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The National Heart Foundation of Australia's (NHFA) Warning Signs campaign ran between 2010 and 2013. This study examines trends in Australian adults' ability to name heart attack symptoms during the campaign and in the years following. Using the NHFA's HeartWatch data (quarterly online surveys) for adults aged 30–59 years, we conducted an adjusted piecewise regression analysis comparing trends in the ability to name symptoms during the campaign period plus one year lag (2010–2014) to the post-campaign period (2015–2020) Over the study period, there were 101,936 Australian adults surveyed. Symptom awareness was high or increased during the campaign period. However, there was a significant downward trend in each year following the campaign period for most symptoms (e.g., chest pain: adjusted odds ratio [AOR] =0.91, 95%CI: 0.56–0.80; arm pain: AOR=0.92, 95%CI: 0.90–0.94). Conversely, the inability to name any heart attack symptom increased in each year following the campaign (3.7% in 2010 to 19.9% in 2020; AOR=1.13, 95%CI: 1.10–1.15); these respondents were more likely to be younger, male, have less than 12 years of education, identify as Aboriginal and/or Torres Strait Islander Peoples, speak a language other than English at home and have no cardiovascular risk factors. Awareness of heart attack symptoms has decreased in the years since the Warning Signs campaign in Australia, with 1 in 5 adults currently unable to name a single heart attack symptom. New approaches are needed to promote and sustain this knowledge, and to ensure people act appropriately and promptly if symptoms occur. [ABSTRACT FROM AUTHOR]

Background: Dual antiplatelet therapy (DAPT) is guideline therapy following acute coronary syndrome (ACS). Novel, potent P2Y12 inhibitors have been developed and studied but it is unclear how this evidence has been incorporated into patient care. We sought to describe the prescribing trends and health care costs of P2Y12therapy in Australia over the last decade.Method: The latest statistical data collected by the Pharmaceutical Benefit Scheme (PBS), Australia, was reviewed. PBS codes for coronary indications were selected. Yearly total prescriptions and cost were then compared between all three P2Y12 inhibitors. Linear trend modelling was used to observe general trends over the data collection period.Results: Total yearly P2Y12 scripts have more than doubled between 2010 (403,880 scripts) and 2020 (994,826 scripts). Clopidogrel is the most prescribed P2Y12 inhibitor and has been for the last decade. Ticagrelor represents 26.2% of total prescriptions but accounts for 75% of PBS spending. More than $30 million is spent on ticagrelor every year with a cost per MACE prevented of $72,637. Prasugrel was the least prescribed agent but was 41% cheaper per major adverse cardiac event (MACE) prevented than ticagrelor before being removed from the Australian market. Without prasugrel available, clopidogrel scripts have increased 10% and ticagrelor scripts remain stable.Conclusion: Clopidogrel remains the most prescribed P2Y12 agent in Australia, despite emergence of more potent P2Y12 inhibitors. Ticagrelor is increasingly prescribed but represents a disproportionately large burden of spending. Whilst prasugrel is the most efficacious, cheaper than ticagrelor and guideline recommended P2Y12 inhibitor after ACS, it represented the minority of scripts before being withdrawn. Rather than use of a potent P2Y12 agent, clinicians are reverting to prescribing clopidogrel. [ABSTRACT FROM AUTHOR]

