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Background Recent data suggest that colchicine may reduce cardiovascular events among patients presenting with acute coronary syndromes. This sub-study of the Australian COPS trial aimed to assess whether colchicine affects health status outcomes. Methods Health status was assessed at baseline and 12-months using the EuroQol-5 Dimension 5-level (EQ-5D-5L) score and the full 19-question Seattle Angina Questionnaire (SAQ). Data were available for 786 patients (388 randomized to colchicine, 398 to placebo). Results Baseline characteristics were well matched between groups; mean age was 60.1 (SD 14.8) years, and 20% were female. Baseline health status scores were impaired, and most parameters demonstrated significant improvement from baseline to 12-months (EQ-5D-5L Visual Analogue Score [VAS] 69.3 to 77.7; SAQ angina frequency score 83.0 to 95.3, both p Conclusions Treatment with colchicine did not appear to affect change in measures of health status following acute coronary syndromes, but it did lead to a greater likelihood of improvement in physical limitation scores. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Peninsula Health, Monash University

Cardiogenic shock is associated with a high risk for morbidity and mortality. The impact of gender on treatment and outcomes is poorly defined. This study aimed to evaluate whether gender influences the clinical management and outcomes of patients with prehospital cardiogenic shock. Consecutive adult patients with cardiogenic shock who were transferred to hospital by emergency medical services (EMS) between January 1, 2015 and June 30, 2019 in Victoria, Australia were included. Data were obtained from individually linked ambulance, hospital, and state death index datasets. The primary outcome assessed was 30-day mortality, stratified by patient gender. Propensity score matching was performed for risk adjustment. Over the study period a total of 3,465 patients were identified and 1,389 patients (40.1%) were women. Propensity score matching yielded 1,330 matched pairs with no differences observed in baseline characteristics, including age, initial vital signs, pre-existing co-morbidities, etiology of shock, and prehospital interventions. In the matched cohort, women had higher rates of 30-day mortality (44.7% vs 39.2%, p = 0.009), underwent less coronary angiography (18.3% vs 27.2%, p0.001), and revascularization with percutaneous coronary intervention (8.9% vs 14.2%, p0.001), compared with men. In conclusion, in this large population-based study, women with cardiogenic shock who were transferred by EMS to hospital had significantly worse survival outcomes and reduced rates of invasive cardiac interventions compared to men. These data underscore the urgent need for targeted public health measures to redress gender differences in outcomes and variation with clinical care for patients with cardiogenic shock.

This study aimed to determine incidences, diagnoses, and outcomes of patients with chest pain attended by paramedics using a large population-based sample.Consecutive emergency medical services (EMS) attendances for non-traumatic chest pain in Victoria, Australia from January 2015 to June 2019 were included. Data were individually linked to emergency, hospital admission and mortality records.During the study period (representing 22,186,930 person-years), chest pain was the reason for contacting EMS in 257,017 of 2,736,570 attendances (9.4%). Overall incidence of chest pain attendances was 1,158 (per 100,000 person-years) with a higher incidence observed with increasing age, among females, among Aboriginal and Torres Strait Islanders, in regional settings, and in socially disadvantaged areas. The most common diagnoses were non-specific pain (46%; 30-day mortality 0.5%), non-ST elevation myocardial infarction (5.3%; mortality 1.3%), pneumonia (3.8%; mortality 3.9%), stable coronary syndromes (3.5%; mortality 0.8%), unstable angina (3.3%; mortality 1.3%), and ST-elevation myocardial infarction (2.8%; mortality 7.0%), while pulmonary embolism (0.7%; mortality 3.2%) and aortic pathologies (0.2%; mortality 22.2%) were rare.Chest pain accounts for one in ten ambulance calls, and underlying causes are diverse. Almost half of patients are discharged from hospital with a diagnosis of non-specific pain and low rates of mortality.

Advances in coronary plaque imaging over the last few decades have led to an increased interest in the identification of novel high-risk plaque features that are associated with cardiovascular events. Existing practices focus on risk stratification and lipid monitoring for primary and secondary prevention of cardiac events, which is limited by a lack of assessment and treatment of vulnerable plaque. In this review, we summarize the multitude of studies that have identified plaque, haemodynamic and patient factors associated with risk of acute coronary syndrome. Future progress in multi-modal imaging strategies and in our understanding of high-risk plaque features could expand treatment options for coronary disease and improve patient outcomes.

AimsThe relationship between lower socioeconomic status (SES) and poor cardiovascular outcomes is well described; however, there exists a paucity of data exploring this association in cardiogenic shock (CS). This study aimed to investigate whether any disparities exist between SES and the incidence, quality of care or outcomes of CS patients attended by emergency medical services (EMS).Methods and resultsThis population-based cohort study included consecutive patients transported by EMS with CS between 1 January 2015 and 30 June 2019 in Victoria, Australia. Data were collected from individually linked ambulance, hospital, and mortality datasets. Patients were stratified into SES quintiles using national census data produced by the Australian Bureau of Statistics.A total of 2628 patients were attended by EMS for CS. The age-standardized incidence of CS amongst all patients was 11.8 [95% confidence interval (95% CI), 11.4–12.3] per 100 000 person-years, with a stepwise increase from the highest to lowest SES quintile (lowest quintile 17.0 vs. highest quintile 9.7 per 100 000 person-years, P-trend ConclusionThis population-based study demonstrated discrepancies between SES status in the incidence, care metrics, and mortality rates of patients presenting to EMS with CS. These findings outline the challenges in equitable healthcare delivery within this cohort.

