Sex- and Age-Specific Differences in Risk Profiles and Early Outcomes in Adults With Acute Coronary Syndromes

BACKGROUND

Adults <55 years of age comprise a quarter of all acute coronary syndromes (ACS) hospitalisations. There is a paucity of data characterising this group, particularly sex differences. This study aimed to compare the clinical and risk profile of patients with ACS aged <55 years with older counterparts, and measure short-term outcomes by age and sex.

METHOD

The study population comprised patients with ACS enrolled in the AUS-Global Registry of Acute Coronary Events (GRACE), Cooperative National Registry of Acute Coronary Syndrome Care (CONCORDANCE) and SNAPSHOT ACS registries. We compared clinical features and combinations of major modifiable risk factors (hypertension, smoking, dyslipidaemia, and diabetes) by sex and age group (20-54, 55-74, 75-94 years). All-cause mortality and major adverse events were identified in-hospital and at 6-months.

RESULTS

There were 16,658 patients included (22.3% aged 20-54 years). Among them, 20-54 year olds had the highest proportion of ST-elevation myocardial infarction compared with sex-matched older age groups. Half of 20-54 year olds were current smokers, compared with a quarter of 55-74 year olds, and had the highest prevalence of no major modifiable risk factors (14.2% women, 12.7% men) and of single risk factors (27.6% women, 29.0% men), driven by smoking. Conversely, this age group had the highest proportion of all four modifiable risk factors (6.6% women, 4.7% men). Mortality at 6 months in 20-54 year olds was similar between men (2.3%) and women (1.7%), although lower than in older age groups.

CONCLUSIONS

Younger adults with ACS are more likely to have either no risk factor, a single risk factor, or all four modifiable risk factors, than older patients. Targeted risk factor prevention and management is warranted in this age group.

Use of secondary prevention medications in metropolitan and non-metropolitan areas: an analysis of 41,925 myocardial infarctions in Australia

BACKGROUND

People in remote areas may have more difficulty accessing healthcare following myocardial infarction (MI) than people in metropolitan areas. We determined whether remoteness was associated with initial and 12-month use of secondary prevention medications following MI in Victoria, Australia.

METHOD

We included all people alive at least 90 days post-discharge following MI between July 2012 and June 2017 in Victoria, Australia (n=41,925). We investigated dispensing of P2Y12 inhibitors (P2Y12i), statins, ACE-inhibitors or angiotensin receptor blockers (ACEI/ARBs), and beta-blockers within 90 days post-discharge. We estimated 12-month medication use using proportion of days covered (PDC). Remoteness was determined using the Accessibility/Remoteness Index of Australia (ARIA). Data were analyzed using adjusted parametric regression models stratified by STEMI and NSTEMI.

RESULTS

There were 10,819 STEMI admissions and 31,106 NSTEMI admissions. Following adjustment across NSTEMI and STEMI, there were no medication classes dispensed in the 90-days post-discharge that differed in a clinically significant way from the least remote (ARIA=0) to the most remote (ARIA=4.8) areas. The largest difference for NSTEMI were ACEi/ARB, with 71%(95%CI 70-72%) versus 80%(76%-83%). For STEMI, it was statins with 89%(88-90%) versus 95%(91-97%). Predicted PDC for STEMI and NSTEMI were not clinically significant across remoteness, with the largest difference in NSTEMI being P2Y12i with 48%(47-50%) versus 55%(51-59%), and in STEMI it was ACEi/ARB with 68%(67-69%) versus 76%(70-80%).

CONCLUSION

Remoteness does not appear to be a clinically significant driver for medication use following MI. Possible differences in cardiovascular outcomes in metropolitan and non-metropolitan areas are not likely to be explained by access to secondary prevention medications.

Rapid access chest pain clinics in Australia and New Zealand

Chest pain is the second most common reason for adult emergency department presentations. Most patients have low or intermediate risk chest pain, which historically has led to inpatient admission for further evaluation. Rapid access chest pain clinics represent an innovative outpatient pathway for these low and intermediate risk patients, and have been shown to be safe and reduce hospital costs. Despite variations in rapid access chest pain clinic models, there are limited data to determine the most effective approach. Developing a national framework could be beneficial to provide sites with evidence, possible models, and business cases. Multicentre data analysis could enhance understanding and monitoring of the service.

Snapshot of suspected acute coronary syndrome assessment processes in the emergency department: A national cross-sectional survey

OBJECTIVE

The Snapshot of Suspected ACS Assessment (SSAASY) study aims to describe the assessment processes for patients with suspected acute coronary syndrome (ACS) in Australian EDs, and to compare these processes with the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (NHFA/CSANZ) guidelines.

METHODS

Between March and May 2021, a cross-sectional survey of Australian EDs was undertaken to investigate the assessment strategies used within the ED. All public and private hospitals identified as having dedicated EDs were invited to participate. Respondents provided data on hospital, ED and cardiac service characteristics. They also provided data on the risk stratification process recommended within their department (risk scores, troponin testing, objective testing for coronary artery disease). Awareness of the NHFA/CSANZ guidelines was assessed.

RESULTS

Responses were received from 109/162 departments (67%). Most sites (n = 100, 92%) reported using dedicated protocols developed by ED clinicians that included risk stratification scores. Highly sensitive troponin assays were used at 103 (94%) sites. Serial troponin testing was performed over 2 h for low-risk patients in 53 (49%) sites and 2-3 h for intermediate and high-risk patients in 74 (68%) sites. Further investigations included exercise stress tests (48%) and stress echocardiography (38%), with 45% of sites ordering outpatient investigations.

CONCLUSIONS

The SSAASY study reported the strategies used to assess suspected ACS. In line with current NHFA/CSANZ guidelines, highly sensitive troponin assays are widely utilised. However, serial sampling intervals were longer than guideline recommendations, suggesting a translational gap between guidelines and clinical practice.

Information Needs and Communication Strategies for People with Coronary Heart Disease: A Scoping Review

A critical aspect of coronary heart disease (CHD) care and secondary prevention is ensuring patients have access to evidence-based information. The purpose of this review is to summarise the guiding principles, content, context and timing of information and education that is beneficial for supporting people with CHD and potential communication strategies, including digital interventions. We conducted a scoping review involving a search of four databases (Web of Science, PubMed, CINAHL, Medline) for articles published from January 2000 to August 2022. Literature was identified through title and abstract screening by expert reviewers. Evidence was synthesised according to the review aims. Results demonstrated that information-sharing, decision-making, goal-setting, positivity and practicality are important aspects of secondary prevention and should be patient-centred and evidenced based with consideration of patient need and preference. Initiation and duration of education is highly variable between and within people, hence communication and support should be regular and ongoing. In conclusion, text messaging programs, smartphone applications and wearable devices are examples of digital health strategies that facilitate education and support for patients with heart disease. There is no one size fits all approach that suits all patients at all stages, hence flexibility and a suite of resources and strategies is optimal.

Patient perceptions of care quality and discharge information following same-day cardiac catheterization laboratory procedures: A mixed-methods study

AIMS

To examine patients' perceptions of care quality following a same-day procedure in the cardiac catheterization laboratory and understand the extent to which they were prepared for discharge.

DESIGN

Single-centre, mixed-methods study.

METHODS

Postdischarge, online survey of patients who underwent a same-day procedure in the cardiac catheterization laboratory (n = 150) and one-on-one interviews with 13 of these patients.

RESULTS

Survey responses were positive with mean scores between 4.39-4.83 out of five and 63.3% of respondents (n = 95) extremely likely to recommend the service to others. Interview data analysis identified three themes: the care experience, information and education for safe discharge, and follow-up needs. Participants spoke highly of their interactions with clinicians and were satisfied with their care experience. Mode and content of information delivered varied, with some participants lacking guidance about postdischarge health management and clarity about follow-up plans.