Background: Clopidogrel in combination with aspirin after acute coronary syndromes (ACS) reduces recurrent ischaemic events compared to aspirin alone. Further reductions in events have been demonstrated when clopidogrel is replaced by ticagrelor or prasugrel albeit with increases in bleeding. There are few studies documenting the patterns of use of P2Y12 inhibitors or their association with outcomes in the Australian population.Aims: To describe the patterns of use of each P2Y12 inhibitor and to determine the associations between initial P2Y12 inhibitor use and outcomes.Methods: Data were extracted from Cooperative National Registry of ACS, Guideline Adherence and Clinical Events (CONCORDANCE)-a prospective database of patients presenting to 43 sites across Australia with ACS. Patients were stratified based on first antiplatelet agent received. Baseline clinical characteristics were compared between these patient groups and hospital investigations, management as well as in-hospital and 12 months outcomes (death, a composite of cardiac-related death, myocardial infarction, and stroke, and major bleeding) were compared between the three treatment cohorts after adjustment for differences in baseline characteristics.Results: Mean ages of the clopidogrel (n=7,537), ticagrelor (n=1,878), and prasugrel (n=347) cohorts were 65, 63, and 58 yrs respectively (p<0.0001), the mean Global Registry of Acute Coronary Events (GRACE) risk scores were 107, 104, and 102 (p=0.0016). The ticagrelor and prasugrel cohorts were more likely to receive percutaneous coronary intervention (PCI) (clopidogrel 52%, ticagrelor 66%, prasugrel 88%, p<0.0001), and evidence based medications (≥4 guideline indicated medications: clopidogrel 76%, ticagrelor 82%, prasugrel 93%, p<0.0001). Patients treated with ticagrelor and prasugrel were less likely to experience in-hospital death (clopidogrel 2.5%, ticagrelor 1.4%, prasugrel 1.2%, p=0.05), major adverse cardiac events (MACE) (clopidogrel 5.1%, ticagrelor 3.0%, prasugrel 3.5% [p=0.01]), or bleeding (clopidogrel 8.4%, ticagrelor 4.6%, prasugrel 7.5% [p<0.001]) compared to clopidogrel. These differences were no longer apparent after multivariable adjustment. There was no difference in outcomes between cohorts at 12 months.Conclusions: In Australia, ticagrelor and prasugrel are used in younger patients who are more likely to undergo percutaneous coronary intervention (PCI) and receive evidence based therapy. Patients receiving clopidogrel were more likely to experience in hospital ischaemic or bleeding events but this was explained by their higher baseline risk. Selection of therapy was not associated with any difference in outcomes at 12-month follow-up, but our findings suggest there is room for improvement towards guideline-driven usage of P2Y12 inhibitors. [ABSTRACT FROM AUTHOR]

Background: Guidelines previously recommended use of dual antiplatelet therapy, statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARB) and beta blockers (five classes of drugs) in patients without contraindications or intolerance after acute coronary syndrome (ACS). However, recent guidelines have taken a more nuanced view regarding the use of ACEI/ARB and beta blockers. Our aim was to develop a composite post-discharge medication indicator, based on available evidence, to support quality improvement.Methods: 4,112 consecutive post-ACS patients who underwent coronary angiography and left ventricular ejection fraction (LVEF) assessment in 2015-16 were recorded in the All New Zealand ACS Quality Improvement (ANZACS-QI) registry. Patients receiving coronary artery bypass grafting were excluded. Three composite indicator algorithms that took into account known contraindications/intolerances were compared across NZ District Health Boards (DHBs): RESULTS: Overall and individual DHB performance was highest (74%, DHB range 52-84%) when reported using the NHFA/CSANZ indicator, and slightly lower (69%, DHB range 48-78%) on the ANZACS-QI indicator. Performance was lowest using the older five-drug-class indicator (65%, DHB range 48-77%).Conclusions: We have developed a composite post-discharge medication indicator appropriate for use in identifying gaps in evidence-based management across NZ, which is now being reported regularly to DHBs. [ABSTRACT FROM AUTHOR]

Background: This research estimates the broader socioeconomic impacts of reducing pre-hospital delay times across Australia in patients with heart attack symptoms.Methods: A cost benefit analysis (CBA) was undertaken to demonstrate the costs and benefits of a public awareness/education campaign to reduce pre-hospital delay time from 5.2hours (Base Case) to 4.1hours (Scenario 1) and 2.0hours (Scenario 2). All assumptions underlying the CBA are supported by academic literature. Financial impacts considered include campaign/public education costs, direct inpatient costs and long-term health care costs. Socioeconomic impacts considered include burden of disease, productivity losses, informal care costs and net deadweight loss.Results: The campaign is expected to generate an additional net benefit of $41.2-139.1 million in comparison to the Base Case, resulting in a benefit cost ratio (BCR) of 3.23-5.06. Disability Adjusted Life Years (DALYs) reduced by 6,046-7,575 years.Conclusion: This research illustrates that an investment in public awareness/education campaign can generate considerable benefits, more than offsetting the costs associated with the campaign and keeping people living longer such as ongoing health care costs. However, significant effort, supplementary strategies and sustained investment will be required to ensure the impact and benefit is sustained over the long term. [ABSTRACT FROM AUTHOR]

