroney T, Lee A. How coronary artery catheterisation has influenced cardiovascular nursing – An historical Australian perspective. Collegian 2020. [DOI: 10.1016/j.colegn.2020.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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110
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Ocsan RJ, Doost A, Marley P, Farshid A. The Rise of Transradial Artery Access for Percutaneous Coronary Intervention in Patients with Acute Coronary Syndromes in Australia. J Interv Cardiol 2020; 2020:4397697. [PMID: 33312077 PMCID: PMC7719530 DOI: 10.1155/2020/4397697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/06/2020] [Accepted: 11/11/2020] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Ryan James Ocsan
- College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
| | - Ata Doost
- College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
- Department of Cardiology, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Paul Marley
- Department of Cardiology, The Canberra Hospital, Canberra, ACT, Australia
| | - Ahmad Farshid
- College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
- Department of Cardiology, The Canberra Hospital, Canberra, ACT, Australia
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111
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Chan A, Philpott H, Lim AH, Au M, Tee D, Harding D, Chinnaratha MA, George B, Singh R. Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence. World J Gastrointest Endosc 2020; 12:408-450. [PMID: 33269053 PMCID: PMC7677885 DOI: 10.4253/wjge.v12.i11.408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/01/2020] [Accepted: 11/05/2020] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic procedures, in both diagnostic and therapeutic purposes is continually expanding and evolving rapidly. In this context, endoscopists will encounter patients prescribed on anticoagulant and antiplatelet medications frequently. This poses an increased risk of intraprocedural and delayed gastrointestinal bleeding. Thus, there is now greater importance on optimal pre, peri and post-operative management of anticoagulant and/or antiplatelet therapy to minimise the risk of post-procedural bleeding, without increasing the risk of a thromboembolic event as a consequence of therapy interruption. Currently, there are position statements and guidelines from the major gastroenterology societies. These are available to assist endoscopists with an evidenced-based systematic approach to anticoagulant and/or antiplatelet management in endoscopic procedures, to ensure optimal patient safety. However, since the publication of these guidelines, there is emerging evidence not previously considered in the recommendations that may warrant changes to our current clinical practices. Most notably and divergent from current position statements, is a growing concern regarding the use of heparin bridging therapy during warfarin cessation and its associated risk of increased bleeding, suggestive that this practice should be avoided. In addition, there is emerging evidence that anticoagulant and/or antiplatelet therapy may be safe to be continued in cold snare polypectomy for small polyps (< 10 mm).
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Affiliation(s)
- Andrew Chan
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
| | - Hamish Philpott
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Amanda H Lim
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
| | - Minnie Au
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
| | - Derrick Tee
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Damian Harding
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Mohamed Asif Chinnaratha
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Biju George
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
| | - Rajvinder Singh
- Department of Gastroenterology, Lyell McEwin Hospital, Adelaide 5112, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide 5005, Australia
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112
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Rea F, Ronco R, Pedretti RFE, Merlino L, Corrao G. Better adherence with out-of-hospital healthcare improved long-term prognosis of acute coronary syndromes: Evidence from an Italian real-world investigation. Int J Cardiol 2020; 318:14-20. [PMID: 32593725 DOI: 10.1016/j.ijcard.2020.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 05/18/2020] [Accepted: 06/12/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients who experience a hospital admission for acute coronary syndromes (ACS) exhibit poor prognosis over the years. The purposes of this study were to evaluate the real-world patterns of out-of-hospital practice in the management of ACS patients and to assess their impact on the risk of selected outcomes. METHODS The cohort of 87,530 residents in the Lombardy Region (Italy) who were newly hospitalised for ACS during 2011-2015 was followed until 2018. Exposure to medical treatment including use of selected drugs, diagnostic procedures and laboratory tests was recorded. The main outcome of interest was re-hospitalisation for cardiovascular (CV) outcomes. Proportional hazards models were fitted to estimate hazard ratio, and 95% confidence intervals (CI), for the exposure-outcome association. Analyses were stratified according to the ACS type. RESULTS The cumulative incidence of re-hospitalisation for CV disease was 33%, 42% and 38% at 5 years after index discharge among STEMI, NSTEMI and unstable angina patients. Within one year from index discharge, between 70% and 80% of patients had at least a prescription of statins, beta-blockers and renin-angiotensin-system blocking agents, underwent ECG and lipid profile examination, and had a cardiologic examination. One patient in five underwent cardiac rehabilitation. Compared with patients who did not adhere to healthcare recommendations, the risk of CV hospital readmission was reduced from 10% (95% CI: 4%-10%) to 23% (12%-32%) among patients who underwent lipid profile examinations and who experienced cardiac rehabilitation. CONCLUSION Close out-of-hospital healthcare must be considered the cornerstone for improving the long-term prognosis of ACS patients.
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Affiliation(s)
- Federico Rea
- National Center for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy; Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
| | - Raffaella Ronco
- National Center for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy; Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | | | - Luca Merlino
- National Center for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy; Epidemiologic Observatory, Lombardy Region Welfare Department, Milan, Italy
| | - Giovanni Corrao
- National Center for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy; Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
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113
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Tuomisto S, Koivula M, Åstedt-Kurki P, Helminen M. Family composition and living arrangements-Cross-sectional study on family involvement to self-managed rehabilitation of people with coronary artery disease. Nurs Open 2020; 7:1715-1724. [PMID: 33072355 PMCID: PMC7544853 DOI: 10.1002/nop2.555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/21/2020] [Accepted: 06/11/2020] [Indexed: 11/24/2022] Open
Abstract
Aim To describe the family composition and living arrangements of persons diagnosed with coronary artery disease and those relationships to family involvement in self‐managed rehabilitation. Design A cross‐sectional study. Methods Data were collected with postal questionnaire from persons diagnosed with coronary artery disease (CAD) by using the Family Involvement in Rehabilitation (FIRE) scale. It measures family members' promotion of patients' rehabilitation and issues encumbering rehabilitation in family. Statistical methods were used to analyse the data. Results Patients' gender and having children in the family were predictors of issues encumbering rehabilitation in the family. But when examining living arrangements, patients who lived with a spouse or underage children had a better environment for recovery than those who lived alone or with adult children. More attention should be paid to targeting appropriate support for persons with coronary artery disease and their family members during the rehabilitation phase.
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Affiliation(s)
- Sonja Tuomisto
- Faculty of Social Sciences Health Sciences University of Tampere Tampere Finland
| | - Meeri Koivula
- Faculty of Social Sciences Health Sciences University of Tampere Tampere Finland
| | - Päivi Åstedt-Kurki
- Faculty of Social Sciences Health Sciences University of Tampere Tampere Finland.,Pirkanmaa Hospital District Tampere Finland
| | - Mika Helminen
- Faculty of Social Sciences Health Sciences University of Tampere Tampere Finland.,Research, Development and Innovation Centre Tampere University Hospital Tampere Finland
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114
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Driscoll A, Hinde S, Harrison A, Bojke L, Doherty P. Estimating the health loss due to poor engagement with cardiac rehabilitation in Australia. Int J Cardiol 2020; 317:7-12. [PMID: 32376418 DOI: 10.1016/j.ijcard.2020.04.088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/07/2020] [Accepted: 04/30/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiac rehabilitation (CR) programs are effective in reducing cardiovascular mortality and readmissions. However, most patients are denied the benefits of CR due to low referral rates. Of those patients referred, commencement rates vary from 28.4% to 60%. This paper quantifies the scale of health loss in Australia due to poor engagement with the program, and estimates how much public funding can be justifiably reallocated to address the problem. METHODS Economic decision modelling was undertaken to estimate the expected lifetime health loss and costs to Medicare. Key parameters were derived from Australian databases, CR registries and meta-analyses. Population health gains associated with uptake rates of 60%, and 85% were calculated. RESULTS CR was associated with a 99.9% probability of being cost-effective, even at a cost-effectiveness threshold lower than conventionally applied. Importantly, an average of 0.52 years of life expectancy are lost due to national uptake being below 60% achieved in some best performing programs in Australia, equivalent to 0.28 quality adjusted life years. The analysis indicates that $12.9 million/year could be justifiably reallocated from public funds to achieve a national uptake rate of 60%, while maintaining cost-effectiveness of CR due to the large health gains that would be expected. CONCLUSION CR is a cost-effective service for patients with coronary heart disease. In Australia, less than a third of patients commence CR, potentially resulting in avoidable patient harm. Additional investment in CR is vital and should be a national priority as the health gains for patients far outweigh the costs.
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Affiliation(s)
- A Driscoll
- Deakin University, School of Nursing and Midwifery, 1 Gheringhap Street, Geelong, VIC 3220, Australia.; Austin Health, Dept of Cardiology, Studley Rd, Heidelberg, VIC 3081, Australia.
| | - S Hinde
- University of York, Centrefor Health Economics, Alcuin A Block, Heslington, York, YO105DD, UK
| | - A Harrison
- University of York, Department of Health Sciences, Seebohm Rowntree Building, Heslington, York YO105DD, UK
| | - L Bojke
- University of York, Centrefor Health Economics, Alcuin A Block, Heslington, York, YO105DD, UK
| | - P Doherty
- University of York, Department of Health Sciences, Seebohm Rowntree Building, Heslington, York YO105DD, UK
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115
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Hughes V, Paige E, Welsh J, Joshy G, Banks E, Korda RJ. Education-related variation in coronary procedure rates and the contribution of private health care in Australia: a prospective cohort study. Int J Equity Health 2020; 19:139. [PMID: 32795313 PMCID: PMC7427777 DOI: 10.1186/s12939-020-01235-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/03/2020] [Indexed: 11/26/2022] Open
Abstract
Background Contemporary Australian evidence on socioeconomic variation in secondary cardiovascular disease (CVD) care, a possible contributor to inequalities in cardiovascular disease outcomes, is lacking. This study examined the relationship between education, an individual-level indicator of socioeconomic position, and receipt of angiography and revascularisation procedures following incident hospitalisation for acute myocardial infarction (AMI) or angina, and the role of private care in this relationship. Methods Participants aged ≥45 from the New South Wales population-based 45 and Up Study with no history of prior ischaemic heart disease hospitalised for AMI or angina were followed for receipt of angiography or revascularisation within 30 days of hospital admission, ascertained through linked hospital records. Education attainment, measured on baseline survey, was categorised as low (no school certificate/qualifications), intermediate (school certificate/trade/apprenticeship/diploma) and high (university degree). Cox regression estimated the association (hazard ratios [HRs]) between education and coronary procedure receipt, adjusting for demographic and health-related factors, and testing for linear trend. Private health insurance was investigated as a mediating variable. Results Among 4454 patients with AMI, 68.3% received angiography within 30 days of admission (crude rate: 25.8/person-year) and 48.8% received revascularisation (rate: 11.7/person-year); corresponding figures among 4348 angina patients were 59.7% (rate: 17.4/person-year) and 30.8% (rate: 5.3/person-year). Procedure rates decreased with decreasing levels of education. Comparing low to high education, angiography rates were 29% lower among AMI patients (adjusted HR = 0.71, 95% CI: 0.56–0.90) and 40% lower among angina patients (0.60, 0.47–0.76). Patterns were similar for revascularisation among those with angina (0.78, 0.61–0.99) but not AMI (0.93, 0.69–1.25). After adjustment for private health insurance status, the HRs were attenuated and there was little evidence of an association between education and angiography among those admitted for AMI. Conclusions There is a socioeconomic gradient in coronary procedures with the most disadvantaged patients being less likely to receive angiography following hospital admission for AMI or angina, and revascularisation procedures for angina. Unequal access to private health care contributes to these differences. The extent to which the remaining variation is clinically appropriate, or whether angiography is being underused among people with low socioeconomic position or overused among those with higher socioeconomic position, is unclear.
