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Introduction: Despite global concerns about the safety and quality of health care, population-wide studies of hospital outcomes are uncommon. The SAFety, Effectiveness of care and Resource use among Australian Hospitals (SAFER Hospitals) study seeks to estimate the incidence of serious adverse events, mortality, unplanned rehospitalisations and direct costs following hospital encounters using nationwide data, and to assess the variation and trends in these outcomes., Methods and Analysis: SAFER Hospitals is a cohort study with retrospective and prospective components. The retrospective component uses data from 2012 to 2018 on all hospitalised patients age ≥18 years included in each State and Territories' Admitted Patient Collections. These routinely collected datasets record every hospital encounter from all public and most private hospitals using a standardised set of variables including patient demographics, primary and secondary diagnoses, procedures and patient status at discharge. The study outcomes are deaths, adverse events, readmissions and emergency care visits. Hospitalisation data will be linked to subsequent hospitalisations and each region's Emergency Department Data Collections and Death Registries to assess readmissions, emergency care encounters and deaths after discharge. Direct hospital costs associated with adverse outcomes will be estimated using data from the National Cost Data Collection. Variation in these outcomes among hospitals will be assessed adjusting for differences in hospitals' case-mix. The prospective component of the study will evaluate the temporal change in outcomes every 4 years from 2019 until 2030., Ethics and Dissemination: Human Research Ethics Committees of the respective Australian states and territories provided ethical approval to conduct this study. A waiver of informed consent was granted for the use of de-identified patient data. Study findings will be disseminated via presentations at conferences and publications in peer-reviewed journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Lifestyle changes are believed responsible for temporal trends of reduced population total cholesterol (TC), but it is uncertain whether this applies to patients with known coronary heart disease (CHD) often prescribed lipid lowering therapy (LLT). We studied temporal TC trends at presentation with acute coronary syndrome (ACS) to determine the contribution of LLT given for secondary prevention., Methods: TC and LLT were obtained in 5592 patients in annual surveys of ACS admissions in Australia between 1999 and 2013, and annual mean trends analysed by linear and segmented regression., Results: TC declined from 5.13±1.1 to 4.53±1.2mmol/L (p<0.001) and LLT (96% statin) use at presentation increased from 37.4% to 47.5% (p=0.005). TC decline was greater in those on LLT vs. those not on therapy, with LLT contributing to 57% of the TC decline. The decline in TC and increase in LLT use was non-linear and much steeper in those with, than without CHD history, and LLT contributed substantially more to the TC decline (79%, p<0.001 vs. 27%, p=0.06 respectively). The rapid decline in TC and increase in LLT, plateauing after 2005 in those with CHD history differed markedly from trends in recent population studies, while TC trend for those without CHD history was slower, linear and consistent with population trends., Conclusions: Declining TC level at presentation for ACS was strongly associated with increasing LLT use in those with a history of CHD, indicating that increasing uptake of LLT for secondary prevention has impacted TC changes in the new millennium., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Acute coronary syndrome (ACS) is a leading cause of cardiovascular-related morbidity and mortality worldwide. The present study investigated the health-related quality of life (HRQOL) and drug prescribing patterns in ACS patients at Riyadh hospitals in Saudi Arabia. This study was a 12-month prospective cross-sectional study that included 356 patients with ACS. The current study showed that younger male (67.42%) and urban (75.84%) patients suffered more from ACS. Moreover, most patients with NSTEMI (51.69%) experienced Grade 1 dyspnea (33.43%) and NYHA Stage 2 (29.80%); however, STEMI patients were at greater mortality risk. The HRQOL questionnaire showed that ACS patients were significantly impaired in all QOL domains (emotional [23.0%, p = 0.001], physical [24.4%, p = 0.003], and social [27.2%, p = 0.002]). Furthermore, the most commonly prescribed medications were statins (93%), antiplatelets (84%), anticoagulants (79%), coronary vasodilators (65%), and beta-blockers (63%). Additionally, 64% of patients received PCIs or CABGs, with the majority of cases receiving PCIs (49%), whereas 9% received dual anticoagulant therapy. Thus, there is an urgent need to educate healthcare teams about the relevance of QOL in ACS control and prevention and the new ACS management recommendations. ACS is also growing among younger people, requiring greater attention and prevention. [ABSTRACT FROM AUTHOR]

