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

Background Cardiovascular disease is the leading cause of disease burden globally. With advancements in medical and surgical care more people are surviving initial acute coronary syndrome (ACS) and are in need of secondary prevention and cardiac rehabilitation (CR). Increasing availability of high quality individual-level data linkage provides robust estimates of outcomes long-term. Purpose To compare 3 year outcomes amongst ACS survivors who did and did not participate in Australian CR programs. Methods SNAPSHOT ACS follow-up study included 1806 patients admitted to 232 hospitals who were followed-up by data linkage (cross-jurisdictional morbidity, national death index, Pharmaceutical Benefit Schedule) at 6 and 36 months to compare those who did/not attend CR. Results In total, the cohort had a mean age of 65.8 (13.4) years, 60% were male, only 25% (461/1806) attended CR. During index admission, attendees were more likely to have had PCI (39% v 14%, p Conclusions Amongst Australian ACS survivors, participation in CR was associated with less likelihood of death and increased prescription of pharmacotherapy. However, attendance at CR was associated with higher rates of repeat ACS and revascularisation. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): New South Wales Cardiovascular Research Network, National Heart Foundation

Background In emergency departments (EDs), assessment of patients with suspected acute coronary syndromes (ACS) represents a major workload and high sensitivity troponin (HsTn) T and I levels are frequently measured. A minority of patients have final diagnosis of myocardial infarction (MI). Methods and results Among 2738 consecutive patients with suspected ACS presenting to ED at Liverpool Hospital, Australia, between March and June 2014, we determined the relative frequencies of 3 patient groups: type-I MI, type-II MI including chronic myocardial injury (CMI), and assessed the use of invasive and pharmacological therapies and 4-year outcomes. Adjudication of MI was according to the 4th universal definition of MI as follows: 1) type-I MI; 2) type-II MI (including acute myocardial injury), and 3) CMI. Of 995 patients (36%) median age 76 years [IQR 65–83]), with at least 2 HsTnT measurements and one >14ng/l, 727 (73%) had chronic myocardial injury, 171 (17%) had type-II MI; and 97 (9.7%) had type-I MI. Patients with type-I MI (mean age 63 years) were younger than those with type-II MI or chronic myocardial injury by 12 and 14 years respectively. The main triggering factors for type-II MI/acute injury included: sepsis (21.1%), acute heart failure (18.3%), tachyarrhythmia (16.9%), anaemia (8.6%) and a combination of factors (16%). In-hospital angiography (62% had PCI) rates were 95% for patients with type-I MI, 24% (7% PCI) for those with type-II MI and 3.4% for CMI. Mortality at 4 years was 55% for type-II MI, 44% for CMI and 18% for type-1 MI (P Conclusion Among unselected patients undergoing HsTnT testing in EDs, type-II MI including acute myocardial injury was more common than type-I MI. Chronic myocardial injury, which occurred in 3 of 4 patients. While patients with type-II MI acute myocardial injury had higher late mortality rates than type-I MI, though after multivariable analyses mortality rates were not different.

Introduction Despite guidelines recommending referral to cardiac rehabilitation (CR), attendance remains poor. Literature cites a complexity of clinical, psychological and social factors as barriers to CR attendance and, females may attend less than males. Social factors including work commitments, may influence attendance, with many Australian CR programs offered during office hours, making access difficult. The Australian retirement age for females and males differs; (females >60 years and males >65 years). We hypothesised that working-age may influence attendance to CR. Purpose In a CR-referred population this study sought to compare working-age of males and females and the association with CR attendance. Methods Data from 24 country and metropolitan CR services between 2013 and 2015 were linked to 49,909 CR-eligible patients defined as, discharged alive with a primary cardiac-related diagnosis and/or interventional procedure, identified through public hospital administrative data (Figure). Only CR-referred patients were included, with males and females categorised by three age groups: 65 years, comparing attendance in univariate analysis. Adjustment for clinical and psychological (International Classification of Disease-10 Australian Modification mental health diagnostic-related group diagnoses) factors were conducted using multi-logistic regression. Results Between 2013–2015, 15,089 patients were referred to CR with 4,819 65 years. Of referrals a total of 4,286 (28.4%) attended CR, 1134 (35%) of whom were female. Univariate analysis observed total attendance by age group ranged between 26–32%, with females less likely to attend than males (65 years; 23.2% v 23.6%, p Conclusion In an Australian cohort, working-age observed no influence on cardiac rehabilitation program attendance, with the period of female retirement age observing a 19% reduction in attendance. Further research on the complexity of factors that may be barriers to attendance is essential to evaluate how to improve cardiac rehabilitation programs to better suit the needs of our cardiac patients. Acknowledgement/Funding Flinders University partnership grant and South Australian Department of Health Local Health Networks