Aims Risk-standardized mortality rates (RSMR) have been used to monitor hospital performance in procedural and disease-based registries, but limitations include the potential to promote risk-averse clinician decisions and a lack of assessment of the whole patient journey. We aimed to determine whether it is feasible to use RSMR at the symptom-level to monitor hospital performance using routinely collected, linked, clinical and administrative data of chest pain presentations. Methods and results We included 192 978 consecutive adult patients (mean age 62 years; 51% female) with acute chest pain without ST-elevation brought via emergency medical services (EMS) to 53 emergency departments in Victoria, Australia (1/1/2015–30/6/2019). From 32 candidate variables, a risk-adjusted logistic regression model for 30-day mortality (C-statistic 0.899) was developed, with excellent calibration in the full cohort and with optimism-adjusted bootstrap internal validation. Annual 30-day RSMR was calculated by dividing each hospital's observed mortality by the expected mortality rate and multiplying it by the annual mean 30-day mortality rate. Hospital performance according to annual 30-day RSMR was lower for outer regional or remote locations and at hospitals without revascularisation capabilities. Hospital rates of angiography or transfer for patients diagnosed with non-ST elevation myocardial infarction (NSTEMI) correlated with annual 30-day RSMR, but no correlations were observed with other existing key performance indicators. Conclusion Annual hospital 30-day RSMR can be feasibly calculated at the symptom-level using routinely collected, linked clinical, and administrative data. This outcome-based metric appears to provide additional information for monitoring hospital performance in comparison with existing process of care key performance measures.

Background: Regionalized systems of care for the management of cardiogenic shock (CS) are increasingly being utilized. This study aims to assess whether receiving hospital characteristics such as the availability of 24-hour coronary angiography, on-site cardiac surgery, and annual treated CS volume influence outcomes in patients transferred by emergency medical services (EMS) to hospital with CS. Methods: This population-based cohort study included consecutive adult patients with CS who were transferred to hospital by EMS between January 1, 2015 and June 30, 2019 in Victoria, Australia. Data were obtained from individually linked ambulance, hospital, and state death index data sets. The primary outcome assessed was 30-day mortality stratified by the availability of 24-hour coronary angiography (cardiac center) at the receiving hospital. Results: A total of 3,217 patients were transferred to hospital with CS. The population had an average age of 67.9 +/- 16.1 years, and 1,289 (40.1%) were female. EMS transfer to a cardiac center was associated with significantly reduced rates of 30-day mortality (adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.64-0.95), compared with noncardiac centers. Compared with the lowest annual CS volume quartile (18 cases per year), hospitals in the highest volume quartile (55 cases per year) had reduced risk of 30-day mortality (aOR, 0.71; 95% CI, 0.56-0.91). A stepwise reduction in the adjusted probability of 30-day mortality was observed in patients transferred by EMS to trauma level 1 centers (34.6%), compared with cardiothoracic surgical centers (39.0%), noncardiac surgical metropolitan (44.9%), and rural (51.3%) cardiac centers, all P0.05. Conclusion: Receiving hospital characteristics are associated with survival outcomes in patients with CS. These finding have important implications for establishing regionalized systems of care for patients with CS who are transferred to hospital by EMS.

ImportancePrehospital point-of-care troponin testing and paramedic risk stratification might improve the efficiency of chest pain care pathways compared with existing processes with equivalent health outcomes, but the association with health care costs is unclear.ObjectiveTo analyze whether prehospital point-of-care troponin testing and paramedic risk stratification could result in cost savings compared with existing chest pain care pathways.Design, Setting, and ParticipantsIn this economic evaluation of adults with acute chest pain without ST-segment elevation, cost-minimization analysis was used to assess linked ambulance, emergency, and hospital attendance in the state of Victoria, Australia, between January 1, 2015, and June 30, 2019.InterventionsParamedic risk stratification and point-of-care troponin testing.Main Outcomes and MeasuresThe outcome was estimated mean annualized statewide costs for acute chest pain. Between May 17 and June 25, 2022, decision tree models were developed to estimate costs under 3 pathways: (1) existing care, (2) paramedic risk stratification and point-of-care troponin testing without prehospital discharge, or (3) prehospital discharge and referral to a virtual emergency department (ED) for low-risk patients. Probabilities for the prehospital pathways were derived from a review of the literature. Multivariable probabilistic sensitivity analysis with 50 000 Monte Carlo iterations was used to estimate mean costs and cost differences among pathways.ResultsA total of 188 551 patients attended by ambulance for chest pain (mean [SD] age, 61.9 [18.3] years; 50.5% female; 49.5% male; Indigenous Australian, 2.0%) were included in the model. Estimated annualized infrastructure and staffing costs for the point-of-care troponin pathways, assuming a 5-year device life span, was $2.27 million for the pathway without prehospital discharge and $4.60 million for the pathway with prehospital discharge (incorporating virtual ED costs). In the decision tree model, total annual cost using prehospital point-of-care troponin and paramedic risk stratification was lower compared with existing care both without prehospital discharge (cost savings, $6.45 million; 95% uncertainty interval [UI], $0.59-$16.52 million; lower in 94.1% of iterations) and with prehospital discharge (cost savings, $42.84 million; 95% UI, $19.35-$72.26 million; lower in 100% of iterations).Conclusions and RelevancePrehospital point-of-care troponin and paramedic risk stratification for patients with acute chest pain could result in substantial cost savings. These findings should be considered by policy makers in decisions surrounding the potential utility of prehospital chest pain risk stratification and point-of-care troponin models provided that safety is confirmed in prospective studies.