PATIENT OR PUBLIC CONTRIBUTION

Participants were patients.

The Association of Sex with Unplanned Cardiac Readmissions following Percutaneous Coronary Intervention in Australia: Results from a Multicentre Outcomes Registry (GenesisCare Cardiovascular Outcomes Registry)

Background and aim: Unplanned cardiac readmissions in patients with percutaneous intervention (PCI) is very common and is seen as a quality indicator of in-hospital care. Most studies have reported on the 30-day cardiac readmission rates, with very limited information being available on 1-year readmission rates and their association with mortality. The aim of this study was to investigate the impact of biological sex at 1-year post-PCI on unplanned cardiac readmissions. Methods and results: Patients enrolled into the GenesisCare Cardiovascular Outcomes Registry (GCOR-PCI) from December 2008 to December 2020 were included in the study. A total of 13,996 patients completed 12 months of follow-up and were assessed for unplanned cardiac readmissions. All patients with unplanned cardiac readmissions in the first year of post-PCI were followed in year 2 (post-PCI) for survival status. The rate of unplanned cardiac readmissions was 10.1%. Women had a 29% higher risk of unplanned cardiac readmission (HR 1.29, 95% CI 1.11 to 1.48; p = 0.001), and female sex was identified as an independent predictor of unplanned cardiac readmissions. Any unplanned cardiac readmission in the first year was associated with a 2.5-fold higher risk of mortality (HR 2.50, 95% CI 1.67 to 3.75; p < 0.001), which was similar for men and women. Conclusion: Unplanned cardiac readmissions in the first year post-PCI was strongly associated with increased all-cause mortality. Whilst the incidence of all-cause mortality was similar between women and men, a higher incidence of unplanned cardiac readmissions was observed for women, suggesting distinct predictors of unplanned cardiac readmissions exist between women and men.

Validation of ICD-10-AM Coding for Myocardial Infarction Subtype in Hospitalisation Data

BACKGROUND

International Classification of Disease (ICD) codes are central for identifying myocardial infarction (MI) in administrative hospitalisation data, however validation of MI subtype codes is limited. We measured the sensitivity and specificity of ICD-10-AM (Australian Modification) codes for ST-elevation MI (STEMI) and non-STEMI (NSTEMI).

METHODS

A sample of MI admissions was obtained from a dataset containing all MI hospitalisations in Western Australia (WA) for 2003, 2008 and 2013. Clinical data were collected from hospital medical records (n=799 patients). Cases were classified by ICD-10-AM codes for STEMI, NSTEMI and unspecified MI, and compared to clinical classification from review of available electrocardiographs (ECGs) and cardiac biomarkers (n=660). Sensitivity and specificity for ICD-10-AM coding versus clinical classification was measured, stratified by calendar year of discharge.

RESULTS

The majority of classifiable cases had MI recorded in the principal diagnosis field (STEMI n=293, 84.2%; NSTEMI n=202, 74.3%; unspecified MI n=20, 50.0%). Overall sensitivity of the ICD-10-AM STEMI code was 86.3% (95% CI 81.7-90.0%) and was higher when restricted to MI as a principal versus secondary diagnosis (88.8% vs 66.7%). Comparable values for NSTEMI were 66.7% (95% CI 61.5-71.6%), and 68.8% vs 61.4% respectively. Between 2003 and 2013, sensitivity for both MI subtypes increased: 80.2-89.5% for STEMI, and 51.2-73.8% for NSTEMI. Specificity was high for NSTEMI throughout (88.2% 95% CI 84.1-91.6%), although improving over time for STEMI (68.1-76.4%).

CONCLUSIONS

The sensitivity and specificity of ICD-10-AM codes for MI subtypes in hospitalisation data are generally high, particularly for principal diagnosis cases. However, the temporal improvement in sensitivity in coding of MI subtypes, particularly NSTEMI, may necessitate modification to trend studies using administrative hospitalisation data.

Assessing the quality of cardiac rehabilitation programs by measuring adherence to the Australian quality indicators

Background

Every year, over 65,000 Australians experience an acute coronary syndrome (ACS) and around one-third occur in people with prior coronary heart disease. Cardiac rehabilitation (CR) aims to prevent a repeat ACS by supporting patients’ return to an active and fulfilling lifestyle. CR programs are efficacious, but audits of clinical practice show variability of program delivery, which may compromise patient outcomes. Core components, quality indicators and accreditation of programs have been introduced internationally to increase program standardisation. With Australian quality indicators (QIs) for cardiac rehabilitation recently introduced, we aimed to conduct a survey in one state of Australia to assess the extent to which programs adhere to the measurement of QIs comparing country, metropolitan, telephone and face to face programs.

Methods

A cross- sectional survey design with face validity testing was used to formulate questions to evaluate cardiac rehabilitation program and personnel characteristics and QI adherence. Between October 2020- December 2021, 23 cardiac rehabilitation programs across country and metropolitan areas were invited to participate. Quality improvement was defined as adherence to the Australian Quality Indicators, and we developed an objective score to calculate program performance categorised by quartiles. Significance of CR completion and time to enrolment between program type (telephone versus face to face) and location (country versus metropolitan were compared using Pearson’s Chi-square and Mann–Whitney U tests.

Results

Among the 23 CR programs, 15 were country and 8 metropolitan-based and 22 were face to face and 1 telephone-based. Median wait time from discharge was 27.0 days, (interquartile range 19.3–46.0) across all programs and country completions of enrolled were 76.9% versus metropolitan 56.5%, p < 0.001 and telephone versus face to face 92.9% versus 59.6% p < 0.001. Pre-program QI adherence was higher than post program for depression, medication adherence, health-related quality of life and comprehensive re-assessment. Seventy four percent of programs were ranked at a medium level of performance (mean score: 11.4/16, SD ± 0.79).

Conclusions

A survey of 23 cardiac rehabilitation programs, showed variability in adherence to measurement of the Australian Cardiovascular and Rehabilitation Association and Australian Heart Foundation Cardiac Rehabilitation Quality Indicators.

Trial registration

Australia New Zealand Clinical Trials Registry (ANZCTR), ACTRN12621000222842, registered 03/03/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07667-2.

Regional Differences in the Ratio of Observed and Expected In-hospital Mortality for Acute Coronary Syndrome Patients in China: The Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project Analysis

Previous studies reported regional variations in in-hospital acute coronary syndrome (ACS) mortality, but the reasons for that were not clearly defined. We explored whether differences in patient characteristics could explain regional variation. The Improving Care for Cardiovascular Disease in China (CCC)-ACS project is an ongoing national registry and quality improvement project, involving 150 tertiary hospitals from 30 provinces across China. We applied a prediction model that included patient-specific variables to calculate the expected in-hospital mortality. For each province, we reported the observed, expected in-hospital mortality and the risk-adjusted ratio which is based on the observed divided by the expected mortality. From 2014 to 2018, 79 585 ACS patients were enrolled. The average in-hospital mortality was 1.8%. There was a wide variation in the in-hospital mortality among different provinces (0.2-3.9%). Patient characteristics explained part of this variation because of differences in the expected in-hospital mortality (0.7-2.8%). There was a substantial variation in the risk-adjusted ratio among provinces (0.2-3.5), which suggests that the variations in the mortality cannot be completely explained by the differences in patient characteristics. In conclusion, we observed a wide regional variation in mortality for ACS, part of which could be explained by the difference in patient characteristics.