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Affiliation(s)
- Veronica Hughes
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, Australia
| | - Ellie Paige
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, Australia.
| | - Jennifer Welsh
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, Australia
| | - Grace Joshy
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, Australia
| | - Emily Banks
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, Australia.,Sax Institute, Sydney, NSW, Australia
| | - Rosemary J Korda
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, Australia
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116
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Lembo RJ, Gullick J, Chow CK, Figtree GA, Kozor R. A Study of Patient Satisfaction and Uncertainty in a Rapid Access Chest Pain Clinic. Heart Lung Circ 2020; 29:e210-e216. [DOI: 10.1016/j.hlc.2020.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 12/22/2019] [Accepted: 01/31/2020] [Indexed: 11/26/2022]
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117
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Nicholls SJ, Nelson M, Astley C, Briffa T, Brown A, Clark R, Colquhoun D, Gallagher R, Hare DL, Inglis S, Jelinek M, O'Neil A, Tirimacco R, Vale M, Redfern J. Optimising Secondary Prevention and Cardiac Rehabilitation for Atherosclerotic Cardiovascular Disease During the COVID-19 Pandemic: A Position Statement From the Cardiac Society of Australia and New Zealand (CSANZ). Heart Lung Circ 2020; 29:e99-e104. [PMID: 32473781 PMCID: PMC7192068 DOI: 10.1016/j.hlc.2020.04.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has introduced a major disruption to the delivery of routine health care across the world. This provides challenges for the use of secondary prevention measures in patients with established atherosclerotic cardiovascular disease (CVD). The aim of this Position Statement is to review the implications for effective delivery of secondary prevention strategies during the COVID-19 pandemic. CHALLENGES The COVID-19 pandemic has introduced limitations for many patients to access standard health services such as visits to health care professionals, medications, imaging and blood tests as well as attendance at cardiac rehabilitation. In addition, the pandemic is having an impact on lifestyle habits and mental health. Taken together, this has the potential to adversely impact the ability of practitioners and patients to adhere to treatment guidelines for the prevention of recurrent cardiovascular events. RECOMMENDATIONS Every effort should be made to deliver safe, ongoing access to health care professionals and the use of evidenced based therapies in individuals with CVD. An increase in use of a range of electronic health platforms has the potential to transform secondary prevention. Integrating research programs that evaluate the utility of these approaches may provide important insights into how to develop more optimal approaches to secondary prevention beyond the pandemic.
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Affiliation(s)
| | - Mark Nelson
- University of Tasmania, Hobart, Tas, Australia
| | | | - Tom Briffa
- University of Western Australia, Perth, WA, Australia
| | - Alex Brown
- South Australian Health and Medical Research Institute and University of Adelaide, Adelaide, SA, Australia
| | - Robyn Clark
- Flinders University, Adelaide, SA, Australia
| | | | | | - David L Hare
- University of Melbourne, Melbourne, Vic, Australia; Austin Health, Melbourne, Vic, Australia
| | - Sally Inglis
- University of Technology Sydney, Sydney, NSW, Australia
| | - Michael Jelinek
- University of Melbourne, Melbourne, Vic, Australia; St. Vincent's Hospital, Melbourne, Vic, Australia
| | | | - Rosy Tirimacco
- Country Health SA Local Health Network, Adelaide, SA, Australia
| | - Margarite Vale
- University of Melbourne, Melbourne, Vic, Australia; The COACH Program, Melbourne, Vic, Australia
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118
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Parsonage WA, Cullen L, Brieger D, Hillis GS, Nasis A, Dwyer N, Wahi S, Lo S, Than M, Kerr A, Devlin G, Chew DK. CSANZ Position Statement on the Evaluation of Patients Presenting With Suspected Acute Coronary Syndromes During the COVID-19 Pandemic. Heart Lung Circ 2020; 29:e105-e110. [PMID: 32601022 PMCID: PMC7241352 DOI: 10.1016/j.hlc.2020.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A pandemic of Coronavirus-19 disease was declared by the World Health Organization on March 11, 2020. The pandemic is expected to place unprecedented demand on health service delivery. This position statement has been developed by the Cardiac Society of Australia and New Zealand to assist clinicians to continue to deliver rapid and safe evaluation of patients presenting with suspected acute cardiac syndrome at this time. The position statement complements, and should be read in conjunction with, the National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016: Section 2 'Assessment of Possible Cardiac Chest Pain'.
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Affiliation(s)
| | - Louise Cullen
- Royal Brisbane & Women's Hospital, Brisbane, Qld, Australia
| | | | | | | | | | - Sudhir Wahi
- Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Sidney Lo
- Liverpool Hospital, Greater Western Sydney, NSW, Australia
| | - Martin Than
- Christchurch Hospital, Christchurch, New Zealand
| | | | | | - Derek K Chew
- Flinders Medical Centre, Adelaide, SA, Australia
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119
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Widespread Introduction of a High-Sensitivity Troponin Assay: Assessing the Impact on Patients and Health Services. J Clin Med 2020; 9:jcm9061883. [PMID: 32560184 PMCID: PMC7356092 DOI: 10.3390/jcm9061883] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/03/2020] [Accepted: 06/09/2020] [Indexed: 11/17/2022] Open
Abstract
Adoption of High-sensitivity troponin (hs-cTn) assays by hospitals worldwide is increasing. We sought to determine the effects of a simultaneous state-wide hs-cTn assay introduction on the implementing health service. A quasi-experimental pre–post design was used. Participants included all adult patients presenting to 21 Australian hospitals who had troponin testing commenced within the Emergency Department (ED). Data were collected for 124,357 episodes of care between 30 April 2018 and 23 April 2019; six months pre- and six months post-implementation of the assay. The primary outcome was hospital length of stay (LOS). Secondary outcomes included ED LOS, 90-day cardiovascular mortality, elevated troponin, diagnosis of acute myocardial infarction (AMI), admission to a cardiology ward, invasive cardiac procedures, and total hospital costs. Following hs-cTn implementation, there was a 1.9-h (95% CI: −2.9 to −1.0 h) reduction in overall LOS. This equated to a cost saving of over 9 million Australian dollars per year. There was no increase in diagnosis of AMI, invasive cardiac procedures or ward admissions. The use of hs-cTn assays facilitates important benefits for health services by enabling more rapid evaluation protocols within the ED. This benefit may be considerable given the large cohort of emergency patients with possible ACS.
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120
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Kasargod C, Devlin G, Lee M, White HD, Kerr AJ. Prescribing Performance Post-Acute Coronary Syndrome Using a Composite Medication Indicator: ANZACS-QI 24. Heart Lung Circ 2020; 29:824-834. [DOI: 10.1016/j.hlc.2019.05.179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/05/2018] [Accepted: 05/17/2019] [Indexed: 11/26/2022]
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121
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Lo STH, Yong AS, Sinhal A, Shetty S, McCann A, Clark D, Galligan L, El-Jack S, Sader M, Tan R, Hallani H, Barlis P, Sechi R, Dictado E, Walton A, Starmer G, Bhagwandeen R, Leung DY, Juergens CP, Bhindi R, Muller DWM, Rajaratnum R, French JK, Kritharides L. Consensus guidelines for interventional cardiology services delivery during covid-19 pandemic in Australia and new Zealand. Heart Lung Circ 2020; 29:e69-e77. [PMID: 32471696 PMCID: PMC7202321 DOI: 10.1016/j.hlc.2020.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The global coronavirus disease (COVID-19) pandemic poses an unprecedented stress on healthcare systems internationally. These Health system-wide demands call for efficient utilisation of resources at this time in a fair, consistent, ethical and efficient manner would improve our ability to treat patients. Excellent co-operation between hospital units (especially intensive care unit [ICU], emergency department [ED] and cardiology) is critical in ensuring optimal patient outcomes. The purpose of this document is to provide practical guidelines for the effective use of interventional cardiology services in Australia and New Zealand. The document will be updated regularly as new evidence and knowledge is gained with time. Goals Considerations.