Background/Introduction Administrative data incorporating the International Classification of Diseases 10th Revision (ICD-10) is commonly used in cardiac research. Using patient records, diagnoses are systematically coded by trained coders who have limited/no clinical experience. Therefore, it is important to understand how systematically coded cardiac diagnoses compare with clinically assessed diagnoses to better analyse and interpret studies that have used linked administrative data to adjudicate patient's diagnosis. Purpose To assess the agreement between the acute coronary syndrome (ACS) diagnoses according to linked data compared to those extracted from hospital medical records by clinicians participating in a national registry and determine the factors associated with diagnoses disagreement. Methods The rate of ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) and unstable angina (UA) obtained from the medical records, from admission to discharge, for the nationwide SNAPSHOT ACS audit in 2012 were compared to the corresponding ICD-10 Australian Modification (ICD-10-AM) codes using linked data from 6 jurisdictions covering all Australian states (6) and territories (2). The proportions of the overall agreement (OA), the positive agreement (PA) and the Cohen's weighted kappa and the 95% confidence interval (CI) were derived using both data sources for STEMI, NSTEMI and UA individually, where kappa≥0.8 confers strong agreement and 0.6≤kappa Results Overall, 3130 patients had both medical records and linked data available for comparison. The degree of agreement was greatest for STEMI and lowest for UA (STEMI: OA=97%, PA=85%, kappa (95% CI)=0.84 (0.81, 0.87); NSTEMI: OA=91%, PA=81%, kappa (95% CI)=0.76 (0.73,0.79); UA: OA = 81%, PA=53%, kappa (95% CI)=0.41 (0.38, 0.45)). Further, the independent factors associated with the disagreement between the medical records and the linked data were the diagnosis of UA (UA vs. STEMI (odds ratio (95% CI)): 6.85 (4.12, 11.40)), not receiving revascularisation (2.27 (1.69, 3.03)), and the state where the ICD-10-AM was coded (p=0.007) (see Figure). Figure 1 Conclusion This study suggests that the agreement between the systematically coded diagnoses from linked administrative data and the diagnosis from the clinical assessment is greater in patients who received revascularisation and worse in those with UA. Also, the degree of agreement varies between states. As the linked data and the ICD codes are being used more often in research to support the evidence-based policies and practice, more attention is needed in testing and improving the accuracy of the ICD-10 codes as well as the ICD-11 codes that are soon to be introduced. Acknowledgement/Funding KH is funded by Heart Foundation Postdoctoral Fellowship. SNAPSHOT data linkage project was funded by the NSW Heart Foundation CVRN Project Grant

Aims Thromboembolic risk stratification schemes and clinical guidelines for atrial fibrillation (AF) regard risk as independent of classification into paroxysmal (PAF) and non-paroxysmal atrial fibrillation (NPAF). The aim of the current study was to conduct a systematic review evaluating the impact of AF type on thromboembolism, bleeding, and mortality. Methods and results PubMed was searched through 27 November 2014 for randomized controlled trials, cohort studies, and case series reporting prospectively collected clinical outcomes stratified by AF type. The incidence of thromboembolism, mortality, and bleeding was extracted. Atrial fibrillation clinical outcome data were extracted from 12 studies containing 99 996 patients. The unadjusted risk ratio (RR) for thromboembolism in NPAF vs. PAF was 1.355 (95% CI: 1.169–1.571, P < 0.001). In the study subset off oral anticoagulation, unadjusted RR was 1.689 (95% CI: 1.151–2.480, P = 0.007). The overall multivariable adjusted hazard ratio (HR) for thromboembolism was 1.384 (95% CI: 1.191–1.608, P < 0.001). The overall unadjusted RR for all-cause mortality was 1.462 (95% CI: 1.255–1.703, P < 0.001). Multivariable adjusted HR for all-cause mortality was 1.217 (95% CI: 1.085–1.365, P < 0.001). Rates of bleeding were similar, with unadjusted RR 1.00 (95% CI: 0.919–1.087, P = 0.994) and adjusted HR 1.025 (95% CI: 0.898–1.170, P = 0.715). Conclusion Non-paroxysmal atrial fibrillation is associated with a highly significant increase in thromboembolism and death. These data suggest the need for new therapies to prevent AF progression and further studies to explore the integration of AF type into models of thromboembolic risk.