Estimating the economic impacts of percutaneous coronary intervention in Australia: a registry-based cost burden study

OBJECTIVES

In this study, we sought to evaluate the costs of percutaneous coronary intervention (PCI) across a variety of indications in Victoria, Australia, using a direct per-person approach, as well as to identify key cost drivers.

DESIGN

A cost-burden study of PCI in Victoria was conducted from the Australian healthcare system perspective.

SETTING

A linked dataset of patients admitted to public hospitals for PCI in Victoria was drawn from the Victorian Cardiac Outcomes Registry (VCOR) and the Victorian Admitted Episodes Dataset. Generalised linear regression modelling was used to evaluate key cost drivers. From 2014 to 2017, 20 345 consecutive PCIs undertaken in Victorian public hospitals were captured in VCOR.

PRIMARY OUTCOME MEASURES

Direct healthcare costs attributed to PCI, estimated using a casemix funding method.

RESULTS

Key cost drivers identified in the cost model included procedural complexity, patient length of stay and vascular access site. Although the total procedural cost increased from $A55 569 740 in 2014 to $A72 179 656 in 2017, mean procedural costs remained stable over time ($A12 521 in 2014 to $A12 185 in 2017) after adjustment for confounding factors. Mean procedural costs were also stable across patient indications for PCI ($A9872 for unstable angina to $A15 930 for ST-elevation myocardial infarction) after adjustment for confounding factors.

CONCLUSIONS

The overall cost burden attributed to PCIs in Victoria is rising over time. However, despite increasing procedural complexity, mean procedural costs remained stable over time which may be, in part, attributed to changes in clinical practice.

Not All STEMI Patients Receive Timely Reperfusion: Considerations for Rural Emergency Departments

Early reperfusion for ST-elevation myocardial infarction (STEMI) is well known to improve patient outcomes. A review of patient records in one rural health service in New South Wales, Australia, suggested that not all STEMI patients were receiving timely reperfusion. Consequently, the aim of this study was to further investigate factors influencing clinical decision making by primary care providers in relation to rural STEMI patients. This cross-sectional observational study was in two phases, a retrospective audit of patient records and a survey of rural general practitioners (GPs). In the first phase, patients with STEMI who were referred from small rural hospitals to a regional hospital emergency department (ED) were identified through the local health district database. In phase two, information from the database informed questions for a survey distributed to the GP visiting medical officers (VMOs) at small rural hospitals in the region. The survey was designed to ascertain factors that may contribute to delays in the care of STEMI patients. Of the STEMI patients identified (n = 139), 15% (21) who were eligible for medical reperfusion were not administered thrombolysis within 4 hours of triage. Auditing of this group's records found that ECGs were inaccurately interpreted for 76% of the missed STEMI patients. In the survey, about 55% of the GP respondents said they “very much agree” with the statement that they felt competent in STEMI management. Only 64% of the GP VMOs agreed they felt competent in diagnosis and management of a failed thrombolysis and not all respondents were aware of the relevant clinical guideline. Patients with missed STEMI are at higher risk of morbidity and mortality and increased length of stay, adding burden to the patient, carer and health service. Without addressing gaps in service provision and better adherence to clinical guidelines, unacceptable delays in STEMI management in rural health services are likely to continue.

Assessment Framework for Recognizing Clinical Deterioration in Patients With ACS Undergoing PCI

TOPIC

Patients with acute coronary syndrome undergoing primary percutaneous coronary intervention are at risk of clinical deterioration that results in similar general signs and symptoms regardless of its cause. However, specific causes and forms of clinical deterioration are associated with key differences in assessment findings. Focused clinical assessments using a modified primary survey enable nurses to rapidly identify the cause and form of clinical deterioration, facilitating targeted treatment.

CLINICAL RELEVANCE

Clinical deterioration during percutaneous coronary intervention is associated with increased mortality and morbidity. Previous studies identified nursing inconsistencies when recognizing clinical deterioration, with inconsistent collection of cues and prioritization of cues related to cardiac performance over more sensitive indicators of clinical deterioration.

PURPOSE OF PAPER

To describe a framework to help nurses optimize physiological cue collection to improve recognition of clinical deterioration during periprocedural care of patients undergoing percutaneous coronary intervention for unstable acute coronary syndrome.

CONTENT COVERED

Literature analysis revealed 7 forms of clinical deterioration in patients undergoing percutaneous coronary intervention: coronary artery occlusion, stroke, ventricular rupture, valvular insufficiency, lethal cardiac arrhythmias, access-site and non-access-site bleeding, and anaphylaxis. Evidence for the pathophysiology, incidence, severity, and clinical features of each form of clinical deterioration is identified. A framework is proposed to help nurses conduct highly focused patient assessments, enabling prompt recognition of and response to the specific forms of clinical deterioration that occur in patients undergoing percutaneous coronary intervention.

SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes: a randomized controlled trial

BACKGROUND

There are well-documented treatment gaps in secondary prevention of coronary heart disease with a lack of clearly defined strategies to assist early physical activity after acute coronary syndromes (ACS). Smartphone technology may provide an innovative platform to close these gaps.

OBJECTIVES

The primary goal of this study was to assess whether a smartphone-based, early cardiac rehabilitation program improved exercise capacity in patients with ACS.

METHODS

A total of 206 patients with ACS across six tertiary Australian hospitals were included in this randomized controlled trial. Participants were randomized to usual care (UC; including referral to traditional cardiac rehabilitation), with or without an adjunctive smartphone-based cardiac rehabilitation program (S-CRP) upon hospital discharge. The primary endpoint was change in exercise capacity, measured by the change in 6-minute walk test distance at 8 weeks when compared to baseline, between groups. Secondary endpoints included uptake and adherence to cardiac rehabilitation, changes in cardiac risk factors, psychological well-being and quality of life status.

RESULTS

Of the 168 patients with complete follow-up (age 56 ± 10 years; 16% females), 83 were in the S-CRP. At 8-week follow-up, the S-CRP group had a clinically significant improvement in 6-minute walk test distance (Δ117 ± 76 vs. Δ91 ± 110 m; P = 0.02). Patients in the S-CRP were more likely to participate (87% vs. 51%, P < 0.001) and adhere (72% vs. 22%, P < 0.001) to a cardiac rehabilitation program. Compared to UC, patients receiving S-CRP had similar smoking cessation rates, LDL-cholesterol levels, blood pressure reduction, depression, anxiety and quality of life measures (all P = NS).

CONCLUSION

In patients with ACS, a S-CRP, as an adjunct to UC improved exercise capacity at 8 weeks in addition to participation and adherence to cardiac rehabilitation (Australian New Zealand Clinical Trials Registry; ACTRN12616000426482).

Long term survival after acute myocardial infarction in Australia and New Zealand, 2009-2015: a population cohort study

OBJECTIVE

To assess long term survival and patient characteristics associated with survival following acute myocardial infarction (AMI) in Australia and New Zealand.

DESIGN

Cohort study.

SETTING, PARTICIPANTS

All patients admitted with AMI (ICD-10-AM codes I21.0-I21.4) to all public and most private hospitals in Australia and New Zealand during 2009-2015.

MAIN OUTCOME MEASURE

All-cause mortality up to seven years after an AMI.