Aims: To examine patients' perceptions of care quality following a same‐day procedure in the cardiac catheterization laboratory and understand the extent to which they were prepared for discharge. Design: Single‐centre, mixed‐methods study. Methods: Postdischarge, online survey of patients who underwent a same‐day procedure in the cardiac catheterization laboratory (n = 150) and one‐on‐one interviews with 13 of these patients. Results: Survey responses were positive with mean scores between 4.39–4.83 out of five and 63.3% of respondents (n = 95) extremely likely to recommend the service to others. Interview data analysis identified three themes: the care experience, information and education for safe discharge, and follow‐up needs. Participants spoke highly of their interactions with clinicians and were satisfied with their care experience. Mode and content of information delivered varied, with some participants lacking guidance about postdischarge health management and clarity about follow‐up plans. Patient or public contribution: Participants were patients. [ABSTRACT FROM AUTHOR]

Aims Pharmaco-invasive percutaneous coronary intervention (PI-PCI) is recommended for patients with ST-elevation myocardial infarction (STEMI)who are unable to undergo timely primary PCI (pPCI). The present study examined late outcomes after PI-PCI (successful reperfusion followed by scheduled PCI or failed reperfusion and rescue PCI)compared with timely and late pPCI (>120 min from first medical contact). Methods and results All patients with STEMI presenting within 12 h of symptom onset, who underwent PCI during their initial hospitalization at Liverpool Hospital (Sydney), from October 2003 to March 2014, were included. Amongst 2091 STEMI patients (80% male), 1077 (52%)underwent pPCI (68% timely, 32% late), and 1014 (48%)received PI-PCI (33% rescue, 67% scheduled). Mortality at 3 years was 11.1% after pPCI (6.7% timely, 20.2% late) and 6.2% after PI-PCI (9.4% rescue, 4.8% scheduled); P < 0.01. After propensity matching, the adjusted mortality hazard ratio (HR) for timely pPCI compared with scheduled PCI was 0.9 (95% CIs 0.4–2.0) and compared with rescue PCI was 0.5 (95% CIs 0.2–0.9). The adjusted mortality HR for late pPCI, compared with scheduled PCI was 2.2 (95% CIs 1.2–3.1)and compared with rescue PCI, it was 1.5 (95% CIs 0.7–2.0). Conclusion Patients who underwent late pPCI had higher mortality rates than those undergoing a pharmaco-invasive strategy. Despite rescue PCI being required in a third of patients, a pharmaco-invasive approach should be considered when delays to PCI are anticipated, as it achieves better outcomes than late pPCI. [ABSTRACT FROM AUTHOR]

Introduction: Early Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion therapy for most patients with ST-segment elevation myocardial infarction (STEMI), and the European guidelines recommend pPCI to occur within 120 min of first medical contact. However, this is not always available. Methods: We performed a retrospective study of patients admitted for STEMI to a level I cardiac intensive care unit in a developing country, to analyze the efficacy of the pharmaco-invasive (PI) strategy versus late PCI over a 2-year follow-up. Results: Four hundred and thirty-nine STEMI patients presented within the first 12 h of symptom onset, pPCI was performed in 154 patients, PI-strategy in 185 patients, and finally Late PCI in 100 patients. All-cause mortality at 2-year risk was statistically significant associated with cardiogenic shock during initial hospitalization, LM and ostio-proximal left anterior descending artery as the culprit artery, severe conductance disorders requiring the use of a temporary pacemaker, and acute kidney disease with glomerular filtration rate < 30 ml/min/1.72 m2 . For the revascularization strategy, there as a well-demonstrated benefit of the pPCI versus Late PCI strategy with (hazard ratio (HR) =0.293; 95% confidence interval (CI) 0.11-0.737; P =0.009), as well as a benefit of the PI-strategy versus Late PCI strategy with (HR =0.433; 95%CI 0.21-0.87; P=0.02). However, there was no difference between the pPCI and PI-strategy. Conclusion: The PI-strategy remains a reasonable alternative for pPCI when the latter is not available, with a prognosis almost identical to pPCI in the long term whenever patients are treated early after the onset of symptoms. [ABSTRACT FROM AUTHOR]