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Affiliation(s)
- S T H Lo
- Department of Cardiology, Liverpool Hospital, NSW, Australia.
| | - A S Yong
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia; University of Sydney, Australia
| | - A Sinhal
- Flinders Medical Centre, SA, Australia
| | - S Shetty
- Department of Cardiology, Fiona Stanley Hospital, WA, Australia
| | - A McCann
- Department of Cardiology, Princess Alexandra Hospital, QLD, Australia; University of Queensland, Australia
| | - D Clark
- Department of Cardiology, Austin Hospital, VIC, Australia
| | - L Galligan
- Department of Cardiology, Royal Hobart Hospital, TAS, Australia
| | - S El-Jack
- Department of Cardiology, North Shore Hospital, New Zealand
| | - M Sader
- University of Sydney, Australia; Department of Cardiology, St George Hospital, NSW, Australia
| | - R Tan
- Department of Cardiology, The Canberra Hospital, ACT, Australia
| | - H Hallani
- Department of Cardiology, The Canberra Hospital, ACT, Australia
| | - P Barlis
- Department of Cardiology, Nepean Hospital, NSW, Australia; Department of Cardiology, The Northern Hospital, VIC, Australia; Department of Cardiology, St Vincents' Hospital, VIC, Australia; University of Melbourne, VIC, Australia
| | - R Sechi
- Department of Nursing, Liverpool Hospital, NSW, Australia
| | - E Dictado
- Department of Nursing, Liverpool Hospital, NSW, Australia
| | - A Walton
- Department of Cardiology, Alfred Hospital, VIC, Australia; Monash University, VIC, Australia
| | - G Starmer
- Department of Cardiology, Cairns Hospital, QLD, Australia
| | - R Bhagwandeen
- Department of Cardiology, John Hunter Hospital, NSW, Australia; Lake Macquarie Private Hospital, NSW, Australia
| | - D Y Leung
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia
| | - C P Juergens
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia
| | - R Bhindi
- University of Sydney, Australia; Department of Cardiology, Royal North Shore Hospital, NSW, Australia
| | - D W M Muller
- University of New South Wales, NSW, Australia; St Vincent's Hospital, NSW, Australia
| | - R Rajaratnum
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia; Western Sydney University, NSW, Australia
| | - J K French
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia; Western Sydney University, NSW, Australia
| | - L Kritharides
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia; University of Sydney, Australia; ANZAC Medical Research Institute, Australia
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122
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Freene N, Borg S, McManus M, Mair T, Tan R, Davey R, Öberg B, Bäck M. Comparison of device-based physical activity and sedentary behaviour following percutaneous coronary intervention in a cohort from Sweden and Australia: a harmonised, exploratory study. BMC Sports Sci Med Rehabil 2020; 12:17. [PMID: 32419950 PMCID: PMC7210676 DOI: 10.1186/s13102-020-00164-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/20/2020] [Indexed: 11/18/2022]
Abstract
Background Few studies have measured device-based physical activity and sedentary behaviour following a percutaneous coronary intervention (PCI), with no studies comparing these behaviours between countries using the same methods. The aim of the study was to compare device-based physical activity and sedentary behaviour, using a harmonised approach, following a PCI on-entry into centre-based cardiac rehabilitation in two countries. Methods A cross-sectional study was conducted at two outpatient cardiac rehabilitation centres in Australia and Sweden. Participants were adults following a PCI and commencing cardiac rehabilitation (Australia n = 50, Sweden n = 133). Prior to discharge from hospital, Australian participants received brief physical activity advice (< 5 mins), while Swedish participants received physical activity counselling for 30 min. A triaxial accelerometer (Actigraph GT3X/ActiSleep) was used to objectively assess physical activity (light (LPA), moderate-to-vigorous (MVPA)) and sedentary behaviour. Outcomes included daily minutes of physical activity and sedentary behaviour, and the proportion and distribution of time spent in each behaviour. Results There was no difference in age, gender or relationship status between countries. Swedish (S) participants commenced cardiac rehabilitation later than Australian (A) participants (days post-PCI A 16 vs S 22, p < 0.001). Proportionally, Swedish participants were significantly more physically active and less sedentary than Australian participants (LPA A 27% vs S 30%, p < 0.05; MVPA A 5% vs S 7%, p < 0.01; sedentary behaviour A 68% vs S 63%, p < 0.001). When adjusting for wear-time, Australian participants were doing less MVPA minutes (A 42 vs S 64, p < 0.001) and more sedentary behaviour minutes (A 573 vs S 571, p < 0.001) per day. Both Swedish and Australian participants spent a large part of the day sedentary, accumulating 9.5 h per day in sedentary behaviour. Conclusion Swedish PCI participants when commencing cardiac rehabilitation are more physically active than Australian participants. Potential explanatory factors are differences in post-PCI in-hospital physical activity education between countries and pre-existing physical activity levels. Despite this, sedentary behaviour is high in both countries. Internationally, interventions to address sedentary behaviour are indicated post-PCI, in both the acute setting and cardiac rehabilitation, in addition to traditional physical activity and cardiac rehabilitation recommendations. Trial registrations Australia: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615000995572. Registered 22 September 2015, Sweden: World Health Organization Trial Registration Data Set: NCT02895451.
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Affiliation(s)
- Nicole Freene
- 1Physiotherapy, Faculty of Health, University of Canberra, Bruce, ACT 2617 Australia.,2Health Research Institute, University of Canberra, Bruce, ACT Australia
| | - Sabina Borg
- 3Department of Health, Medicine and Caring Sciences, Unit of Physiotherapy, Linköping University, Linköping, Sweden.,4Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | | | - Tarryn Mair
- Exercise Physiology, Canberra Health Services, Garran, ACT Australia
| | - Ren Tan
- Cardiology, Canberra Health Services, Garran, ACT Australia
| | - Rachel Davey
- 2Health Research Institute, University of Canberra, Bruce, ACT Australia.,7Centre for Research and Action in Public Health, University of Canberra, Bruce, ACT Australia
| | - Birgitta Öberg
- 3Department of Health, Medicine and Caring Sciences, Unit of Physiotherapy, Linköping University, Linköping, Sweden
| | - Maria Bäck
- 3Department of Health, Medicine and Caring Sciences, Unit of Physiotherapy, Linköping University, Linköping, Sweden.,8Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
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123
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Taylor LK, Nelson MA, Gale M, Trevena J, Brieger DB, Winch S, Cretikos MA, Newman LA, Phung HN, Faddy SC, Kelly PM, Chant K. Cardiac procedures in ST-segment-elevation myocardial infarction - the influence of age, geography and Aboriginality. BMC Cardiovasc Disord 2020; 20:224. [PMID: 32408860 PMCID: PMC7227061 DOI: 10.1186/s12872-020-01487-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 04/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background Timely restoration of bloodflow acute ST-segment elevation myocardial infarction (STEMI) reduces myocardial damage and improves prognosis. The objective of this study was describe the association of demographic factors with hospitalisation rates for STEMI and time to angiography, Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Graft (CABG) in New South Wales (NSW) and the Australian Capital Territory (ACT), Australia. Methods This was an observational cohort study using linked population health data. We used linked records of NSW and the ACT hospitalisations and the Australian Government Medicare Benefits Schedule (MBS) for persons aged 35 and over hospitalised with STEMI in the period 1 July 2010 to 30 June 2014. Survival analysis was used to determine the time between STEMI admission and angiography, PCI and CABG, with a competing risk of death without cardiac procedure. Results Of 13,117 STEMI hospitalisations, 71% were among males; 55% were 65-plus years; 64% lived in major cities, and 2.6% were Aboriginal people. STEMI hospitalisation occurred at a younger age in males than females. Angiography and PCI rates decreased with age: angiography 69% vs 42% and PCI 60% vs 34% on day 0 for ages 35-44 and 75-plus respectively. Lower angiography and PCI rates and higher CABG rates were observed outside major cities. Aboriginal people with STEMI were younger and more likely to live outside a major city. Angiography, PCI and CABG rates were similar for Aboriginal and non-Aboriginal people of the same age and remoteness area. Conclusions There is a need to improve access to definitive revascularisation for STEMI among appropriately selected older patients and in regional areas. Aboriginal people with STEMI, as a population, are disproportionately affected by access to definitive revascularisation outside major cities. Improving access to timely definitive revascularisation in regional areas may assist in closing the gap in cardiovascular outcomes between Aboriginal and non-Aboriginal people.
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Affiliation(s)
- Lee K Taylor
- Centre for Epidemiology and Evidence, NSW Ministry of Health, Sydney, Australia
| | - Michael A Nelson
- Centre for Epidemiology and Evidence, NSW Ministry of Health, Sydney, Australia.
| | - Marianne Gale
- Office of the Chief Health Officer, NSW Ministry of Health, Sydney, Australia
| | - Judy Trevena
- Centre for Epidemiology and Evidence, NSW Ministry of Health, Sydney, Australia
| | | | - Scott Winch
- Illawarra Local Aboriginal Lands Council, Wollongong, Australia
| | | | - Leah A Newman
- Epidemiology Section, Population Health Protection and Prevention, ACT Health, Canberra, Australia
| | - Hai N Phung
- Epidemiology Section, Population Health Protection and Prevention, ACT Health, Canberra, Australia
| | | | - Paul M Kelly
- ACT Chief Health Officer & Deputy Director-General, Population Health Protection and Prevention, ACT Health, Canberra, Australia
| | - Kerry Chant
- Chief Health Officer, NSW Ministry of Health, Sydney, Australia
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124
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Examining the translational success of an initiative to accelerate the assessment of chest pain for patients in an Australian emergency department: a pre-post study. BMC Health Serv Res 2020; 20:419. [PMID: 32404106 PMCID: PMC7222586 DOI: 10.1186/s12913-020-05296-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 05/05/2020] [Indexed: 12/14/2022] Open
Abstract
Background The Improved assessment of chest pain trial (IMPACT) protocol is an accelerated strategy for the risk stratification and management of patients presenting to the emergency department (ED) with chest pain. This study sought to describe the adoption, sustainability and health services implications of implementing the IMPACT protocol. Methods This was a study of adult patients in a large Australian tertiary hospital who had serial troponin testing commenced within the ED. Data from two periods were utilized; the pre-implementation period (8th April 2012 to 5th April 2014) and the post-implementation period (6th April 2014 to 2nd April 2016). The primary outcome was the proportion of patients undergoing accelerated care. Secondary endpoints were ED assessment time, hospital length of stay, and costs. Data were compared in the pre- and post-implementation periods. Results The proportion of patients receiving accelerated care increased from 3% in the pre- to 34% in the post-intervention period. This increase occurred rapidly after implementation of IMPACT and was sustained over a 2-year period. For patients with troponin concentrations <99th percentile, the mean ED assessment time reduced from 12.3 h in the pre- to 10.1 h in the post-implementation period. Mean hospital length of stay was similar in the pre- and post-implementation periods (82.4 and 80.9 h). The average cost of chest pain assessment reduced from $3520 pre implementation to $3204 post implementation; a $316 reduction per patient. Conclusions The IMPACT protocol was rapidly adopted and utilised after implementation into standard care. The initial increase in the proportion of patients undergoing accelerated assessment, followed by a plateau towards the end of the study period indicate adoption and sustainability of the IMPACT protocol over a two-year period. Modest reductions in length of stay and cost were seen after implementation. Given the large number of patients investigated for chest pain, such reductions may have substantial impact on the overall healthcare system.