RESULTS

239 402 initial admissions with AMI were identified; the mean age of the patients was 69.3 years (SD, 14.3 years), 154 287 were men (64.5%), and 64 335 had ST-elevation myocardial infarction (STEMI; 26.9%). 7-year survival after AMI was 62.3% (STEMI, 70.8%; non-ST-elevation myocardial infarction [NSTEMI], 59.2%); survival exceeded 85% for people under 65 years of age, but was 17.4% for those aged 85 years or more. 120 155 patients (50.2%) underwent revascularisation (STEMI, 72.2%; NSTEMI, 42.1%); 7-year survival exceeded 80% for patients in each group who underwent revascularisation, and was lower than 45% for those who did not. Being older (85 years or older v 18-54 years: adjusted hazard ratio [aHR], 10.6; 95% CI, 10.1-11.1) or a woman (aHR, 1.15; 95% CI, 1.13-1.17) were each associated with greater long term mortality during the study period, as was prior heart failure (aHR, 1.79; 95% CI, 1.76-1.83). Several non-cardiac conditions and geriatric syndromes common in these patients were independently associated with lower long term survival, including major and metastatic cancer, cirrhosis and end-stage liver disease, and dementia.

CONCLUSION

AMI care in Australia and New Zealand is associated with high rates of long term survival; 7-year rates exceed 80% for patients under 65 years of age and for those who undergo revascularisation. Efforts to further improve survival should target patients with NSTEMI, who are often older and have several comorbid conditions, for whom revascularisation rates are low and survival after AMI poor.

Factors that influence whether patients with acute coronary syndromes undergo cardiac catheterisation

OBJECTIVE

To determine whether the availability of invasive coronary angiography at the hospital of presentation influences catheterisation rates for patients with acute coronary syndrome (ACS), and whether presenting to a catheterisation-capable hospital is associated with better outcomes for patients with ACS.

DESIGN, SETTING

Retrospective cohort study; analysis of Cooperative National Registry of Acute Coronary Events (CONCORDANCE) data.

SETTING, PARTICIPANTS

Adults admitted with ACS to 43 Australian hospitals (including 31 catheterisation-capable hospitals), February 2009 - October 2018.

MAIN OUTCOME MEASURES

Major adverse cardiovascular events (myocardial infarction, stroke, congestive heart failure, cardiogenic shock, cardiovascular death) and all-cause deaths in hospital and by six and 12- or 24-month follow-up.

RESULTS

The proportion of women among the 5637 patients who presented to catheterisation-capable hospitals was smaller than for the 2608 patients who presented to hospitals without catheterisation facilities (28% v 33%); the proportion of patients diagnosed with ST elevation myocardial infarction was larger (32% v 20%). The proportions of patients who underwent catheterisation (81% v 70%) or percutaneous coronary intervention (49% v 35%) were larger for those who presented to catheterisation-capable hospitals. The baseline characteristics of patients who underwent catheterisation were similar for both presentation hospital categories, as were rates of major adverse cardiovascular events and all-cause death in hospital and by 6- and 12- or 24-month follow-up.

CONCLUSIONS

Although a larger proportion of patients who presented to catheterisation-capable hospitals underwent catheterisation, patients with similar characteristics were selected for the procedure, independent of the hospital of presentation. Major outcomes for patients were also similar, suggesting equitable management of patients with ACS across Australia.

The design and evaluation of a pre-procedure checklist specific to the cardiac catheterisation laboratory

BACKGROUND

With the increasing complexity of procedures being performed in the cardiac catheterisation laboratory, the multidisciplinary team has the challenge of providing safe care to patients who present with a multitude of healthcare needs. Although the use of a surgical safety checklist has become standard practice in operating theatres worldwide, the use of a pre-procedure checklist has not been routinely adopted into interventional cardiology.

OBJECTIVE

The aim of this study was to design and evaluate a pre-procedure checklist specific to the cardiac catheterisation laboratory.

METHOD

A descriptive, exploratory design was used to develop a specifically designed pre-procedure checklist for use in the cardiac catheterisation laboratory in a private hospital in Melbourne, Australia. The pre-procedure checklist was developed by exploring the multidisciplinary team's opinion regarding the organisation's previous surgical pre-procedure checklist through a pre-implementation survey and focus groups. Following an expert review, and implementation of the proposed pre-procedure checklist, a post-implementation survey was completed.

RESULTS

Thirty-five (70%) cardiac catheterisation laboratory healthcare professionals completed the pre-implementation survey, with 31 (62%) completing the post-implementation survey. Ninety-one per cent of participants agreed that important clinical information required for interventional procedures was not documented on the previous surgical checklist. A specific checklist was developed from the results of the survey and six focus groups (N = 25) and implemented in the cardiac catheterisation laboratory. In the post-implementation survey, participants identified that the cardiac catheterisation laboratory specific pre-procedure checklist included all relevant clinical information and improved documentation of patient information.

CONCLUSION

The development of a specific cardiac catheterisation laboratory pre-procedure checklist has led to an improved transfer of pertinent clinical information required prior to procedures being performed in the unit. The outcome of this study has implications for other cardiac catheterisation laboratories with the potential to standardise practice within interventional cardiology practice and improve patient safety outcomes.

Rates and Patterns of First-Time Admissions for Acute Coronary Syndromes across Western Australia Using Linked Administrative Health Data 2007-2015

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.

A Smartphone App for Patients With Acute Coronary Syndrome (MoTER-ACS): User-Centered Design Approach

BACKGROUND

Postdischarge interventions are limited for patients with acute coronary syndrome (ACS) due to few scheduled visits to outpatient clinics and the need to travel from remote areas. Smartphones have become viable lifestyle technology to deliver home-based educational and health interventions.

OBJECTIVE

The aim of this study was to develop a smartphone-based intervention for providing postdischarge support to patients with ACS.

METHODS

The content of Mobile Technology-Enabled Rehabilitation for Patients with ACS (MoTER-ACS) was derived from a series of small studies, termed prestudy surveys, conducted in 2017. The prestudy surveys were conducted in Prince Charles Hospital, Queensland, Australia, and consisted of questionnaires among a convenience sample of patients with ACS (n=30), a focus group discussion with health care professionals (n=10), and an online survey among cardiologists (n=15). Responses from the patient survey identified educational topics of MoTER-ACS. The focus group with health care professionals assisted with identifying educational materials, health monitoring, and self-management interventions. Based on the results of the cardiologists' survey, monitoring of symptoms related to heart failure exacerbation was considered as a weekly diary.

RESULTS

The MoTER-ACS app covers multimedia educational materials to adopt a healthy lifestyle and includes user-friendly tools to monitor physiological and health parameters such as blood pressure, weight, and pain, assisting patients in self-managing their condition. A web portal that is linked to the data from the smartphone app is available to clinicians to regularly access patients' data and provide support.

CONCLUSIONS

The MoTER-ACS platform extends the capabilities of previous mobile health platforms by providing a home-based educational and self-management intervention for patients with ACS following discharge from the hospital. The MoTER-ACS intervention narrows the gap between existing hospital-based programs and home-based interventions by complementing the postdischarge program for patients with ACS.

Rural and Remote Cardiology During the COVID-19 Pandemic: Cardiac Society of Australia and New Zealand (CSANZ) Consensus Statement

THE CHALLENGES

Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors. The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations, and people with known CVD have increased morbidity and mortality from coronavirus disease 2019 (COVID-19). In addition, COVID-19 is associated with serious cardiac manifestations, potentially placing additional demand on limited regional services at a time of diminished visiting metropolitan support with restricted travel. Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity. Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic.

MAIN RECOMMENDATIONS

Health districts, cardiologists and government agencies need to minimise impacts on the already vulnerable cardiovascular health of regional and remote Australians and New Zealanders throughout the COVID-19 pandemic. Changes in management should include.

Efficacy of Smartphone-Based Secondary Preventive Strategies in Coronary Artery Disease

Background:

Cardiac rehabilitation programs provide a comprehensive framework for the institution of secondary preventive measures. Smartphone technology can provide a platform for the delivery of such programs and is a promising alternative to hospital-based services. However, there is limited evidence to date supporting this approach. Accordingly, we performed a systematic review and meta-analysis examining smartphone-based secondary prevention programs to traditional cardiac rehabilitation in patients with established coronary artery disease to ascertain the feasibility and effectiveness of these interventions.