Background and aim: Unplanned cardiac readmissions in patients with percutaneous intervention (PCI) is very common and is seen as a quality indicator of in-hospital care. Most studies have reported on the 30-day cardiac readmission rates, with very limited information being available on 1-year readmission rates and their association with mortality. The aim of this study was to investigate the impact of biological sex at 1-year post-PCI on unplanned cardiac readmissions. Methods and results: Patients enrolled into the GenesisCare Cardiovascular Outcomes Registry (GCOR-PCI) from December 2008 to December 2020 were included in the study. A total of 13,996 patients completed 12 months of follow-up and were assessed for unplanned cardiac readmissions. All patients with unplanned cardiac readmissions in the first year of post-PCI were followed in year 2 (post-PCI) for survival status. The rate of unplanned cardiac readmissions was 10.1%. Women had a 29% higher risk of unplanned cardiac readmission (HR 1.29, 95% CI 1.11 to 1.48; p = 0.001), and female sex was identified as an independent predictor of unplanned cardiac readmissions. Any unplanned cardiac readmission in the first year was associated with a 2.5-fold higher risk of mortality (HR 2.50, 95% CI 1.67 to 3.75; p < 0.001), which was similar for men and women. Conclusion: Unplanned cardiac readmissions in the first year post-PCI was strongly associated with increased all-cause mortality. Whilst the incidence of all-cause mortality was similar between women and men, a higher incidence of unplanned cardiac readmissions was observed for women, suggesting distinct predictors of unplanned cardiac readmissions exist between women and men. [ABSTRACT FROM AUTHOR]

Acute ischemic cardiac injury predisposes one to cognitive impairment, dementia, and depression. Pathophysiologically, recent positron emission tomography data suggest astroglial activation after experimental myocardial infarction (MI). We analyzed peripheral surrogate markers of glial (and neuronal) damage serially within 12 months after the first ST-elevation MI (STEMI). Serum levels of glial fibrillary acidic protein (GFAP) and neurofilament light chain (NfL) were quantified using ultra-sensitive molecular immunoassays. Sufficient biomaterial was available from 45 STEMI patients (aged 28 to 78 years, median 56 years, 11% female). The median (quartiles) of GFAP was 63.8 (47.0, 89.9) pg/mL and of NfL 10.6 (7.2, 14.8) pg/mL at study entry 0–4 days after STEMI. GFAP after STEMI increased in the first 3 months, with a median change of +7.8 (0.4, 19.4) pg/mL (p = 0.007). It remained elevated without further relevant increases after 6 months (+11.7 (0.6, 23.5) pg/mL; p = 0.015), and 12 months (+10.3 (1.5, 22.7) pg/mL; p = 0.010) compared to the baseline. Larger relative infarction size was associated with a higher increase in GFAP (ρ = 0.41; p = 0.009). In contrast, NfL remained unaltered in the course of one year. Our findings support the idea of central nervous system involvement after MI, with GFAP as a potential peripheral biomarker of chronic glial damage as one pathophysiologic pathway. [ABSTRACT FROM AUTHOR]