Aims Catheter-based renal artery sympathetic denervation has emerged as a novel therapy for treatment of patients with drug-resistant hypertension. Initial studies were performed using a single electrode radiofrequency catheter, but recent advances in catheter design have allowed the development of multi-electrode systems that can deliver lesions with a pre-determined pattern. This study was designed to evaluate the safety and efficacy of the EnligHTN™ multi-electrode system. Methods and results We conducted the first-in-human, prospective, multi-centre, non-randomized study in 46 patients (67% male, mean age 60 years, and mean baseline office blood pressure 176/96 mmHg) with drug-resistant hypertension. The primary efficacy objective was change in office blood pressure from baseline to 6 months. Safety measures included all adverse events with a focus on the renal artery and other vascular complications and changes in renal function. Renal artery denervation, using the EnligHTN™ system significantly reduced the office blood pressure from baseline to 1, 3, and 6 months by −28/10, −27/10 and −26/10 mmHg, respectively ( P < 0.0001). No acute renal artery injury or other serious vascular complications occurred. Small, non-clinically relevant, changes in average estimated glomerular filtration rate were reported from baseline (87 ± 19 mL/min/1.73 m2) to 6 months post-procedure (82 ± 20 mL/min/1.73 m2). Conclusion Renal sympathetic denervation, using the EnligHTN™ multi-electrode catheter results in a rapid and significant office blood pressure reduction that was sustained through 6 months. The EnligHTN™ system delivers a promising therapy for the treatment of drug-resistant hypertension.

Aims To assess the efficacy of platelet glycoprotein IIb/IIIa inhibitors in patients with acute coronary syndromes primarily medically managed. Methods and Results We performed a meta-analysis of the randomized clinical trials of platelet glycoprotein IIb/IIIa inhibitor therapy in the medical management of non-ST-elevation acute coronary syndromes. Among 29570 patients, IIb/IIIa integrin blockade was associated with a reduction in death or non-fatal myocardial infarction at 30 days, from 11·5% to 10·7% (odds ratio 0·91, P =0·02). Patients undergoing percutaneous coronary intervention during index hospitalization sustained a greater reduction in ischaemic events (odds ratio 0·82, P =0·01) than patients medically managed (odds ratio 0·95, P =0·27). Among patients undergoing intervention, the benefit was more pronounced if the procedure was performed during glycoprotein IIb/IIIa inhibitor infusion (odds ratio 0·74; P =0·02), than if revascularization was performed after drug discontinuation (odds ratio 0·87, P =0·17). Conclusion This analysis, including the entire large-scale trial experience of intravenous glycoprotein IIb/IIIa inhibitors in patients with acute coronary syndromes primarily medically managed, demonstrates an overall significant, albeit moderate, reduction in 30-day death or myocardial infarction associated with therapy. Although not based on a prospectively defined hypothesis, the findings suggest a gradient of benefit conferred by these agents depending on the revascularization strategy used. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved .

Objective: In the absence of head-to-head clinical data, the objective of this study was to indirectly compare the efficacy and safety of a bivalirudin-based anticoagulation strategy to heparin monotherapy in patients with ST-elevation myocardial infarction (STEMI) intended for primary percutaneous coronary intervention (PPCI). Methods: A systematic literature review was performed to identify randomised controlled trials (RCTs) to build a network of bivalirudin and heparin monotherapy strategies in STEMI patients using heparin with glycoprotein IIb/IIIa inhibitor (GPI) as a common reference strategy. Identified data were analysed using fixed and random effects network meta-analysis (NMA). A base-case analysis was constructed from intention-to-treat populations in the RCTs. Sensitivity analysis was also performed. Outcomes (mortality, stroke, myocardial infarction, ischaemic target vessel revascularisation (TVR), major adverse cardiovascular events (MACE), TIMI major and minor bleeding) were evaluated at 30 days and 1 year. Results: Eight RCTs (including 8,807 patients) were identified for inclusion in the NMA. At 30 days, the bivalirudin-based strategy was expected to result in lower mortality rates than heparin monotherapy (odds ratio (OR) 0.55; credible interval (CrL: 0.32, 0.95). This relationship was sustained at 1 year. At 30 days, the risk of stroke (OR: 0.88; CrL: 0.37, 2.13), myocardial infarction (OR: 0.79; CrL: 0.40, 1.55), ischaemic TVR (OR: 0.75; CrL: 0.38, 1.46), TIMI major bleeding (OR: 0.85; CrL: 0.47, 1.52), TIMI minor bleeding (OR: 0.70; CrL: 0.41, 1.18) and TIMI major and minor bleedings (OR: 0.66; CrL: 0.45, 0.98) tended to be numerically reduced with bivalirudin in comparison to heparin monotherapy. The findings of sensitivity analyses were in line with the base case analysis. Conclusion: For patients with STEMI intended for PPCI, bivalirudin is associated with lower mortality rates in comparison to heparin monotherapy. Also, the risk of ischaemic and bleeding outcomes may also be reduced by bivalirudin. This study suggests that bivalirudin is more effective and safer than heparin monotherapy and should therefore be preferred over heparin monotherapy.

Introduction: There is variation in the evidence based treatment of patients with chronic kidney disease (CKD) presenting with an acute coronary syndrome (ACS). We characterised the clinical factors impacting on management of patients with ACS and CKD in an unselected multicentre Australian registry population. Methods: Of the 2435 patients presenting and surviving an ACS, 593 had CKD (glomerular filtration rate (GFR)