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125
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Murali S, Vogrin S, Noaman S, Dinh DT, Brennan AL, Lefkovits J, Reid CM, Cox N, Chan W. Bleeding Severity in Percutaneous Coronary Intervention (PCI) and Its Impact on Short-Term Clinical Outcomes. J Clin Med 2020; 9:jcm9051426. [PMID: 32403442 PMCID: PMC7291133 DOI: 10.3390/jcm9051426] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 11/27/2022] Open
Abstract
Bleeding severity in patients undergoing percutaneous coronary intervention (PCI), defined by the Bleeding Academic Research Consortium (BARC), portends adverse prognosis. We analysed data from 37,866 Australian patients undergoing PCI enrolled in the Victorian Cardiac Outcomes Registry (VCOR), and investigated the association between increasing BARC severity and in-hospital and 30-day major adverse cardiac and cerebrovascular events (MACCE) (a composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularisation, or stroke). Independent predictors associated with major bleeding (BARC groups 3&5), and MACCE were also assessed. There was a stepwise increase in in-hospital and 30-day MACCE with greater severity of bleeding. Independent predictors of bleeding included female sex (Odds Ratio (OR) 1.34), age (OR 1.02), fibrinolytic therapy (OR 1.77), femoral access (OR 1.51), and ticagrelor (OR 1.42), all significant at the p < 0.001 level. Following adjustment of clinically important variables, BARC 3&5 bleeds (OR 4.37) were still predictive of cumulative in-hospital and 30-day MACCE. In conclusion, major bleeding is an uncommon but potentially fatal PCI complication and was independently associated with greater MACCE rates. Efforts to mitigate the occurrence of bleeding, including radial access and judicious use of potent antiplatelet therapies, may ameliorate the risk of short-term adverse clinical outcomes.
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Affiliation(s)
- Shashank Murali
- Department of Medicine, University of Melbourne, Melbourne 3010, Victoria, Australia; (S.M.); (S.N.)
| | - Sara Vogrin
- Department of Medicine-Western Health, Melbourne Medical School, University of Melbourne, Melbourne 3010, Victoria, Australia;
| | - Samer Noaman
- Department of Medicine, University of Melbourne, Melbourne 3010, Victoria, Australia; (S.M.); (S.N.)
- Department of Cardiology, Western Health, St Albans 3021, Victoria, Australia;
- Department of Cardiology, Alfred Health, Melbourne 3004, Victoria, Australia
| | - Diem T. Dinh
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
| | - Angela L. Brennan
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
| | - Jeffrey Lefkovits
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
| | - Christopher M. Reid
- School of Public Health & Preventive Medicine, Monash University, Melbourne 3004, Victoria, Australia; (D.T.D.); (A.L.B.); (J.L.); (C.M.R.)
- School of Public Health, Curtin University, Perth 6102, Western Australia, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, St Albans 3021, Victoria, Australia;
| | - William Chan
- Department of Medicine, University of Melbourne, Melbourne 3010, Victoria, Australia; (S.M.); (S.N.)
- Department of Cardiology, Western Health, St Albans 3021, Victoria, Australia;
- Department of Cardiology, Alfred Health, Melbourne 3004, Victoria, Australia
- Correspondence: ; Tel.: +61-(03)-8345-1333
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Abstract
Objectives: Although the factors driving emergency department demand have been extensively investigated, a comparatively minimal amount is known about the factors that are driving an increase in emergency ambulance demand. Methods: We conducted a retrospective observational study of consecutive cases attended by Ambulance Victoria in Melbourne, Australia from 2008 to 2015. Incidence rates were calculated, and adjusted time series regression analyses were performed to assess the driving factors of ambulance demand. Results: A total of 2,443,952 consecutive cases were included. Demand grew by 29.2% over the 8-year period. The age-specific incidence increased significantly over time for patients aged < 60 years, but not for patients aged ≥ 60 years. After adjustment for seasonality and population growth, demand increased by 1.4% per annum (incident rate ratio [IRR] = 1.014 [1.011-1.017]). The largest annual growth in demand was observed in patients with a history of mental health issues (IRR = 1.058 [1.054-1.062]), alcohol/drug abuse (IRR = 1.061 [1.056-1.066]), or a Charlson Comorbidity Index [CCI] score ≥ 4 (IRR = 1.045 [1.039-1.051]). Cases involving patients of relative socio-economic/educational disadvantage, younger age, or with no preexisting health conditions according to the CCI also grew faster than the overall patient population. Cases requiring transport to hospital increased by 1.2% annually (IRR = 1.012 [1.009-1.016]), although patients not requiring medical intervention from paramedics increased by 6.7% annually (IRR = 1.067 [1.063-1.072]). Conclusions: Increases in ambulance demand exceeded population growth. Emergency ambulances were increasingly utilized for transport of patients who did not require medical intervention from paramedics. Identifying the characteristics of patients driving ambulance demand will enable targeted demand management strategies.
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Zheng W, Wang G, Ma J, Wu S, Zhang H, Zheng J, Xu F, Wang J, Chen Y. Evaluation and comparison of six GRACE models for the stratification of undifferentiated chest pain in the emergency department. BMC Cardiovasc Disord 2020; 20:199. [PMID: 32334528 PMCID: PMC7183650 DOI: 10.1186/s12872-020-01476-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/12/2020] [Indexed: 02/07/2023] Open
Abstract
Background The Global Registry of Acute Coronary Events (GRACE) score is recommended for stratifying chest pain. However, there are six formulas used to calculate the GRACE score for different outcomes of acute coronary syndrome (ACS), including death (Dth) or composite of death and myocardial infarction (MI), while in hospital (IH), within 6 months after discharge (OH6m) or from admission to 6 months later (IH6m). We aimed to perform the first comprehensive evaluation and comparison of six GRACE models to predict 30-day major adverse cardiac events (MACEs) in patients with acute chest pain in the emergency department (ED). Methods Patients with acute chest pain were consecutively recruited from August 24, 2015 to September 30, 2017 from the EDs of two public hospitals in China. The 30-day MACEs included death, acute myocardial infarction (AMI), emergency revascularization, cardiac arrest and cardiogenic shock. The correlation, calibration, discrimination, reclassification and diagnostic accuracy at certain cutoff values of six GRACE models were evaluated. Comparisons with the History, ECG, Age, Risk Factors, and Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) scores were conducted. Results A total of 2886 patients were analyzed, with 590 (20.4%) patients experiencing outcomes. The GRACE (IHDthMI), GRACE (IH6mDthMI), GRACE (IHDth), GRACE (IH6mDth), GRACE (OH6mDth) and GRACE (OH6mDthMI) showed positive linear correlations with the actual MACE rates (r ≥ 0.568, P < 0.001). All these models had good calibration (Hosmer-Lemeshow test, P ≥ 0.073) except GRACE (IHDthMI) (P < 0.001). The corresponding C-statistics were 0.83(0.81,0.84), 0.82(0.81,0.83), 0.75(0.73,0.76), 0.73(0.72,0.75), 0.72(0.70,0.73) and 0.70(0.68,0.71), respectively, first two of which were comparable to HEART (0.82, 0.80–0.83) and superior to TIMI (0.71, 0.69–0.73). With a sensitivity ≥95%, GRACE (IHDthMI) ≤81 and GRACE (IH6mDthMI) ≤79 identified 868(30%) and 821(28%) patients as low risk, respectively, which were significantly better than other GRACEs and HEART ≤3(22%). With a specificity ≥95%, GRACE (IHDthMI) > 186 and GRACE (IH6mDthMI) > 161 could recognize 12% and 11% patients as high risk, which were greater than other GRACEs, HEART ≥8(9%) and TIMI ≥5(8%). Conclusions In this Chinese setting, certain strengths of GRACE models beyond HEART and TIMI scores were still noteworthy for stratifying chest pain patients. The validation and reasonable application of appropriate GRACE models in the evaluation of undifferentiated chest pain should be recommended.
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Affiliation(s)
- Wen Zheng
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Guangmei Wang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Jingjing Ma
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Shuo Wu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - He Zhang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Jiaqi Zheng
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Jiali Wang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Yuguo Chen
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China. .,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China. .,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China. .,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China.
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128
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Agostino JW, Wong D, Paige E, Wade V, Connell C, Davey ME, Peiris DP, Fitzsimmons D, Burgess CP, Mahoney R, Lonsdale E, Fernando P, Malamoo L, Eades S, Brown A, Jennings G, Lovett RW, Banks E. Cardiovascular disease risk assessment for Aboriginal and Torres Strait Islander adults aged under 35 years: a consensus statement. Med J Aust 2020; 212:422-427. [PMID: 32172533 DOI: 10.5694/mja2.50529] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cardiovascular disease (CVD) is a leading cause of preventable morbidity and mortality in Aboriginal and Torres Strait Islander peoples. This statement from the Australian Chronic Disease Prevention Alliance, the Royal Australian College of General Practitioners, the National Aboriginal Community Controlled Health Organisation and the Editorial Committee for Remote Primary Health Care Manuals communicates the latest consensus advice of guideline developers, aligning recommendations on the age to commence Aboriginal and Torres Strait Islander CVD risk assessment across three guidelines. MAIN RECOMMENDATIONS: In Aboriginal and Torres Strait Islander peoples without existing CVD: CVD risk factor screening should commence from the age of 18 years at the latest, including for blood glucose level or glycated haemoglobin, estimated glomerular filtration rate, serum lipids, urine albumin to creatinine ratio, and other risk factors such as blood pressure, history of familial hypercholesterolaemia, and smoking status. Individuals aged 18-29 years with the following clinical conditions are automatically conferred high CVD risk: ▶type 2 diabetes and microalbuminuria; ▶moderate to severe chronic kidney disease; ▶systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg; ▶familial hypercholesterolaemia; or ▶serum total cholesterol > 7.5 mmol/L. Assessment using the National Vascular Disease Prevention Alliance absolute CVD risk algorithm should commence from the age of 30 years at the latest - consider upward adjustment of calculated CVD risk score, accounting for local guideline use, risk factor and CVD epidemiology, and clinical discretion. Assessment should occur as part of an annual health check or opportunistically. Subsequent review should be conducted according to level of risk. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: From age 18 years (at the latest), Aboriginal and Torres Strait Islander adults should undergo CVD risk factor screening, and from age 30 years (at the latest), they should undergo absolute CVD risk assessment using the NVDPA risk algorithm.