Methods:

A systematic search of PubMed, MEDLINE, EMBASE, and the Cochrane Library was conducted. A meta-analysis was performed using a random-effects model with the outcomes of interest being 6-minute walk test (6MWT) distance, systolic blood pressure, low-density lipoprotein (LDL) cholesterol, and body mass index (BMI).

Results:

A total of 8 studies with 1120 patients across 5 countries were included in the quantitative analysis. Follow-up ranged from 6 weeks to 12 months. Five studies examined all patients post acute coronary syndrome, 2 studies examined only patients undergoing percutaneous coronary intervention, and 1 study examined all patients with a diagnosis of coronary artery disease, independent of intervention. Exercise capacity, as measured by the 6MWT, was significantly greater in the smartphone group (20.10 meters, 95% confidence interval [CI] 7.44-33.97; P < .001; I² = 45.58). There was no significant difference in BMI reduction, systolic blood pressure, or LDL cholesterol levels between groups (P value for all > .05).

Conclusion:

Publicly available smartphone-based cardiac rehabilitation programs are a convenient and easily disseminated intervention which show merit in exercise promotion in patients with established coronary artery disease. Further research is required to establish the clinical significance of recent findings favoring their use.

Sex-Specific Differences in Percutaneous Coronary Intervention Outcomes After a Cardiac Event: A Cohort Study Examining the Role of Depression, Worry and Autonomic Function

BACKGROUND

To determine whether differential all-cause hospital readmission exists for men and women 2 years after percutaneous coronary intervention (PCI) treatment for acute coronary syndrome (ACS), and to identify potential autonomic and psychological pathways contributing to this association.

METHODS

Four hundred and sixteen (416) patients admitted with ACS were recruited from coronary care wards. Participants attended the study centre at one (T0) and 12 (T1) months following discharge. Heart rate variability (HRV) was used to assess autonomic functioning measured via a three-lead electrocardiogram. Psychological variables of interest (pathological worry, depression and phobic anxiety) were measured using validated self-report questionnaires. Percutaneous coronary intervention treatment data were collected from hospital records. The primary outcome was 2-year all-cause hospital readmission (yes/no). Logistic regression modelling using both complete case analysis and multiple imputation analysis was applied.

RESULTS

Men who received PCI had a significant reduction in the odds of being rehospitalised over the following 2 years, relative to women who did not (OR=0.45, 95% CI=0.20, 0.98). No other group benefited to this extent. Adjustment for age, ACS severity and Very Low Frequency (VLF) Power appeared to strengthen the association in both the complete case analysis and multiple imputation analysis models. The inclusion of depression and worry also marginally explained these associations in the multiple imputation analysis model.

CONCLUSIONS

Men who receive PCI after ACS were less likely to be readmitted to hospital over the following 2 years than their female counterparts. The small sample size of women and observational study design limit interpretation of the findings. However, heart rate variability, specifically VLF power, requires further investigation as a driver of such sex-specific outcomes.

Cardiac procedures in ST-segment-elevation myocardial infarction - the influence of age, geography and Aboriginality

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.

Challenges in Managing Acute Cardiovascular Diseases and Follow Up Care in Rural Areas: A Narrative Review

This narrative review explores relevant literature that is related to the challenges in implementing evidence-based management for clinicians in rural and remote areas, while primarily focussing on management of acute coronary syndrome (ACS) and follow up care. A targeted literature search around rural/urban differences in the management of ACS, cardiovascular disease, and cardiac rehabilitation identified multiple issues that are related to access, including the ability to pay, transport and geographic distances, delays in patients seeking care, access to diagnostic testing, and timely treatment in an appropriate facility. Workforce shortages or lack of ready access to relevant expertise, cultural differences, and complexity that arises from comorbidities and from geographical isolation amplified diagnostic challenges. Given the urgency in management of ACS, rural clinicians must act quickly to achieve optimal patient outcomes. New technologies and quality improvement approaches enable better access to rapid diagnosis, as well as specialist input and care. Achieving an uptake of cardiac rehabilitation in rural and remote settings poses challenges that may reduce with the use of alternative models to centre-based rehabilitation and use of modern technologies. Expediting improvement in cardiovascular outcomes and reducing rural disparities requires system changes and that clinicians embrace attention to prevention, emergency management, and follow up care in rural contexts.

Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction: Understanding and addressing the global risk-treatment paradox

Clinical guidelines for the treatment of patients with non-ST-segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long-term mortality risk than patients with ST-segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the "treatment-risk paradox"). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four "P" factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long-term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.

A comparison of cardiac troponin T delta change methods and the importance of the clinical context in the assessment of acute coronary syndrome

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.

Contemporary invasive management and in-hospital outcomes of patients with non-ST-segment elevation myocardial infarction in China: Findings from China Acute Myocardial Infarction (CAMI) Registry

BACKGROUND

Few studies have investigated the use of invasive strategy for patients with non-ST-segment elevation myocardial infarction (NSTEMI) in China. We aimed to describe the contemporary pattern of management, medically and invasively, in patients with NSTEMI across China.

METHODS

Using data of China Acute Myocardial Infarction Registry, we analyzed the baseline characteristics, in-hospital medication, index coronary angiography (CAG) and revascularization by stratification of gender, age, and risk assessment. Primary outcomes included in-hospital major adverse cardio-cerebral events (MACCE, a composite of all-cause death, myocardial (re)infarction, and stroke) and length of stay (LOS).

RESULTS

A total of 10,266 NSTEMI patients were enrolled between January 2013 and November 2016. Dual antiplatelet therapy and statins were prescribed in 92.9% and 92.1% of overall patients respectively. CAG was performed in 45.6% of these patients, and 40.9% had an index revascularization. Female, older or higher risk patients were less likely to receive CAG or revascularization. The rates of CAG were 67.9% in the provincial-level, 46.2% in the prefectural, and 12.1% in the county-level hospitals. Of those patients undergoing revascularization, 77.0% (1,156/1,501) very-high-risk patients received urgent revascularization and 16.2% (440/2,699) high-risk patients underwent early revascularization as recommended. The overall in-hospital MACCE was 6.7%, and the median LOS was 10 (6) days. Revascularization was associated with reduction for in-hospital MACCE regardless of risk and age.

CONCLUSION

Invasive management was underused and profoundly deferred among patients with NSTEMI in China. The risk-treatment paradox, procedure deferral and medical resources distribution imbalance may represent opportunities for improvement.

Can Older Adults Benefit from Smart Devices, Wearables, and Other Digital Health Options to Enhance Cardiac Rehabilitation?

Cardiovascular disease (CVD) is the leading cause of death and disease burden globally. Improving reach, access, and effectiveness of postdischarge care through cardiac rehabilitation and secondary prevention strategies is an international priority. The current proliferation of mobile technology has resulted in widespread development and availability of digital health interventions that can reduce cardiovascular risk. Text-messaging programs and apps have been shown to improve health outcomes. Other areas of research investigating the use of wearable devices are still emerging but lack robust data. Mobile and smartphone ownership is increasing among older populations, and digital health is not limited by age.

Ad libitum Mediterranean diet reduces subcutaneous but not visceral fat in patients with coronary heart disease: A randomised controlled pilot study

BACKGROUND & AIMS

The Mediterranean diet (MedDiet) is recognised to reduce risk of coronary heart disease (CHD), in part, via its anti-inflammatory and antioxidant properties, which may be mediated via effects on body fat distribution. Diet efficacy via these mechanisms is however unclear in patients with diagnosed CHD. This study aimed to determine: (1) the effect of ad libitum MedDiet versus low-fat diet intervention on adiposity, anti-inflammatory marker adiponectin, oxidative stress marker malondialdehyde (MDA) and traditional CVD risk markers, and (2) whether improvement in MedDiet adherence score in the pooled cohort was associated with these risk markers, in a pilot cohort of Australian patients post coronary event.