Aims: Contemporary long-term survival following a heart failure (HF) hospitalization is uncertain. We evaluated survival up to 10 years after a HF hospitalization using national data from Australia and New Zealand, identified predictors of survival, and estimated the attributable loss in life expectancy.Methods and Results: Patients hospitalized with a primary diagnosis of HF from 2008-2017 were identified and all-cause mortality assessed by linking with Death Registries. Flexible parametric survival models were used to estimate survival, predictors of survival and loss in life expectancy. A total of 283 048 patients with HF were included (mean age 78.2 ± 12.3 years, 50.8% male). Of these, 48.3% (48.1-48.5) were surviving by 3 years, 34.1% (33.9-34.3) by 5 years and 17.1% (16.8-17.4) by 10 years (median survival 2.8 years). Survival declined with age with 53.4% of patients aged 18-54 years and 6.2% aged ≥85 years alive by 10 years (adjusted hazard ratio [aHR] for mortality 4.84, 95% confidence interval [CI] 4.65-5.04 for ≥85 years vs. 18-54 years) and was worse in male patients (aHR 1.14, 95% CI 1.13-1.15). Prior HF (aHR 1.20, 95% CI 1.18-1.22), valvular and rheumatic heart disease (aHR 1.11, 95% CI 1.10-1.13) and vascular disease (aHR 1.07, 95% CI 1.04-1.09) were cardiovascular comorbidities most strongly associated with long-term death. Non-cardiovascular comorbidities and geriatric syndromes were common and associated with higher mortality. Compared with the general population, HF was associated with a loss of 7.3 years in life expectancy (or 56.6% of the expected life expectancy) and reached 20.5 years for those aged 18-54 years.Conclusion: Less than one in five patients hospitalized for HF were surviving by 10 years with patients experiencing almost 60% loss in life expectancy compared with the general population, highlighting the considerable persisting societal burden of HF. Concerted multidisciplinary efforts are needed to improve post-hospitalization outcomes of HF. [ABSTRACT FROM AUTHOR]

Background: Outcome prediction tools for patients with type 2 diabetes mellitus (T2DM) undergoing percutaneous coronary intervention (PCI) are lacking. Here, we developed a machine learning-based metabolite classifier for predicting 1-year major adverse cardiovascular events (MACEs) after PCI among patients with T2DM. Methods: Serum metabolomic profiling was performed in a nested case–control study of 108 matched pairs of patients with T2DM occurring and not occurring MACEs at 1 year after PCI, then the matched pairs were 1:1 assigned into the discovery and internal validation sets. External validation was conducted using targeted metabolite analyses in an independent prospective cohort of 301 patients with T2DM receiving PCI. The function of candidate metabolites was explored in high glucose-cultured human aortic smooth muscle cells (HASMCs). Results: Overall, serum metabolome profiles differed between diabetic patients with and without 1-year MACEs after PCI. Through VSURF, a machine learning approach for feature selection, we identified the 6 most important metabolic predictors, which mainly targeted the nicotinamide adenine dinucleotide (NAD+) metabolism. The 6-metabolite model based on random forest and XGBoost algorithms yielded an area under the curve (AUC) of ≥ 0.90 for predicting MACEs in both discovery and internal validation sets. External validation of the 6-metabolite classifier also showed good accuracy in predicting MACEs (AUC 0.94, 95% CI 0.91–0.97) and target lesion failure (AUC 0.89, 95% CI 0.83–0.95). In vitro, there were significant impacts of altering NAD+ biosynthesis on bioenergetic profiles, inflammation and proliferation of HASMCs. Conclusion: The 6-metabolite model may help for noninvasive prediction of 1-year MACEs following PCI among patients with T2DM. [ABSTRACT FROM AUTHOR]

Background: Quality indicators are used to quantify the quality of care. A large number of quality indicators makes assessment of overall quality difficult, time consuming and impractical. There is consequently an increasing interest for composite measures based on a combination of multiple indicators. Objective: To examine the use of different approaches to construct composite measures of quality of care and to assess the use of methodological considerations and justifications. Methods: We conducted a literature search on PubMed and EMBASE databases (latest update 1 December 2020). For each publication, we extracted information on the weighting and aggregation methodology that had been used to construct composite indicator(s). Results: A total of 2711 publications were identified of which 145 were included after a screening process. Opportunity scoring with equal weights was the most used approach (86/145, 59%) followed by all-or-none scoring (48/145, 33%). Other approaches regarding aggregation or weighting of individual indicators were used in 32 publications (22%). The rationale for selecting a specific type of composite measure was reported in 36 publications (25%), whereas 22 papers (15%) addressed limitations regarding the composite measure. Conclusion: Opportunity scoring and all-or-none scoring are the most frequently used approaches when constructing composite measures of quality of care. The attention towards the rationale and limitations of the composite measures appears low. Discussion: Considering the widespread use and the potential implications for decision-making of composite measures, a high level of transparency regarding the construction process of the composite and the functionality of the measures is crucial. [ABSTRACT FROM AUTHOR]