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Affiliation(s)
- Jason W Agostino
- Australian National University, Canberra, ACT.,National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT
| | - Deborah Wong
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT
| | - Ellie Paige
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT
| | - Vicki Wade
- RHD Australia, Menzies School of Health Research, Darwin, NT
| | - Cia Connell
- National Heart Foundation of Australia, Melbourne, VIC
| | | | - David P Peiris
- George Institute for Global Health, UNSW Sydney, Sydney, NSW
| | - Dana Fitzsimmons
- Top End Health Services, Northern Territory Government, Darwin, NT
| | - C Paul Burgess
- Northern Territory Medical Program, Flinders University, Darwin, NT
| | - Ray Mahoney
- Australian E-Health Research Centre, CSIRO, Brisbane, QLD
| | - Emma Lonsdale
- Australian Chronic Disease Prevention Alliance, Sydney, NSW
| | | | | | - Sandra Eades
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, VIC
| | - Alex Brown
- University of Adelaide, Adelaide, SA.,University of South Australia, Adelaide, SA
| | | | - Raymond W Lovett
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT
| | - Emily Banks
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT
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129
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Cardioprotective medication adherence in Western Australians in the first year after myocardial infarction: restricted cubic spline analysis of adherence-outcome relationships. Sci Rep 2020; 10:4315. [PMID: 32152400 PMCID: PMC7062740 DOI: 10.1038/s41598-020-60799-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/10/2020] [Indexed: 11/30/2022] Open
Abstract
Adherence to cardioprotective medications following myocardial infarction (MI) is commonly assessed using a binary threshold of 80%. We investigated the relationship between medication adherence as a continuous measure and outcomes in MI survivors using restricted cubic splines (RCS). We identified all patients aged ≥65 years hospitalised for MI from 2003–2008 who survived one-year post-discharge (n = 5938). Adherence to statins, beta-blockers, renin angiotensin system inhibitors (RASI) and clopidogrel was calculated using proportion of days covered to one-year post-discharge (landmark date). Outcomes were 1-year all-cause death and major adverse cardiac events (MACE) after the landmark date. Adherence-outcome associations were estimated from RCS Cox regression models. RCS analyses indicated decreasing risk for both outcomes above 60% adherence for statins, RASI and clopidogrel, with each 10% increase in adherence associated with a 13.9%, 12.1% and 18.0% decrease respectively in adjusted risk of all-cause death (all p < 0.02). Similar results were observed for MACE (all p < 0.03). Beta-blockers had no effect on outcomes at any level of adherence. In MI survivors, increasing adherence to statins, RASI, and clopidogrel, but not beta blockers, is associated with a decreasing risk of death/MACE with no adherence threshold beyond 60%. Medication adherence should be considered as a continuous measure in outcomes analyses.
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130
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Evaluation of Cardiac Rehabilitation Performance and Initial Benchmarks for Australia: An Observational Cross-State and Territory Snapshot Study. Heart Lung Circ 2020; 29:1397-1404. [PMID: 32094082 DOI: 10.1016/j.hlc.2020.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 11/12/2019] [Accepted: 01/11/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Australia, unlike most high-income countries, does not have published benchmarks for cardiac rehabilitation (CR) delivery. This study provides cross-state data on CR delivery for initial benchmarks and assesses performance against international minimal standards. METHODS A prospective observational study March-May 2017 of CR programs in NSW (n=36), Tasmania (n=2) and ACT (n=1) was undertaken. Data were collected on 11 indicators (published dictionary), then classified as higher or lower performing using the UK National Audit of Cardiac Rehabilitation (NACR) criteria. Equity of access to higher performing CR was assessed using logistic regression. RESULTS Participants (n=2,436) had a mean age of 66.06±12.54 years, 68.9% were male, 16.2% culturally and linguistically diverse (CALD) and 2.6% Aboriginal and Torres Strait Islander peoples. At patient level, waiting time was median 15 (Interquartile range [IQR] 9-25) days, 24.3% had an assessment before starting, 41.8% on completion, a median 12 sessions (IQR 6-16) were delivered, which 59.1% completed and 75.4% were linked to ongoing care. At program level, using NACR criteria, 18.0% were classified as higher performing and ≥87.1% met waiting time criteria, however, only 20.5% met duration criteria. Evidence of inequitable access to higher performing programs was present with substantially higher odds for participants living in major cities (OR 28.11 95%CI 18.41, 44.92) and with every decade younger age (OR 1.89-2.94) and lower odds by 89.0% for principal referral hospital-based services (OR 0.11 95%CI 0.08, 0.14) and 31.0% for people having a CALD background (OR 0.69 95%CI 0.49, 0.97). CONCLUSIONS This study provides initial national CR performance benchmarks for quality improvement in Australia. While wait times are minimised, few programs are higher performing or met minimum duration standards. There is an urgent need to resource and support CR quality and access outside of major cities, in principal referral hospitals and for older and diverse patients.
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131
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Hsu B, Falster MO, Schaffer AL, Pearson S, Jorm L, Brieger DB. Antiplatelet therapy within 30 days of percutaneous coronary intervention with stent implantation. Med J Aust 2020; 213:124-125. [PMID: 32067236 DOI: 10.5694/mja2.50507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/18/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Benjumin Hsu
- Centre for Big Data Research in Health, UNSW Australia, Sydney, NSW
| | | | | | - Sallie Pearson
- Centre for Big Data Research in Health, UNSW Australia, Sydney, NSW.,Menzies Centre for Health Policy, University of Sydney, Sydney, NSW
| | - Louisa Jorm
- Centre for Big Data Research in Health, UNSW Australia, Sydney, NSW
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132
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Crilly J, Greenslade JH, Berndt S, Hawkins T, Cullen L. Facilitators and barriers for emergency department clinicians using a rapid chest pain assessment protocol: qualitative interview research. BMC Health Serv Res 2020; 20:74. [PMID: 32005238 PMCID: PMC6995126 DOI: 10.1186/s12913-020-4923-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 01/21/2020] [Indexed: 12/27/2022] Open
Abstract
Background Guideline-based processes for the assessment of chest pain are lengthy and resource intensive. The IMProved Assessment of Chest Pain Trial (IMPACT) protocol was introduced in one Australian hospital Emergency Department (ED) to more efficiently risk stratify patients. The theoretical domains framework is a useful approach to assist in identifying barriers and facilitators to the implementation of new guidelines in clinical practice. The aim of this study was to understand clinicians’ perceptions of facilitators and barriers to the use of the IMPACT protocol. Methods Guided by the theoretical domains framework, semi-structured interviews with nine ED clinical staff (medical and nursing) were undertaken in 2016. Content analysis was conducted independently by two researchers to identify those theoretical domains that facilitated or hindered protocol use. Results Domains most often reported as fundamental to the use of the IMPACT protocol included ‘social/professional role and identity’, ‘environmental context and resources’ and ‘social influences’. These factors seemingly influenced professional confidence, with participants noting ‘goals’ that included standardisation of practice, enhanced patient safety, and reduced need for unnecessary testing. The domain ‘environmental context and resources’ also contained the most noted barrier - the need to inform new members of staff regarding protocol use. Opportunities to overcome this barrier included modelling of protocol use by staff at all levels and education – both formal and informal. Conclusions A range of domains were identified by ED staff as influencing their chest pain management behaviour. Fundamental to its use were champions/leaders that were trusted and accessible, as well as social influences (other staff within ED and other specialty areas) that enabled and supported protocol use. Research investigating the implementation and perceived use of the protocol at other sites, of varied geographical locations, is warranted.
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Affiliation(s)
- Julia Crilly
- Department of Emergency Medicine, Gold Coast Health, 1 Hospital Blvd, Southport, QLD, 4215, Australia. .,Menzies Health Institute Queensland, Griffith University, Gold Coast, 4222, QLD, Australia.
| | - Jaimi H Greenslade
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, QLD, 4059, Australia.,Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Sara Berndt
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Tracey Hawkins
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Louise Cullen
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, QLD, 4059, Australia.,Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia.,School of Medicine, Faculty of Health and Behavioural Sciences, The University of Queensland, 288 Herston Road, Herston, QLD, 4006, Australia
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133
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Watkins S. Effective decision-making: applying the theories to nursing practice. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:98-101. [PMID: 31972119 DOI: 10.12968/bjon.2020.29.2.98] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Many theories have been proposed for the decision-making conducted by nurses across all practices and disciplines. These theories are fundamental to consider when reflecting on our decision-making processes to inform future practice. In this article three of these theories are juxtaposed with a case study of a patient presenting with an ST-segment elevation myocardial infarction (STEMI). These theories are descriptive, normative and prescriptive, and will be used to analyse and interpret the process of decision-making within the context of patient assessment.
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Affiliation(s)
- Samantha Watkins
- Emergency Department Staff Nurse, Frimley Health NHS Foundation Trust, Frimley
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134
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Yudi MB, Farouque O, Andrianopoulos N, Ajani AE, Brennan A, Murphy AC, Lefkovits J, Reid CM, Oqueli E, Sebastian M, Duffy SJ, Clark DJ. Prognostic significance of suboptimal secondary prevention pharmacotherapy after acute coronary syndromes. Intern Med J 2020; 51:366-374. [PMID: 31943665 DOI: 10.1111/imj.14750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/02/2020] [Accepted: 01/06/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Optimal secondary prevention pharmacotherapy is the cornerstone of post-acute coronary syndrome (ACS) management. The prognostic impact of not receiving five guideline-recommended therapies is poorly described. AIM To ascertain the prognostic significance of suboptimal pharmacotherapy in ACS survivors. METHODS Consecutive patients with ACS from the Melbourne Interventional Group registry who were alive at 30 days following their index percutaneous coronary intervention were included. Patients were divided into three categories based on the number of secondary prevention medications prescribed. The optimal medical therapy (OMT), near-optimal medical therapy (NMT), suboptimal medical therapy (SMT) groups were prescribed 5, 4 and ≤ 3 medications, respectively. Primary endpoint was long-term mortality. Cox-proportional hazard modelling was undertaken to assess independent predictors of survival. RESULTS Of the 9375 patients included, 5678 (60.6%) received OMT, 2903 (31.0%) received NMT and 794 (8.5%) received SMT. Patients receiving SMT were older, more likely to be female and had higher burden of comorbidities (renal impairment, congestive heart failure, diabetes, peripheral vascular disease; P < 0.01 for all). SMT was associated with higher long-term mortality at 3.9 ± 2.2 years when compared to NMT and OMT (16.8% vs 10.5% vs 8.2%, P < 0.001). Compared to OMT, SMT was an independent predictor of long-term mortality (hazard ratio, HR 1.62, 95% confidence interval, CI 1.30-2.02, P < 0.01) while NMT was associated with a clinically significant 14% mortality hazard (HR 1.14, 95% CI 0.97-1.34, P = 0.11). CONCLUSIONS There is a graded long-term hazard associated with not receiving OMT after an ACS. Improvements in secondary prevention pharmacotherapy models of care are warranted to further decrease the long-term mortality.
