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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: To describe the long-term mortality of a complete national cohort of acute coronary syndrome (ACS) patients enrolled in 2002, to compare this with a national age, sex and Māori ethnicity matched population, and to assess the influence of baseline factors on the 12-year mortality.Methods: We reviewed 721 patients with a discharge diagnosis of an ACS who were enrolled in the first New Zealand ACS audit group cohort over 14days in May 2002. We matched the cohort to the national mortality database using each patient's unique national identity number.Results: Over a median follow-up of 12.7 years of 721 patients discharged with an ACS, overall mortality was 52%: ST-elevation myocardial infarction (STEMI) (58%), non-ST-elevation myocardial infarction (NSTEMI) (61%) and unstable angina pectoris (UAP) (42%) patients, p<0.0001. In an age-adjusted survival model, males had a 29% increased mortality rate compared to females with a hazard ratio of 1.29 (95% CI 1.04, 1.61, p=0.019). Over 12 years there were 339 (47%) deaths, compared to 284 (39%) deaths observed in the matched population. The standardised mortality ratio for patients admitted with an ACS in New Zealand is 1.3 (95% CI 1.2, 1.5) with eight patients per 100 not surviving to 12 years compared to this matched population.Conclusions: The high mortality rate in this ACS cohort is a stark reminder of the prognostic implications of a presentation with an ACS. It emphasises the on-going need for optimal management of these patients throughout every stage of their initial treatment and subsequent on-going care. [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]

Background: Acute heart failure (HF) associated with an acute coronary syndrome (ACS) predicts adverse outcome. There have been important recent improvements in ACS management. Our aim was to describe the management and outcomes in those with and without HF in a contemporary ACS cohort.Methods: Consecutive patients presenting with ACS between 2007 and 2011 were enrolled in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. Outcomes and medication dispensing were obtained using anonymised linkage to national data sets. A summary pharmacotherapy measure of "quadruple therapy" was defined as dispensing of at least one agent from each of the four evidence-based classes - anti-platelet, statin, angiotensin converting enzyme inhibitor/angiotensin receptor blocker and beta blocker.Results: Of 3743 ACS patients 14% had acute HF. Acute heart failure patients were older (69.2±12.6 vs 62.3±12.8 years, p<0.001), less likely to have coronary angiography (66% vs 86%, p<0.001) and revascularisation (46% vs 62%, p<0.001). Immediate post-discharge quadruple therapy was higher for those with than without HF (61% vs 55%, p=0.02) but fell to similar levels by one-year (45% vs 53%, p=0.55). At four years follow-up nearly half of those presenting with ACS and HF had died. After adjustment, HF remained a strong predictor of death within 28 days (OR 2.9, 95%CI 1.5 - 5.5) and beyond 28 days (HR 1.8, 95%CI 1.5 - 2.3).Conclusion: Acute heart failure complicating ACS is associated with heightened risk of short-term and long-term mortality. One in three ACS patients with HF did not have coronary angiography and less than half received quadruple therapy a year after presentation. [ABSTRACT FROM AUTHOR]

Background: Cohort studies of STEMI patients have reported that over 30% receive no reperfusion. Barriers to greater use of reperfusion in STEMI patients require further elucidation.Methods: We collected data on STEMI patients with no reperfusion as part of the SNAPSHOT ACS Registry, which recruited consecutive ACS patients in 478 hospitals throughout Australia and New Zealand during 14-27 May 2012.Results: Of 4387 patients enrolled, 419 were diagnosed with STEMI. Primary PCI (PPCI) was performed in 160 (38.2%), fibrinolysis was used in 105 (25.1%), and 154 (36.7%) had no reperfusion. Patients with no reperfusion had a mean age of 70.3±15.0 years compared with 63.1±13.5 in the reperfusion group (p<0.0001). There were more females in the no reperfusion group (37.1% v 23.0% p=0.002) and they were significantly more likely to have prior PCI or CABG, heart failure, atrial fibrillation, chronic kidney disease and other vascular disease, and to be nursing home residents (all p<0.05). Patients without reperfusion had a significantly higher mortality in hospital (11.7% v 4.9%, p=0.011). In 370 patients who presented within 12hours, 28 had early angiography without PCI, which was considered an attempt at reperfusion. Therefore reperfusion was attempted in 293 of 370 eligible patients (79.2%).Conclusion: Of consecutive STEMI patients, 36.7% did not receive any reperfusion and they had a higher risk of death in hospital. In eligible patients, reperfusion was attempted in 79.2%. National strategies to encourage earlier medical contact and greater use of reperfusion in eligible patients may lead to better outcomes. [ABSTRACT FROM AUTHOR]