Background: Cardiac troponin (T and I) are considered the standard markers for detection of myocardial damage and the diagnosis of acute coronary syndrome (ACS) among patients who present to an emergency department with chest pain. However, these markers can be released in other situations and may be associated with short- and long-term clinical outcomes. In this study, we examine late mortality rates among patients presenting with a suspected ACS due to an unstable coronary plaque and those patients having a non-ACS.Methods: 4388 patients were hospitalised with suspected ACS, between 14 and 27 May 2012 in the Australia and New Zealand SNAPSHOT ACS study. Those patients were categorised in five diagnostic groups: 1) ST elevation MI (n=419); 2) non-ST elevation MI (n=1012); 3) unstable angina (n=925); 4) non-ACS diagnoses (n=837); and 5) chest pain considered unlikely ischaemic (not otherwise specified, n=1195).Result: The respective mortality rates at 18 months in these groups were 16.2%, 16.3%, 6.8%, 12.8%, and 4.8%; Pearson χ2=110 p<0.001. Among non-ACS diagnoses patients (group 4) those with the highest mortality rates (cardiac (14.4%), respiratory (18.2%), sepsis (15.4%) and neoplastic (67%) diagnoses) had the highest rates of elevated troponin levels (48%, 31%, 38% and 67% respectively). By contrast, those with the lowest mortality rates (musculoskeletal (2.9%), gastrointestinal disorders (3.9%) and non-specific chest pain (7.4%)) had the lowest rate of elevated troponin levels (9%, 18% and 15.8% respectively). However, after adjusting for baseline clinical and demographic characteristics, the mortality rate at 18 months for patients with elevated troponin was similar for ACS or non-ACS diagnoses (Hazard Ratio, 95% C.I.0.98-1.07, p=0.333).Conclusions: Among patients in the 2012 SNAPSHOT ACS study, non-ACS diagnoses characterised by high rates of elevated troponin levels had high mortality rates similar to those diagnosed with ACS. Therapies known to be effective in ACS patients, including early invasive management, should be examined in these non-ACS patients with troponin elevations within adequately powered randomised trials. [ABSTRACT FROM AUTHOR]

Objectives: To compare the predictive ability of three risk stratification tools used to assess patients presenting to the ED with potential acute coronary syndrome. Design: Pre-planned analysis of an observational study. Setting: A single tertiary referral hospital. Participants: 1495 patients presented with chest pain. 948 patients were screened and enrolled. Patients with at least 5min of chest pain suggestive of ACS were eligible. Interventions: Subjects were risk categorised using the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines (HFA/CSANZ), the TIMI score and the GRACE score. Three strata of the TIMI and GRACE score were used to compare to the HFA/CSANZ risk categories. Main outcome measurement: 30-Day cardiac event rates including cardiac death, acute myocardial infarction and unstable angina. Results: There were 152 events in 91 patients (9.6%). The discriminatory ability of the scores determined by the AUC was 0.83 (95% CI 0.79–0.87) for the GRACE score, 0.79 (95% CI 0.74–0.83) for TIMI score and 0.75 (95% CI 0.70–0.80) for HFA/CSANZ. The AUCs with three strata of the GRACE and TIMI scores were 0.76 (95% CI 0.72–0.81) and 0.68 (95% CI 0.62–0.73) respectively. Conclusions: All three scores were similar in performance in quantifying risk in ED patients with possible ACS. The GRACE score identified a sizable low risk cohort with high sensitivity and NPV but complexity of this tool may limit its utility. Improved scores are needed to allow early identification of low- and high-risk patients to support improvements in patient flow and ED overcrowding. [ABSTRACT FROM AUTHOR]