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Affiliation(s)
- Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Nick Andrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Alexandra C Murphy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Ballarat, Victoria, Australia
| | - Martin Sebastian
- Department of Cardiology, Barwon Health, Geelong, Victoria, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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135
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The effects of cardiac rehabilitation on haemodynamic parameters measured by impedance cardiography in patients with coronary artery disease. VOJNOSANIT PREGL 2020. [DOI: 10.2298/vsp200810126s] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background / Aim. Well-organized cardiovascular rehabilitation (CVR) reduces
cardiovascular burden by influencing cardiovascular risk factors, improving
the quality of life and reducing mortality and hospital readmission.
However, its effects on hemodynamic status are largely unknown. The aim of
our study was to evaluate the influence of three-week CVR program on
hemodynamic status and to investigate if there is a correlation between
physical strain tolerance and hemodynamic parameters measured by impedance
cardiography (ICG) before and after CVR program in patients with coronary
artery disease. Methods. Fifty-two patients attended a three-week CVR
program. At the beginning and at the end of rehabilitation program
laboratory tests, exercise stress tests (EST) and ICG measurements were
taken. Results. Patients showed better strain tolerance on the second
exercise stress test (EST2) by achieving higher strain level (Z=2,315;
p=0,021) and longer duration of test (Z=2,305; p=0,021). There was a strong
positive correlation between the level of EST2 and cardiac output (CO)
(r=0,538; p<0,001) and stroke volume (SV) (r=0,380; p=0,017) on the second
ICG (ICG2). Also, there was a strong negative correlation between EST2 level
and systemic vascular resistance (SVR) (r=-0,472; p=0,002) and SVR index
(SSVRI) (r=-0,407; p=0,010) on ICG2. There was a strong positive correlation
between EST2 duration and CO (r=0.517; p=0.001) as well as between EST2
duration and SV (r=0.340; p=0.034), and a strong negative correlation
between EST2 duration and SVR (r=-0.504; p=0.001) as well as between EST2
duration and SVRI (r=-0.448; p=0.004), according to ICG2. Conclusion. Our
study showed that a well-designed CVR program can lead to better physical
strain tolerance. Furthermore, CVR led to a significant positive correlation
between EST and cardiac output as well as between EST and stroke volume
measured by ICG. On the other hand, there was a significant negative
correlation between EST and vascular related parameters according to ICG at
the end of the CVR program.
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136
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Wang G, Zheng W, Wu S, Ma J, Zhang H, Zheng J, Wang J, Xu F, Chen Y. Comparison of usual care and the HEART score for effectively and safely discharging patients with low-risk chest pain in the emergency department: would the score always help? Clin Cardiol 2019; 43:371-378. [PMID: 31867780 PMCID: PMC7144490 DOI: 10.1002/clc.23325] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/12/2019] [Accepted: 12/12/2019] [Indexed: 12/23/2022] Open
Abstract
Background Triage decisions for chest pain patients receiving usual care are based on a dynamic and comprehensive strategy performed in the physician's mind. It remains controversial whether simple, structured risk tools can surpass real, complex judgments. Hypothesis The potentially used History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score would help identify low‐risk patients for discharge. Methods Patients with acute, non‐traumatic chest pain managed according to usual care were consecutively enrolled in a tertiary university hospital in China from August 24, 2015 to September 30, 2017. Major adverse cardiac events (MACE) included death, acute myocardial infarction, revascularization, and significant coronary stenosis (>50%) within 30 days. We compared the efficacy and safety of usual care and the potentially used HEART score in this population. Results Of 2185 patients analyzed, 926 (42.4%) patients were directly discharged by usual care, whereas HEART≤3 would have identified 524 (24.0%) patients as low‐risk (P < .001). The MACE rate in discharged patients was 2.2% (20/926) and would have been 5.2% (27/524) in those with HEART≤3 (P = .002). For discharged patients, the MACE rates in HEART≤3 vs HEART>3 groups were not significantly different (1.5% vs 2.7%, P = .225). Negative predictive value (NPV) was higher with usual care than with the HEART score (P = .003), but sensitivity was similar. For 340 patients with serial troponins, usual care was superior to the potentially used HEART score in regard to efficacy. Conclusions At this institution, usual care identified many more patients for discharge than the HEART score would have without apparently different outcomes in discharged patients with lower vs higher HEART scores. The HEART score would not appear to provide helpful risk stratification.
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Affiliation(s)
- Guangmei Wang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Wen Zheng
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Shuo Wu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Jingjing Ma
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - He Zhang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Jiaqi Zheng
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Jiali Wang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Yuguo Chen
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, China
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137
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Cartledge S, Thomas E, Hollier K, Maddison R. Development of standardised programme content for phase II cardiac rehabilitation programmes in Australia using a modified Delphi process. BMJ Open 2019; 9:e032279. [PMID: 31796485 PMCID: PMC7003389 DOI: 10.1136/bmjopen-2019-032279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/16/2019] [Accepted: 11/06/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To develop standardised programme content for Australian phase II cardiac rehabilitation (CR) programme. DESIGN Using the RAND/UCLA appropriateness method (RAM), a two-phase process including a comprehensive literature review and a two round modified Delphi process was undertaken to develop and validate content of a standardised CR programmes. PARTICIPANTS An invited multidisciplinary expert advisory group (EAG; n=16), including CR health professionals (nurses, allied health professionals, cardiologist), academics, policy makers, representation from the Australian Cardiovascular Health and Rehabilitation Association and consumers, provided oversight of the literature review and assisted with development of best practice statements. Twelve members of the EAG went onto participate in the modified Delphi process rating the necessity of statements in two rounds on a scale of 1 (not necessary) to 9 (essential). MAIN OUTCOME MEASURE Best practice statements that achieved a median score of ≥8 on a nine-point scale were categorised as 'essential'; statements that achieved a median score of ≥6 were categorised as 'desirable' and statements with a median score of <6 were omitted. RESULTS 49 best practice statements were developed from the literature across ten areas of care within four module domains (CR foundations, developing heart health knowledge, psychosocial health and life beyond CR). At the end of a two-round validation process a total of 47 best practice statements were finalised; 29 statements were rated as essential, 18 as desirable and 2 statements were omitted. CONCLUSIONS For the first time in Australia, an evidence-based and consensus-led standardised programme content for phase II CR has been developed that can be provided to CR coordinators.
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Affiliation(s)
- Susie Cartledge
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, Victoria, Australia
| | - Emma Thomas
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Kerry Hollier
- National Heart Foundation of Australia, Melbourne, Victoria, Australia
| | - R Maddison
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, Victoria, Australia
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138
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Zhang S, Zhou H, Zhuang X, Yang D, Sun X, Zhong X, Lin X, Hu X, Huang Y, Liao X, Du Z. Critical appraisal of guidelines for coronary artery disease on dual antiplatelet therapy: More consensus than controversies. Clin Cardiol 2019; 42:1170-1180. [PMID: 31609463 PMCID: PMC6906997 DOI: 10.1002/clc.23275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/11/2019] [Accepted: 09/17/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) in the form of aspirin plus a P2 Y12 inhibitor, when indicated, is one of the key treatments in coronary artery disease (CAD). Many recommendations on DAPT in patients with CAD based on current guidelines are largely inconsistent. In our current study, we aimed at systematically reviewing DAPT-relevant clinical practice guidelines, and highlighting their commonalities and differences for better informed decision-making. METHODS Contemporary guidelines in English were searched in MEDLINE, Embase and websites of guideline organizations and professional societies. Guidelines with recommendations on DAPT for CAD patients were included. Guideline quality was appraised with the 6-domain Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. The reporting of conflicts of interest (COI) was assessed individually with supplementary items from the RIGHT (Reporting Item for Practice Guidelines in Healthcare) checklist. Meanwhile, extraction of recommendations was performed. RESULTS A total of 18 guidelines fulfilled our inclusion criteria. Most of them were graded with relatively good scores averaging from 42% to 74%. Domains for lower scores were in "stakeholder involvement" and "application." The reporting of COI was satisfactory. For the recommendations on DAPT, most guidelines with high AGREE II scores included consistent recommendations on the timing and P2 Y12 inhibitor selection. Nonetheless, conflicts still exist on the duration of DAPT. CONCLUSIONS Quality of guidelines for DAPT in CAD was relatively high, though defects existed in "Applicability" and "Stakeholder Involvement." As these guidelines developed, DAPT recommendations gradually converged on a consensus. Clinical decision should be made on an individual basis.