METHODS

Participants (62 ± 9 years, 83% male) were randomised to 6-month ad libitum MedDiet (n = 34) or low-fat diet (n = 31). Pre- and post-intervention, dietary adherence, anthropometry, body composition (Dual-energy X-ray Absorptiometry) and venepuncture measures were conducted.

RESULTS

The MedDiet group reduced subcutaneous adipose tissue (SAT) area compared to the low-fat diet group (12.5 cm² more, p = 0.04) but not visceral adipose tissue or other body composition measures. In the pooled cohort, participants with greatest improvement in MedDiet adherence score had significantly lower waist circumference (-2.81 cm, p = 0.01) and SAT area (-27.1 cm², p = 0.04) compared to participants with no improvement in score at 6-months. There were no changes in adiponectin, MDA or other risk markers in the MedDiet compared to low-fat diet group, and no differences in 6-month levels between categories of improvement in MedDiet score (p > 0.05). Within the MedDiet group only, the proportion of participants taking beta-blocker medication reduced from baseline to 6-months (71% vs. 56%, p-trend = 0.007).

CONCLUSIONS

Adherence to 6-month ad libitum MedDiet reduced subcutaneous fat and waist circumference which discounts the misconception that this healthy but high fat diet leads to body fat gain. The effect of MedDiet on body fat distribution and consequent anti-inflammatory and antioxidant effects, as well as need for medications, in patients with CHD warrants exploration in larger studies. Clinically significant effects on these markers may require adjunct exercise and/or caloric restriction.

TRIAL REGISTRATION

ACTRN12616000156482.

The Keeping on Track Study: Exploring the Activity Levels and Utilization of Healthcare Services of Acute Coronary Syndrome (ACS) Patients in the First 30-Days after Discharge from Hospital

The aim of this study was to investigate the impact of bedside discharge education on activity levels and healthcare utilization for patients with acute coronary syndrome (ACS) in the first 30 days post-discharge. Knowledge recall and objective activity and location data were collected by global positioning systems (GPS). Participants were asked to carry the tracking applications (apps) for 30–90 days. Eighteen participants were recruited (6 metropolitan 12 rural) 61% ST elevation myocardial infarction (STEMI), mean age 55 years, 83% male. Recall of discharge education included knowledge of diagnosis (recall = 100%), procedures (e.g., angiogram = 40%), and comorbidities (e.g., hypertension = 60%, diabetes = 100%). In the first 30 days post-discharge, median steps per day was 2506 (standard deviation (SD) ± 369) steps (one participant completed 10,000 steps), 62% visited a general practitioner (GP) 16% attended cardiac rehabilitation, 16% visited a cardiologist, 72% a pharmacist, 27% visited the emergency department for cardiac event, and 61% a pathology service (blood tests). Adherence to using the activity tracking apps was 87%. Managing Big Data from the GPS and physical activity tracking apps was a challenge with over 300,000 lines of raw data cleaned to 90,000 data points for analysis. This study was an example of the application of objective data from the real world to help understand post-ACS discharge patient activity. Rates of access to services in the first 30 days continue to be of concern.

What is the Optimal Rate of Invasive Coronary Angiography After Acute Coronary Syndrome? (ANZACS-QI 22)

BACKGROUND

Invasive coronary angiography plays a pivotal role in the management of acute coronary syndromes (ACS). Wide variability in its use has been previously documented. Our aim was to investigate whether coronary angiography is being used appropriately prior to discharge after ACS, taking into account relative contraindications of the procedure.

METHODS

Patients presenting with ACS in 2015 to two large, demographically distinct New Zealand (NZ) District Health Boards (DHBs)-Counties Manukau (CMDHB) and Waitemata (WDHB)-were identified from the NZ Ministry of Health National Dataset using ICD-10-AM codes. Patients' clinical data were obtained from the electronic and paper clinical records. Pre-defined relative contraindications to coronary angiography were identified.

RESULTS

Of the 3,809 patient admissions coded with ACS, 600 patient admissions (300 from each DHB) were reviewed. Sixty-one (61) (10%) did not meet diagnostic criteria for ACS on review of clinical data and were excluded. Of the patients reviewed, 55% received coronary angiography, with a higher rate in WDHB than CMDHB (61% and 49%, respectively) and 37.5% had relative contraindications documented. The overall rate of angiography was appropriately high in those without a relative contraindication (90.3%) and low in those with one (7.4%). There were fewer patients with relative contraindications in WDHB than CMDHB (36.7% and 48.5%) but the rate of angiography in those with (6.9% and 7.8%) and without (92.5% and 87.5%) contraindications in the two DHBs was similar.

CONCLUSIONS

The decision to offer coronary angiography after ACS appears to be appropriately influenced by the presence or absence of relative contraindications. Approximately 60% of patients had no documented relative contraindication suggesting that this may be an appropriate angiography rate in New Zealand practice. However, differences between the two DHBs of around 10% appear to be clinically appropriate due to variation in contraindication rates.

Physicians' lifestyle advice on primary and secondary cardiovascular disease prevention in Germany: A comparison between the STAAB cohort study and the German subset of EUROASPIRE IV

Background

We assessed prevalence and determinants in appropriate physician-led lifestyle advice (PLA) in a population-based sample of individuals without cardiovascular disease (CVD) compared with a sample of CVD patients.

Methods

PLA was assessed via questionnaire in a subsample of the population-based Characteristics and Course of Heart Failure Stages A-B and Determinants of Progression (STAAB) cohort free of CVD (primary prevention sample) and the German subset of the fourth EUROASPIRE survey (EUROASPIRE-IV) comprising CVD patients (secondary prevention sample). PLA was fulfilled if the participant reported having ever been told by a physician to: stop smoking (current/former smokers), reduce weight (overweight/obese participants), increase physical activity (physically inactive participants) or keep to a healthy diet (all participants). Factors associated with receiving at least 50% of the PLA were identified using logistic regression.

Results

Information on PLA was available in 665 STAAB participants (55 ± 11; 55% females) and in 536 EUROASPIRE-IV patients (67 ± 9; 18% females). Except for smoking, appropriate PLA was more frequently given in the secondary compared with the primary prevention sample. Determinants associated with appropriate PLA in primary prevention were: diabetes mellitus (odds ratio (OR) 4.54; 95% confidence interval (CI) 1.88–10.95), hyperlipidaemia (OR 3.12; 95% CI 2.06–4.73) and hypertension (OR 1.74; 95% CI 1.15–2.62); in secondary prevention: age (OR per year 0.96; 95% CI 0.93–0.98) and diabetes mellitus (OR 2.33; 95% CI 1.20–4.54).

Conclusions

In primary prevention, PLA was mainly determined by the presence of vascular risk factors, whereas in secondary prevention the level of PLA was higher in general, but the association between CVD risk factors and PLA was less pronounced.

The relationship between phobic anxiety and 2-year readmission after Acute Coronary Syndrome: What is the role of heart rate variability?

OBJECTIVE

Phobic anxiety is a risk factor for poor prognosis following Acute Coronary Syndrome (ACS). A psychophysiological marker of vagal function, autonomic dysfunction may play a critical role in this relationship. The aim of the study was two-fold: to assess whether phobic anxiety was characterised by autonomic dysfunction (heart rate variability) in the short (1-month) and longer term (12-months) following ACS, and (ii) to quantify the extent to which HRV parameters modified the effect of phobic anxiety on all-cause hospital readmission over 2 years.

