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BACKGROUND Permanent pacemaker (PPM) and implantable cardioverter defibrillator (ICD) implant rates have increased in New Zealand over the past decade. This study aims to provide a contemporary analysis of regional variation in implant rates. METHOD New PPM and ICD implants in patients ≥15 years were identified for ten years (2009 to 2018) using procedure coding in the National Minimum Datasets, which collects all New Zealand public hospital admissions. Age-standardised new implant rates per million adult population were calculated for each of the four regions (Northern, Midland, Central and Southern) and the 20 district health boards (DHBs) across those regions. Trend analysis was performed using joinpoint regression. RESULTS New PPM implant rates increased nationally by 3.4%/year (p

Background Takotsubo syndrome (TS) is often triggered by an acute physical or emotional stressor. We hypothesised that medium-term prognosis may be better for TS patients with an associated emotional stressor than for those with an acute physical illness. Methods We identified consecutive TS patients presenting in New Zealand (2006–2018). The clinical presentation and outcomes of TS patients according to types of stressor (physical, emotional or no stressor) were assessed. Post-discharge survival after TS was compared with age- and gender-matched patients after myocardial infarction (MI) and people in the community without known cardiovascular disease (CVD). Results Of 632 TS patients (95.9% women, mean age 65.0±11.1 years), 27.4% had an associated acute physical stressor, 46.4% an emotional stressor and 26.2% no evident stressor. In-hospital mortality was similar for each group (1.7%, 1.2%, 0.3% respectively, p=0.29). In a median 4.4 years post-discharge there were 54 deaths (53 non-cardiac). Compared with patients without known CVD, TS patients with physical stress and those with MI were less likely to survive (HR 4.46, 95%CI 3.10–6.42; HR 4.23, 95%CI 3.81–4.70 respectively) but survival for TS patients associated with emotional stress or no stressor was similar (HR 1.11, 95%CI 0.66–1.85; HR 1.08, 95%CI 0.54–2.18, respectively). Recurrence was similar among the three groups (p=0.14). Conclusion Takotsubo syndrome associated with physical stressor has a post-discharge mortality risk as high as after MI. In contrast, prognosis for TS triggered by an emotional stressor is excellent, and similar to that of those without known CVD.

At Middlemore Hospital, acute coronary syndrome (ACS) patients are admitted under the care of one of seven cardiologists working on a weekly rotation. Between 2010 and 2018 patients under the care of three of the cardiologists were followed up in a "medical only" post-ACS follow-up clinic model where the cardiologist or registrar saw all patients. Those admitted under the other four cardiologists were seen in a "nurse-led, cardiologist-supported" follow-up model where the majority of patients were seen by a nurse specialist. The study aim was to compare quality of care and outcomes between patients managed under these two follow-up clinic models.The ANZACS-QI registry was used to identify all ACS admissions, 2010 to 2018. The ANZACS-QI records for 5296 patients, discharged alive, were anonymously linked with hospital clinic follow-up and national administrative datasets. Time to follow-up, medication dispensation and titration and one-year clinical outcomes were compared for the two follow-up models.Characteristics of patients managed under each model were similar. 4395 patients attended follow up, 74% in the nurse-led model. At one year there were no differences between the medical- and nurse-led cohorts in all-cause mortality (4.6% vs 3.9, p=0.29), rehospitalisations for myocardial infarction (MI) (9.2% vs 8.3%, p=0.31), stroke (1.2% vs 1.4% p=0.71), heart failure (5.7% vs 6.9%, p=0.15) or a combined endpoint of all-cause mortality and/or rehospitalisation for MI/stroke/HF (15.2% vs 14.8%, p=0.71). Patients were seen earlier post-discharge in the nurse-led model, (mean 83 vs 101 days). Medication dispensation one year post-discharge was similar for both models of care.The nurse-led model is associated with earlier access to follow-up, was equally as effective at maintaining secondary prevention pharmacotherapy and associated with similar survival and readmission with non-fatal ACS/stroke/heart failure.