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Affiliation(s)
- Shaozhao Zhang
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Huimin Zhou
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Xiaodong Zhuang
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Daya Yang
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Xiuting Sun
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Xiangbin Zhong
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Xiaoyu Lin
- Department of AnesthesiologyThe Third Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Xun Hu
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Yiquan Huang
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Xinxue Liao
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
| | - Zhimin Du
- Cardiology DepartmentFirst Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
- NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouChina
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139
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Cardiac rehabilitation services: A global perspective on performance and barriers. IJC HEART & VASCULATURE 2019; 24:100410. [PMID: 31763436 PMCID: PMC6859525 DOI: 10.1016/j.ijcha.2019.100410] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 11/29/2022]
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140
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Health-related quality of life and exercise-based cardiac rehabilitation in contemporary acute coronary syndrome patients: a systematic review and meta-analysis. Qual Life Res 2019; 29:579-592. [PMID: 31691204 DOI: 10.1007/s11136-019-02338-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE To review the literature on health-related quality of life (HRQoL) outcomes for exercise-based cardiac rehabilitation (EBCR) in contemporary acute coronary syndrome (ACS) patients. METHODS Electronic databases (CENTRAL, MEDLINE, Embase, and CINAHL) were searched from January 2000 to March 2019 for randomised controlled trials (RCTs) comparing EBCR to a no-exercise control in ACS patients recruited after year 2000, follow-up of at least 6 months, and HRQoL as outcome. Potential papers were independently screened by two reviewers. Risks of bias were assessed using the Cochrane Tool. Data analyses were performed using RevMan v5.3, random effects model. RESULTS Fourteen RCTs (1739 participants) were included, with eight studies suitable for meta-analyses. EBCR resulted in statistically significant and clinically important improvements in physical performance (mean difference [MD] 7.09, 95% CI 0.08, 14.11) and general health (MD 5.08, 95% CI 1.03, 9.13) (SF-36) at 6 months, and in physical functioning (MD 9.82, 95% CI 1.46, 18.19) at 12 months. Statistically significant and sustained improvements were also found in social and physical functioning. Meta-analysis of two studies using the MacNew Heart Disease HRQoL instrument did not show any significant benefits. Of the six studies unsuitable for meta-analyses, five reported significant changes in overall HRQoL, general physical activity levels and functional capacity, or quality-adjusted life-years (QALYs). CONCLUSIONS In an era where adherence to clinical practice guidelines has improved survival, EBCR still achieves clinically meaningful improvements in physical performance, general health, and physical functioning in the short and long term in contemporary ACS patients.
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141
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McCreanor V, Parsonage WA, Whiteman DC, Olsen C, Barnett AG, Graves N. Pharmaceutical use and costs in patients with coronary artery disease, using Australian observational data. BMJ Open 2019; 9:e029360. [PMID: 31678937 PMCID: PMC6830622 DOI: 10.1136/bmjopen-2019-029360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES We aimed to estimate the annual pharmaceutical costs for patients with stable coronary artery disease, using Australian administrative data, comparing patients who had undergone interventional treatment with those had not. We also aimed to compare the duration of dual antiplatelet therapy (DAPT) prescription in the real-world, with recommended guidelines. DESIGN An observational study using administrative data. PARTICIPANTS We used data from the QSkin study, a population-based prospective study assessing skin cancer risk. Participants were invited from the Queensland population, not based on perceived skin cancer risk, and had consented to future use of their data for approved research projects. MAIN OUTCOME MEASURES We calculated 12-month costs of pharmaceutical therapy for coronary artery disease for patients in each of three clinically relevant groups: medical therapy only, following coronary stent implantation and following coronary artery bypass graft surgery. We measured the duration of DAPT following stent implantation and total duration of DAPT, where it was prescribed, in the medical therapy only group. RESULTS Estimated mean annual pharmaceutical costs were highest in the stent group at AUD$1920, compared with AUD$1481 in the medical therapy group, and AUD$881 in the coronary artery bypass group. There were similar rates of prescriptions of symptom relief drugs following stent insertion, compared with the medical therapy only group. The median duration of DAPT in the stent group was 16, and 31 months in the medical therapy group. CONCLUSIONS Our results suggest that despite the common expectation that the burden of medical therapy is reduced following coronary stent insertion for stable coronary artery disease, this does not occur in practice. Many patients also appear to continue DAPT longer than guidelines recommend, which may put them at unnecessarily elevated risk of bleeding events.
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Affiliation(s)
- Victoria McCreanor
- Australian Centre for Health Services Innovation (AusHSI), Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- Capital Markets CRC Ltd, Sydney, New South Wales, Australia
| | - William A Parsonage
- Australian Centre for Health Services Innovation (AusHSI), Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- Cardiology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - David C Whiteman
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Catherine Olsen
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Adrian G Barnett
- Australian Centre for Health Services Innovation (AusHSI), Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation (AusHSI), Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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142
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Abstract
A case is described in which the short-acting glycoprotein IIb/IIIa receptor antagonist tirofiban was used in combination with heparin, aspirin and prasugrel to successfully treat extensive intracoronary thrombus in a delayed presentation STEMI, illustrating the utility of this approach.
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143
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Jenkins C. Too little, too late? The underuse of beta-blockers in COPD needs evidence to address clinical uncertainty. Respirology 2019; 25:122-123. [PMID: 31591800 DOI: 10.1111/resp.13702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 09/05/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Christine Jenkins
- Respiratory Group, The George Institute for Global Health Sydney, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Department of Thoracic Medicine, Concord Hospital, Sydney, NSW, Australia.,Respiratory Discipline, University of Sydney, Sydney, NSW, Australia
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144
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Welsh J, Korda RJ, Joshy G, Greaves K, Banks E. Variation in coronary angiography and revascularisation procedures in relation to psychological distress among patients admitted to hospital with myocardial infarction or angina. J Psychosom Res 2019; 125:109794. [PMID: 31445320 DOI: 10.1016/j.jpsychores.2019.109794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 07/24/2019] [Accepted: 08/03/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Cardiac patients with psychological distress have a poorer prognosis than patients without distress; which may in part reflect differences in treatment. We quantified variation in coronary angiography and revascularisation procedures according to psychological distress among patients admitted with incident acute myocardial infarction (AMI) or angina. METHODS Questionnaire data (collected 2006-09) from 45 and Up Study participants were linked to hospitalisation and mortality data, to 30 June 2016. Among patients free from ischaemic heart disease at baseline and subsequently hospitalised with AMI or angina, Cox regression was used to model the association between distress (Kessler-10 scores: low [10-<12], mild [12-<16], moderate [16-<22] and high [22-50]) - assessed on the questionnaire - and coronary angiography and revascularisation procedures (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) within 30 days of admission, adjusting for personal characteristics, including physical functioning. RESULTS Proportions receiving angiography and PCI/CABG were 71.4% and 51.7% following AMI (n = 3749), and 61.3% and 31.3% for angina patients (n = 3772), respectively. Following AMI, age-sex-adjusted rates of PCI/CABG were lower with higher levels of distress (test for trend: p = .037), as were rates of angiography and PCI/CABG (p < .01) following admission with angina. After additional adjustment for personal characteristics, associations between distress and procedure rates attenuated substantively and were no longer significant, except that PCI/CABG rates remained lower among angina patients with high versus low distress (HR = 0.76, 95%CI: 0.59-0.99). CONCLUSION Distress-related variation in coronary procedures largely reflects differences in personal characteristics. Whether lower revascularisation rates among angina patients with high compared to low distress are clinically appropriate or represent under-treatment remains unclear.
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Affiliation(s)
- Jennifer Welsh
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Australia.
| | - Rosemary J Korda
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Australia.
| | - Grace Joshy
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Australia.
| | - Kim Greaves
- Sunshine Coast University Hospital, Australia; Griffith University, Australia.
| | - Emily Banks
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Australia; The Sax Institute, Australia.
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145
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A comparison of cardiac troponin T delta change methods and the importance of the clinical context in the assessment of acute coronary syndrome. Ann Clin Biochem 2019; 56:701-707. [DOI: 10.1177/0004563219876671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The management of patients presenting with symptoms suggestive of acute coronary syndrome is a significant challenge for clinicians. Guidelines for the diagnosis of acute myocardial infarction require a rise and/or fall of cardiac troponin, along with other criteria. Knowing what constitutes a significant delta change from baseline is still unclear and the literature is varied. Methods We compared three methods for determining cardiac troponin delta changes (relative, absolute and z-scores) for detecting acute myocardial infarction in 806 patients presenting to an emergency department with symptoms suggestive of acute coronary syndrome. Blood specimens were collected at admission and 2, 3, 4 and 6 h postadmission and tested on the Roche Elecsys high-sensitivity troponin T assay. Results A positive diagnosis for acute myocardial infarction was found in 39 (4.8%) patients. ROC AUC showed better performance for the absolute and z-score delta change (0.959–0.988 and 0.956–0.988, respectively) compared with relative delta change (0.921–0.960) at all time points in the diagnosis of acute myocardial infarction. Optimal timing for the second sample was at 4–6 h postadmission. Conclusions Although not statistically significant, the results show a trend of absolute and z-score delta change performing better than relative delta change for the diagnosis of acute myocardial infarction. The z-score approach allows for a single cut-off value across multiple high-sensitivity assays which could be useful in the clinical setting. Our study also highlighted the importance of interpreting cardiac troponin changes in the clinical context with a combination of the patient’s clinical history and electrocardiogram.
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146
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Scovelle AJ, Milner A, Beauchamp A, Byrnes J, Norton R, Woodward M, O'Neil A. The Importance of Considering Sex and Gender in Cardiovascular Research. Heart Lung Circ 2019; 29:e7-e8. [PMID: 31526681 DOI: 10.1016/j.hlc.2019.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 08/24/2019] [Indexed: 01/16/2023]
Affiliation(s)
- Anna J Scovelle
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Vic, Australia
| | - Allison Milner
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Vic, Australia
| | - Alison Beauchamp
- Melbourne Medical School, University of Melbourne, Melbourne, Vic, Australia
| | - Joshua Byrnes
- School of Medicine, Griffith University, Brisbane, Qld, Australia
| | - Robyn Norton
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia; The George Institute for Global Health, University of Oxford, Oxford, UK
| | - Mark Woodward
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia; The George Institute for Global Health, University of Oxford, Oxford, UK
| | - Adrienne O'Neil
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Vic, Australia; IMPACT Strategic Research Centre, Deakin University, Melbourne, Vic, Australia.