Background: Structured risk-stratification to guide clinician assessment and engagement with evidence-based therapies may reduce care variance and improve patient outcomes for Acute Coronary Syndrome (ACS). The Australian Grace Risk score Intervention Study (AGRIS) explored the impact of the GRACE Risk Tool for stratification of ischaemic and bleeding risk in ACS. While hospitals in the active arm had a higher overall rate of invasive ACS management, there was neutral impact on important secondary prevention prescriptions/referrals, hospital performance measures, myocardial infarction and 12-month mortality leading to early trial cessation. Given the Grace Risk Tool is under investigation internationally, this process evaluation study provides important insights into the possible contribution of implementation fidelity on the AGRIS study findings.Methods: Using maximum variation sampling, five hospitals were selected from the 12 centres enrolled in the active arm of AGRIS. From these facilities, 16 local implementation stakeholders (Cardiology advanced practice nurses, junior and senior doctors, study coordinators) consented to a semi-structured interview guided by the Theoretical Domains Framework. Directed Content Analysis of qualitative data was structured using the Capability/Opportunity/Motivation-Behaviour (COM-B) model.Results: Physical capability was enhanced by tool usability. While local stakeholders supported educating frontline clinicians, non-cardiology clinicians struggled with specialist terminology. Physical opportunity was enhanced by the paper-based format but was hampered when busy clinicians viewed risk-stratification as one more thing to do, or when form visibility was neglected. Social opportunity was supported by a culture of research/evidence yet challenged by clinical workflow and rotating medical officers. Automatic motivation was strengthened by positive reinforcement. Reflective motivation revealed the GRACE Risk Tool as supporting but potentially overriding clinical judgment. Divergent professional roles and identity were a major barrier to integration of risk-stratification into routine Emergency Department practice. The cumulative result revealed poor form completion behaviors and a failure to embed risk-stratification into routine patient assessment, communication, documentation, and clinical practice behaviors.Conclusions: Numerous factors negatively influenced AGRIS implementation fidelity. Given the prominence of risk assessment recommendations in United States, European and Australian guidelines, strategies that strengthen collaboration with Emergency Departments and integrate automated processes for risk-stratification may improve future translation internationally. [ABSTRACT FROM AUTHOR]

Background: The safety and efficacy profile of bivalirudin has not been examined in a randomised controlled trial of patients undergoing rescue PCI. Objectives: We conducted an open-label, multi-centre, randomised controlled trial to compare bivalirudin with heparin ± glycoprotein IIb/IIIa inhibitors (GPIs) in patients undergoing rescue PCI. Methods: Between 2010–2015, we randomly assigned 83 patients undergoing rescue PCI to bivalirudin (n = 42) or heparin ± GPIs (n = 41). The primary safety endpoint was any ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) bleeding at 90 days. The primary efficacy endpoint was infarct size measured by peak troponin levels as a multiple of the local upper reference limit (Tn/URL). Secondary endpoints included periprocedural change in haemoglobin adjusted for red cells transfused, TIMI (Thrombolysis in Myocardial Infarction) bleeding, ST-segment recovery and infarct size determined by the Selvester QRS score. Results: The trial was terminated due to slow recruitment and futility after an interim analysis of 83 patients. The primary safety endpoint occurred in 6 (14%) patients in the bivalirudin group (4.8% GPIs) and 3 (7.3%) in the heparin ± GPIs group (54% GPIs) (risk ratio, 1.95, 95% confidence interval [CI], 0.52–7.3, P = 0.48). Infarct size was similar between the two groups (mean Tn/URL, 730 [±675] for bivalirudin, versus 984 [±1585] for heparin ± GPIs, difference, 254, 95% CI, -283-794, P = 0.86). There was a smaller decrease in the periprocedural haemoglobin level with bivalirudin than heparin ± GPIs (-7.5% [±15] versus -14% [±17], difference, -6.5%, 95% CI, -0.83–14, P = 0.0067). The rate of complete (≥70%) ST-segment recovery post-PCI was higher in patients randomised to heparin ± GPIs compared with bivalirudin. Conclusions: Whether bivalirudin compared with heparin ± GPI reduces bleeding in rescue PCI could not be determined. Slow recruitment and futility in the context of lower-than-expected bleeding event rates led to the termination of this trial (ANZCTR.org.au, ACTRN12610000152022). [ABSTRACT FROM AUTHOR]