Coronary angiography in patients with previous coronary artery bypass grafts (CABG) is technically more difficult with increased procedure time, radiation exposure and in-hospital complications. In a contemporary national registry of acute coronary syndrome (ACS) patients undergoing an invasive strategy, we compared the management and outcomes of patients with and without prior CABG.The All New Zealand ACS Quality Improvement (ANZACS-QI) registry was used to identify patients admitted to New Zealand public hospitals with an ACS who underwent invasive coronary angiography (2014-2018). Outcomes were ascertained by anonymised linkage to national datasets.Of 26,869 patients, 1,791 (6.7%) had prior CABG and 25,078 (93.3%) had no prior CABG. Prior CABG patients were older (mean age 71 years vs 65 years), more comorbid and less likely to be revascularised than those without CABG (49.8% vs 73.0%). Compared to patients without CABG, at a mean follow-up of 2.1 years, patients with prior CABG had higher all-cause mortality (HR 2.03 (1.80-2.29)), and were more likely to have recurrent myocardial infarction (HR 2.70 (2.40-3.04)), rehospitalisation with congestive cardiac failure (HR 2.36 (2.10-2.66)) and stroke (HR 1.82 (1.41-2.34)).In contemporary real-world practice, despite half of the patients with ACS and prior CABG receiving PCI, the outcomes remain poor compared with those without prior CABG.

Ethnic variation in implantable cardioverter defibrillator (ICD) implant rates have been reported internationally but have not previously been examined in New Zealand. This study examined trends in new ICD implants by ethnicity over an extended period.All patients who received a new ICD implant between 2005 and 2019 were identified using the National Minimum Dataset, which collects information on all public hospital admissions in New Zealand. Ethnicity was classified using the following standard prioritisation: Māori, Pacific, Asian and European/Other. New ICD implant rates were analysed by ethnicity and age groups.A total of 5,514 new ICDs were implanted. New ICD implant rates increased from 41.4/million in 2005 to 98.2/million in 2019, an average increase of 5.4%/year (p0.01). The highest age-standardised implant rates were among Māori, followed by Pacific, European/Other and Asian ethnicities. The largest increase was seen in Pacific people at 8.9%/year (p0.01), followed by Māori and Asian people at 4.7%/year and 4.3%/year respectively (both p0.01). In European/Other patients, ICD implant rates increased by 10.3%/year (p0.01) between 2005 to 2012, then plateaued at -0.4%/year (p=0.71) between 2012 to 2019. By 2019, the age-standardised implant rates in Māori and Pacific people were two-fold higher than European/Others.There is marked ethnic variation in ICD implant rates in New Zealand. The higher implant rates in Māori and Pacific parallel known ethnic differences in rates of underlying cardiac disease. The more rapid increase in implant rates in these ethnic groups may represent more equitable treatment over time.

Guidelines recommend angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB)/angiotensin receptor neprilysin inhibitors (ARNI); beta blockers; and mineralocorticoid receptor antagonists (MRA) in patients with symptomatic heart failure and reduced left ventricular ejection fraction before consideration of primary prevention implantable cardioverter defibrillator (ICD). This study aims to investigate dispensing rates of guideline-directed medical therapy (GDMT) before and after primary prevention ICD implantation in New Zealand.All patients receiving a primary prevention ICD between 2009 and 2018 were identified using nationally collected data on all public hospital admissions in New Zealand. This was anonymously linked to national pharmaceutical data to obtain medication dispensing. Medications were categorised as low dose (50% of target dose), 50-99% of target dose or target dose based on international guidelines.Of the 1,698 patients identified, ACEi/ARB/ARNI, beta blockers and MRA were dispensed in 80.2%, 83.6% and 45.4%, respectively, prior to ICD implant. However, ≥50% target doses of each medication class were dispensed in only 51.8%, 51.8% and 34.5%, respectively. Only 15.8% of patients were receiving ≥50% target doses of all three classes of medications. In the 1,666 patients who survived 1 year after ICD implant, the proportions of patients dispensed each class of medications remained largely unchanged.Dispensing of GDMT was suboptimal in patients before and after primary prevention ICD implantation in New Zealand, and only a minority received ≥50% target doses of all classes of medication. Interventions are needed to optimise use of these standard evidence-based medications to improve clinical outcomes and avoid unnecessary device implantation.