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147
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Chew DP, Lambrakis K, Blyth A, Seshadri A, Edmonds MJR, Briffa T, Cullen LA, Quinn S, Karnon J, Chuang A, Nelson AJ, Wright D, Horsfall M, Morton E, French JK, Papendick C. A Randomized Trial of a 1-Hour Troponin T Protocol in Suspected Acute Coronary Syndromes: The Rapid Assessment of Possible Acute Coronary Syndrome in the Emergency Department With High-Sensitivity Troponin T Study (RAPID-TnT). Circulation 2019; 140:1543-1556. [PMID: 31478763 DOI: 10.1161/circulationaha.119.042891] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High-sensitivity troponin assays promise earlier discrimination of myocardial infarction. Yet, the benefits and harms of this improved discriminatory performance when incorporated within rapid testing protocols, with respect to subsequent testing and clinical events, has not been evaluated in an in-practice patient-level randomized study. This multicenter study evaluated the noninferiority of a 0/1-hour high-sensitivity cardiac troponin T (hs-cTnT) protocol in comparison with a 0/3-hour masked hs-cTnT protocol in patients with suspected acute coronary syndrome presenting to the emergency department (ED). METHODS Patients were randomly assigned to either a 0/1-hour hs-cTnT protocol (reported to the limit of detection [<5 ng/L]) or masked hs-cTnT reported to ≤29 ng/L evaluated at 0/3-hours (standard arm). The 30-day primary end point was all-cause death and myocardial infarction. Noninferiority was defined as an absolute margin of 0.5% determined by Poisson regression. RESULTS In total, 3378 participants with an emergency presentation were randomly assigned between August 2015 and April 2019. Ninety participants were deemed ineligible or withdrew consent. The remaining participants received care guided either by the 0/1-hour hs-cTnT protocol (n=1646) or the 0/3-hour standard masked hs-cTnT protocol (n=1642) and were followed for 30 days. Median age was 59 (49-70) years, and 47% were female. Participants in the 0/1-hour arm were more likely to be discharged from the ED (0/1-hour arm: 45.1% versus standard arm: 32.3%, P<0.001) and median ED length of stay was shorter (0/1-hour arm: 4.6 [interquartile range, 3.4-6.4] hours versus standard arm: 5.6 (interquartile range, 4.0-7.1) hours, P<0.001). Those randomly assigned to the 0/1-hour protocol were less likely to undergo functional cardiac testing (0/1-hour arm: 7.5% versus standard arm: 11.0%, P<0.001). The 0/1-hour hs-cTnT protocol was not inferior to standard care (0/1-hour arm: 17/1646 [1.0%] versus 16/1642 [1.0%]; incidence rate ratio, 1.06 [ 0.53-2.11], noninferiority P value=0.006, superiority P value=0.867), although an increase in myocardial injury was observed. Among patients discharged from ED, the 0/1-hour protocol had a negative predictive value of 99.6% (95% CI, 99.0-99.9%) for 30-day death or myocardial infarction. CONCLUSIONS This in-practice evaluation of a 0/1-hour hs-cTnT protocol embedded in ED care enabled more rapid discharge of patients with suspected acute coronary syndrome. Improving short-term outcomes among patients with newly recognized troponin T elevation will require an evolution in management strategies for these patients. CLINICAL TRIAL REGISTRATION URL: https://www.anzctr.org.au. Unique identifier: ACTRN12615001379505.
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Affiliation(s)
- Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Health and Medical Research Institute, Adelaide (D.P.C., A.J.C.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Kristina Lambrakis
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Andrew Blyth
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Anil Seshadri
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Michael J R Edmonds
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth (T.B.)
| | - Louise A Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Australia (L.A.C.).,School of Public Health, Queensland University of Technology, Brisbane, Australia (L.A.C.).,School of Medicine, University of Queensland, Brisbane, Australia (L.A.C.)
| | - Stephen Quinn
- Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Australia (S.Q.)
| | - Jonathan Karnon
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.)
| | - Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Adam J Nelson
- South Australian Health and Medical Research Institute, Adelaide (D.P.C., A.J.C.).,School of Medicine, University of Adelaide, Australia (A.J.C.)
| | - Deborah Wright
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Matthew Horsfall
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Erin Morton
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.)
| | - John K French
- Department of Cardiology, University of New South Wales, Sydney, Australia (J.K.F.)
| | - Cynthia Papendick
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
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148
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Parkin L, Quon J, Sharples K, Barson D, Dummer J. Underuse of beta‐blockers by patients with COPD and co‐morbid acute coronary syndrome: A nationwide follow‐up study in New Zealand. Respirology 2019; 25:173-182. [DOI: 10.1111/resp.13662] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 04/16/2019] [Accepted: 06/27/2019] [Indexed: 01/06/2023]
Affiliation(s)
- Lianne Parkin
- Pharmacoepidemiology Research Network Dunedin New Zealand
- Department of Preventive and Social Medicine, Dunedin School of MedicineUniversity of Otago Dunedin New Zealand
| | - Joshua Quon
- Dunedin School of MedicineUniversity of Otago Dunedin New Zealand
| | - Katrina Sharples
- Pharmacoepidemiology Research Network Dunedin New Zealand
- Department of Medicine, Dunedin School of MedicineUniversity of Otago Dunedin New Zealand
- Department of Mathematics and StatisticsUniversity of Otago Dunedin New Zealand
| | - David Barson
- Pharmacoepidemiology Research Network Dunedin New Zealand
- Department of Preventive and Social Medicine, Dunedin School of MedicineUniversity of Otago Dunedin New Zealand
| | - Jack Dummer
- Pharmacoepidemiology Research Network Dunedin New Zealand
- Department of Medicine, Dunedin School of MedicineUniversity of Otago Dunedin New Zealand
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Zhou H, Zhang S, Sun X, Yang D, Zhuang X, Guo Y, Hu X, Du Z, Zhang M, Liao X. Lipid management for coronary heart disease patients: an appraisal of updated international guidelines applying Appraisal of Guidelines for Research and Evaluation II-clinical practice guideline appraisal for lipid management in coronary heart disease. J Thorac Dis 2019; 11:3534-3546. [PMID: 31559060 PMCID: PMC6753419 DOI: 10.21037/jtd.2019.07.71] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 03/28/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clinical practice guidelines (CPGs) provide many recommendations for hyperlipidemia management, but some of them are still debatable. METHODS We applied the six-domain Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument to evaluate the quality of guidelines with lipid management recommendations for coronary heart disease (CHD), including dyslipidemia and CHD guidelines published from 2009 to 2019. Meanwhile, we synthesized and compared major recommendations and present the consistency and controversy in current dyslipidemia management. RESULTS Among 19 guidelines included, ten guidelines ("strongly recommended" with AGREE scores 61-94%) performed better than the other nine (38-65% as "recommended with some modification") For blood lipid tests, most CHD guidelines simply required fasting sample while dyslipidemia guidelines preferred non-fasting sample except in high triglycerides state. Most guidelines consistently chose low-density lipoprotein cholesterol (LDL-C) as the primary lipid-lowering target (LLT), while non-high-density lipoprotein cholesterol (non-HDL-C) and apolipoprotein B were mainly selected as secondary LLTs. The specific goals of LDL-C lowering were either to lower than 70 mg/dL or with at least 50% reduction. All guidelines recommended high intensity or maximally tolerable doses of statins, while ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors were recommended as second-line therapy. CONCLUSIONS The general quality of guidelines for lipid management is satisfactory. Consensus has been reached on the specific goal of lipid reduction and the intensity of statins therapy. Further research is needed to validate the application of non-fasting sample and non-HDL-C target, as well as the efficacy and safety of ezetimibe and PCSK9 inhibitors.
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Affiliation(s)
- Huimin Zhou
- Cardiology Department, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou 510080, China
| | - Shaozhao Zhang
- Cardiology Department, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou 510080, China
| | - Xiuting Sun
- Cardiology Department, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou 510080, China
| | - Daya Yang
- Cardiology Department, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou 510080, China
| | - Xiaodong Zhuang
- Cardiology Department, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou 510080, China
- Center for Information Technology & Statistics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Yue Guo
- Cardiology Department, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou 510080, China
| | - Xun Hu
- Cardiology Department, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou 510080, China
| | - Zhimin Du
- Cardiology Department, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou 510080, China
| | - Meifen Zhang
- School of Nursing, Sun Yat-sen University, Guangzhou 510080, China
| | - Xinxue Liao
- Cardiology Department, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou 510080, China
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Khan AA, Williams T, Al-Omary MS, Feeney AL, Majeed T, Savage L, Stewart P, Faddy S, Collins NJ, Fletcher P, Boyle AJ. Pre-hospital thrombolysis for ST-segment elevation myocardial infarction in regional Australia: long-term follow up. Intern Med J 2019; 50:711-715. [PMID: 31237408 DOI: 10.1111/imj.14412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/10/2019] [Accepted: 06/18/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Delivering reperfusion therapy to patients with ST-segment elevation myocardial infarction (STEMI) in regional areas without access to tertiary cardiology care remains challenging. The systems of care in Hunter New England Health, New South Wales, Australia (area covered = 130 000 km2 ) to provide reperfusion to patients with STEMI involve a 12-lead electrocardiogram in the ambulance, discussion between cardiologist and paramedic, followed by pre-hospital thrombolysis (PHT) delivered in ambulance to appropriate patients >60 min from the cardiac catheterisation laboratories. Patients who can access the cardiac catheterisation laboratories within 60 min are treated with primary percutaneous coronary intervention (PCI). AIMS We have previously reported excellent 12-month outcomes for patients receiving PHT and the aim of the current analysis is to look at the long term outcomes. METHODS We assessed long-term all-cause mortality and major adverse cardiovascular events of STEMI patients undergoing PHT in our health district from August 2008 to August 2013 and compared with the primary PCI group. RESULTS One hundred and fifty (mean age: 62 ± 13 years, males: 76%, n = 114) patients were administered PHT and 334 patients (mean age: 65 ± 13 years, males: 75%, n = 251) underwent primary PCI during the study period. During a median follow up of 6.2 years (interquartile range: 4.8-7.4 years) all-cause mortality was 16% and 19% in the PHT and primary PCI groups respectively (P = 0.4). CONCLUSION Our real-world experience shows that PHT followed by early transfer to a primary PCI-capable centre is an effective reperfusion strategy, with comparable results to primary PCI, and mortality benefits are sustained to more than 6 years.
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Affiliation(s)
- Arshad A Khan
- Department of Cardiovascular Medicine, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Trent Williams
- Department of Cardiovascular Medicine, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Mohamed S Al-Omary
- Department of Cardiovascular Medicine, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Alex L Feeney
- Department of Cardiovascular Medicine, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia
| | - Tazeen Majeed
- University of Newcastle, Newcastle, New South Wales, Australia
| | - Lindsay Savage
- Department of Cardiovascular Medicine, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia
| | - Paul Stewart
- NSW Ambulance, Sydney, New South Wales, Australia
| | - Steven Faddy
- NSW Ambulance, Sydney, New South Wales, Australia
| | - Nicholas J Collins
- Department of Cardiovascular Medicine, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Peter Fletcher
- Department of Cardiovascular Medicine, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Andrew J Boyle
- Department of Cardiovascular Medicine, John Hunter Hospital, Hunter New England Health, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, Newcastle, New South Wales, Australia
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