METHODS

The ADVENT study followed 416 ACS patients. At 1-month following discharge (T0), phobic anxiety and autonomic functioning were assessed using the Crown Crisp Index (CCI) and 11 indices of heart rate variability (HRV), respectively. HRV was measured again at 12-months (T1) (n = 359). Hospital readmission (all cause) was derived from an audit of hospital records by two medically trained research fellows. Generalised linear modelling (GLM) was used to first determine the association between CCI score at T0 and HRV parameters at T0 and T1. Binary logistic regression was used to measure the relationship between CCI scores and readmission (yes/no) and the extent to which HRV parameters modified this effect.

RESULTS

CCI scores were associated with 7 of the 11 indices of HRV: Average RR (ms), SDRR (ms), RMSSD (ms), SDSD (ms), pRR50 (%), LF Powers (ms2) and HF Powers (ms2) at T0 but not T1. CCI scores at T0 significantly predicted likelihood of readmission to hospital in the subsequent 2 year period. No parameter of HRV at T0 modified this effect.

LIMITATIONS

We were unable to provide adjudicated major adverse coronary events outcome data, or account for changes in medication adherence, diet or physical activity.

CONCLUSIONS

While phobic anxiety is associated with both reduced vagal function in the short term after an ACS event and 2 year all cause readmission, HRV does not appear to be the pathway by which phobic anxiety drives this outcome.

Missed Acute Myocardial Infarction (MAMI) in a rural and regional setting

Background

Delay in treatment and/or failure to provide reperfusion in ST-segment elevation myocardial infarction (STEMI) impacts on morbidity and mortality. This occurs more often outside metropolitan areas yet the reasons for this are unclear. This study aimed to describe factors associated with missed diagnosis of acute myocardial infarction (MAMI) in a rural and regional setting.

Methods

Using a retrospective cohort design, patients who presented with STEMI and failed to receive reperfusion therapy within four hours were identified as MAMI. Univariate analyses were undertaken to identify differences in clinical characteristics between the treated STEMI group and the MAMI group. Mortality, 30-day readmission rates and length of hospital stay are reported.

Results

Of 100 patients identified as MAMI (70 male, 30 female), 24 died in hospital. Demographics and time from symptom onset were similar in the treated STEMI and MAMI groups. Of the MAMI patients who died, rural hospitals recorded the highest inpatient mortality (69.6% p = 0.008). MAMI patients compared to treated STEMI patients had higher 30 day readmission (31.6% vs 3.3%, p = 0.001) and longer length of stay (5.5 vs 4.3 days p = 0.029). Inaccurate identification of STEMI on electrocardiogram (72%) and diagnostic uncertainty (65%) were associated with MAMI. The Glasgow algorithm to identify STEMI was utilised on 57% of occasions, with 93% accuracy.

Conclusion

Mortality following MAMI is high particularly in smaller rural hospitals. MAMI results in increased length of stay and readmission rate. Electrocardiogram interpretation and diagnostic accuracy require improvement to determine if this improves patient outcomes.

Patients' narratives of their patient participation in the myocardial infarction pathway

AIM

To explore how patients in areas without local percutaneous coronary intervention (PCI) facilities experience patient participation in different phases of the myocardial infarction pathway.

BACKGROUND

Acute treatment of myocardial infarction often involves PCI. In Norway, this treatment is centralized at certain hospitals; thus, patients often require long-distance transportation and experience frequent hospital transfers. Short hospital stays, transfers between hospitals and the patient's emotional state pose challenges to promoting patient participation.

DESIGN

A qualitative design with a narrative approach.

METHODS

Participants were recruited through purposive sampling. Eight men and two women were interviewed in 2016.

FINDINGS

Four themes related to the patients' experiences at the beginning, middle and end of the pathway were identified: (a) Lack of verbal communication in the acute phase; (b) trust in healthcare professionals and treatment; (c) lack of participation and coordination at discharge; and (d) shared decision-making in rehabilitation. The findings showed how the patients moved from a low level of patient participation in the acute phase to a high level of patient participation in the rehabilitation phase.

CONCLUSION

This is the first study to explore patient participation in different phases of the myocardial infarction pathway. We argue that individual plans for information and patient participation are important to improve patient involvement in an earlier stage of the pathway. Further research from a healthcare professional perspective can be valuable to understand this topic.

IMPACT

This study gives new insight that can be valuable for healthcare professionals in implementing patient participation throughout the pathway.

Effect of cardiac rehabilitation on 24-month all-cause hospital readmissions: A prospective cohort study

BACKGROUND

Ageing populations and increasing survival following acute coronary syndrome has resulted in large numbers of people living with cardiovascular disease and at high risk of hospitalizations. Rising hospital admissions have a significant financial cost to the healthcare system.

AIM

The purpose of this study was to determine whether cardiac rehabilitation is protective against long-term hospital readmission (frequency and length) following acute coronary syndrome.

METHODS

Data from 416 Australian patients with acute coronary syndrome enrolled in the Anxiety Depression and heart rate Variability in cardiac patients: Evaluating the impact of Negative emotions on functioning after Twenty four months (ADVENT) prospective cohort study between January 2013-June 2014 was analyzed secondarily. Participants self-reported cardiac rehabilitation attendance over the 12 months post-discharge. All-cause readmission data were extracted from hospital records 24 months post-index event. The association between cardiac rehabilitation and all-cause readmission, frequency of readmissions, and length of stay was assessed using three methods (a) regression analysis, (b) propensity score matching, and (c) inverse probability treatment weighting.

RESULTS

Overall, 416 patients consented (53% of eligible patients), of which 414 (99.5%) survived the first 30 days post-discharge and were included in the analysis. Medical records were located for 409 participants after 24 months (98% follow-up rate). In total, 267 (65%) reported attending cardiac rehabilitation; there were 392 readmissions by 239 patients. Cardiac rehabilitation attendance was not associated with all-cause hospital readmission; however, it was associated with lower frequency of hospital admissions (odds ratio 0.53, 95% confidence interval: 0.31-0.91 p-value:0.022) and length of stay (coefficient -1.21 days, 95% confidence interval: -2.46-0.26; marginally significant p-value: 0.055) in adjusted models.

CONCLUSION

This study substantiates the long-term benefits of cardiac rehabilitation on readmissions, including length of stay, which would result in lower costs to the healthcare system.

High intensity interval training exercise as a novel protocol for cardiac rehabilitation program in ischemic Egyptian patients with mild left ventricular dysfunction

Background

Exercise-based Cardiac rehabilitation (CR) plays a major role in reducing mortality and morbidity in patients with coronary artery disease (CAD). The standard protocol is usually of moderate intensity exercise. High-intensity interval training (HIIT) consists of alternating periods of intensive aerobic exercise with periods of passive or active moderate/mild intensity recovery.

Aim

This study aimed to assess HIIT program for ischemic patients attending CR after percutaneous coronary intervention (PCI) who have mild left ventricular dysfunction and to compare its effect on the functional capacity and quality of life with standard exercise CR program.

Patients and methods

Our study included 40 patients with documented CAD, who participated in the outpatient CR program in Ain Shams University hospital (Al-Demerdash Hospital) divided into two equal groups, each included 20 patients. Group A included the patients who underwent standard cardiac rehabilitation program, while group B joined the high intensity interval training exercise protocol.

Results

Groups A and B showed significant improvement in all items of comparison; especially functional capacity, lipid profile and quality of life. Group B showed better improvements in the emotional well-being items of QOL parameters.

Conclusion

We emphasize the positive effects of exercise-based CR program on patients with CAD and mild left ventricular dysfunction after PCI. The novel high intensity cardiac training proved to be safe and at least as beneficial as the standard moderate intensity cardiac training protocols, with better quality of life improvement.

SMARTphone and social media-based Cardiac Rehabilitation and Secondary Prevention (SMART-CR/SP) for patients with coronary heart disease in China: a randomised controlled trial protocol

INTRODUCTION

The burden of cardiovascular disease (CVD) is rapidly increasing in developing countries, however access to cardiac rehabilitation and secondary prevention (CR/SP) in these countries is limited. Alternative delivery models that are low-cost and easy to access are urgently needed to address this service gap. The objective of this study is to investigate whether a smartphone and social media-based (WeChat) home CR/SP programme can facilitate risk factor monitoring and modification to improve disease self-management and health outcomes in patients with coronary heart disease (CHD), after percutaneous coronary intervention (PCI) therapy.

METHODS AND ANALYSIS

We propose a single-blind, randomised controlled trial of 300 patients post-PCI with follow-up over 12 months. The intervention group will receive a smartphone-based and WeChat-based CR/SP programme providing education and support for risk factor monitoring and modification. SMART-CR/SP incorporates core components of modern CR/SP: physical activity tracking with interactive feedback and goal setting; education modules addressing CHD understanding and self-management; remote blood pressure monitoring and strategies to improve medication adherence. Furthermore, a dedicated data portal and a CR/SP coach will facilitate individualised supervision and counselling. The control group will receive usual care but no formal CR/SP programme. The primary outcome is change in exercise capacity measured by 6 minute walk test distance. Secondary outcomes include knowledge and awareness of CHD, risk factor status, medication adherence, psychological well-being and quality of life, major cardiovascular events, re-hospitalisations and all-cause mortality. To assess the feasibility and patients' acceptance of the intervention, a process evaluation will be performed at the conclusion of the study.

ETHICS AND DISSEMINATION

Ethics approval was granted by both the Human Research Ethics Committee of Fudan University Zhongshan Hospital (HREC B2016-058) and Curtin University Human Research Ethics Office (HRE2016-0120). Results will be disseminated via peer-reviewed publications and presentations at conferences.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR-INR-16009598; Pre-results.

Management, characteristics and outcomes of patients with acute coronary syndrome in Sri Lanka

Background

Ischaemic heart disease is the leading cause of in-hospital mortality in Sri Lanka. Acute Coronary Syndrome Sri Lanka Audit Project (ACSSLAP) is the first national clinical-audit project that evaluated patient characteristics, clinical outcomes and care provided by state-sector hospitals.

Methods

ACSSLAP prospectively evaluated acute care, in-hospital care and discharge plans provided by all state-sector hospitals managing patients with ACS. Data were collected from 30 consecutive patients from each hospital during 2–4 weeks window. Local and international recommendations were used as audit standards.

Results

Data from 87/98 (88.7%) hospitals recruited 2177 patients, with 2116 confirmed as having ACS. Mean age was 61.4±11.8 years (range 20–95) and 58.7% (n=1242) were males. There were 813 (38.4%) patients with unstable angina, 695 (32.8%) with non-ST-elevation myocardial infarction (NSTEMI) and 608 (28.7%) with ST-elevation myocardial infarction (STEMI). Both STEMI (69.9%) and NSTEMI (61.4%) were more in males (P<0.001). Aspirin, clopidogrel and statins were given to over 90% in acute setting and on discharge. In STEMI, 407 (66.9%) were reperfused; 384 (63.2%) were given fibrinolytics and only 23 (3.8%) underwent primary percutaneous coronary intervention (PCI). Only 42.3 % had thrombolysis in <30 min and 62.5% had PCI in <90 min. On discharge, beta-blockers and ACE inhibitors/angiotensin II receptor blockers were given to only 50.7% and 69.2%, respectively and only 17.6% had coronary interventions planned.

Conclusions

In patients with ACS, aspirin, clopidogrel and statin use met audit standards in acute setting and on discharge. Vast majority of patients with STEMI underwent fibrinolyisis than PCI, due to limited resources. Primary PCI, planned coronary interventions and timely thrombolysis need improvement in Sri Lanka.

Understanding patients and spouses experiences of patient education following a cardiac event and eliciting attitudes and preferences towards incorporating cardiopulmonary resuscitation training: A qualitative study

AIM

The aim of this study was to gain a comprehensive perspective about the experience of patient and spousal education following an acute cardiac event. The second objective was to elicit an understanding of patient and spousal attitudes, preferences and intentions towards future cardiopulmonary resuscitation training.

BACKGROUND

Patients with cardiovascular disease require comprehensive patient and family education to ensure adequate long-term disease management. As cardiac patients are at risk of future cardiac events, including out-of-hospital cardiac arrest, providing cardiopulmonary resuscitation training to patients and family members has long been advocated.

DESIGN

We conducted a qualitative study underpinned by phenomenology and the Theory of Planned Behaviour.

METHODS

Semi-structured interviews were conducted with cardiac patients and their spouses (N = 12 patient-spouse pairs) between March 2015-April 2016 purposively sampled from a cardiology ward. Interviews were transcribed verbatim and thematic analysis undertaken.

FINDINGS

Nine male and three female patients and their spouses were recruited. Ages ranged from 47-75 years. Four strongly interrelated themes emerged: the emotional response to the event, information, control and responsibility. There was evidence of positive attitudes and intentions from the TPB towards undertaking cardiopulmonary resuscitation training in the future. Only the eldest patient spouse pair were not interested in undertaking training.

CONCLUSIONS

Findings suggest cardiac patients and spouses have unmet education needs following an acute cardiac event. Information increased control and decreased negative emotions associated with diagnosis. Participants' preferences were for inclusion of cardiopulmonary resuscitation training in cardiac rehabilitation programs.

TEXT messages to improve MEDication adherence and Secondary prevention (TEXTMEDS) after acute coronary syndrome: a randomised clinical trial protocol

BACKGROUND

Identifying simple, low-cost and scalable means of supporting lifestyle change and medication adherence for patients following a cardiovascular (CV) event is important.

OBJECTIVE

The TEXTMEDS (TEXT messages to improve MEDication adherence and Secondary prevention) study aims to investigate whether a cardiac education and support programme sent via mobile phone text message improves medication adherence and risk factor levels in patients following an acute coronary syndrome (ACS).

STUDY DESIGN

A single-blind, multicentre, randomised clinical trial of 1400 patients after an ACS with 12 months follow-up. The intervention group will receive multiple weekly text messages that provide information, motivation, support to adhere to medications, quit smoking (if relevant) and recommendations for healthy diet and exercise. The primary endpoint is the percentage of patients who are adherent to cardioprotective medications and the key secondary outcomes are mean systolic blood pressure (BP) and low-density lipoprotein cholesterol. Secondary outcomes will also include total cholesterol, mean diastolic BP, the percentage of participants who are adherent to each cardioprotective medication class, the percentage of participants who achieve target levels of CV risk factors, major vascular events, hospital readmissions and all-cause mortality. The study will be augmented by formal economic and process evaluations to assess acceptability, utility and cost-effectiveness.

SUMMARY

The study will provide multicentre randomised trial evidence of the effects of a text message-based programme on cardioprotective medication adherence and levels of CV risk factors.

ETHICS AND DISSEMINATION

Primary ethics approval was received from Western Sydney Local Health District Human Research Ethics Committee (HREC2012/12/4.1 (3648) AU RED HREC/13/WMEAD/15). Results will be disseminated via peer-reviewed publications and presentations at international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12613000793718; Pre-results.