Copyright of Farmacia is the property of Societatea de Stiinte Farmaceutice Romania and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Farmacia is the property of Societatea de Stiinte Farmaceutice Romania and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Few studies have measured device-based physical activity and sedentary behaviour following a percutaneous coronary intervention (PCI), with no studies comparing these behaviours between countries using the same methods. The aim of the study was to compare device-based physical activity and sedentary behaviour, using a harmonised approach, following a PCI on-entry into centre-based cardiac rehabilitation in two countries. Methods: A cross-sectional study was conducted at two outpatient cardiac rehabilitation centres in Australia and Sweden. Participants were adults following a PCI and commencing cardiac rehabilitation (Australia n = 50, Sweden n = 133). Prior to discharge from hospital, Australian participants received brief physical activity advice (< 5 mins), while Swedish participants received physical activity counselling for 30 min. A triaxial accelerometer (Actigraph GT3X/ActiSleep) was used to objectively assess physical activity (light (LPA), moderate-to-vigorous (MVPA)) and sedentary behaviour. Outcomes included daily minutes of physical activity and sedentary behaviour, and the proportion and distribution of time spent in each behaviour. Results: There was no difference in age, gender or relationship status between countries. Swedish (S) participants commenced cardiac rehabilitation later than Australian (A) participants (days post-PCI A 16 vs S 22, p < 0.001). Proportionally, Swedish participants were significantly more physically active and less sedentary than Australian participants (LPA A 27% vs S 30%, p < 0.05; MVPA A 5% vs S 7%, p < 0.01; sedentary behaviour A 68% vs S 63%, p < 0.001). When adjusting for wear-time, Australian participants were doing less MVPA minutes (A 42 vs S 64, p < 0.001) and more sedentary behaviour minutes (A 573 vs S 571, p < 0.001) per day. Both Swedish and Australian participants spent a large part of the day sedentary, accumulating 9.5 h per day in sedentary behaviour. Conclusion: Swedish PCI participants when commencing cardiac rehabilitation are more physically active than Australian participants. Potential explanatory factors are differences in post-PCI in-hospital physical activity education between countries and pre-existing physical activity levels. Despite this, sedentary behaviour is high in both countries. Internationally, interventions to address sedentary behaviour are indicated post-PCI, in both the acute setting and cardiac rehabilitation, in addition to traditional physical activity and cardiac rehabilitation recommendations. Trial registrations: Australia: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615000995572. Registered 22 September 2015, Sweden: World Health Organization Trial Registration Data Set: NCT02895451. [ABSTRACT FROM AUTHOR]

Aims ST-segment elevation myocardial infarction (STEMI) guidelines recommend primary percutaneous coronary intervention (pPCI) as the default reperfusion strategy when feasible ≤120 min of diagnostic ECG, and a pharmaco-invasive strategy otherwise. There is, however, a lack of direct evidence to support the guidelines, and in real-world situations, pPCI is often performed beyond recommended timelines. To assess 5-year outcomes according to timing of pPCI (timely vs. late) compared with a pharmaco-invasive strategy (fibrinolysis with referral to PCI centre). Methods and results The French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) programme consists of nationwide observational surveys consecutively recruiting patients admitted for acute myocardial infarction every 5 years. Among the 4250 STEMI patients in the 2005 and 2010 cohorts, those with reperfusion therapy and onset-to-first call time <12 h (n  = 2942) were included. Outcomes at 5 years were compared according to type of reperfusion strategy and timing of pPCI, using Cox multivariable analyses and propensity score matching. Among those, 1288 (54%) patients had timely pPCI (≤120 min from ECG), 830 (28%) late pPCI (>120 min), and 824 (28%) intravenous fibrinolysis. Five-year survival was higher with a pharmaco-invasive strategy (89.8%) compared with late pPCI [79.5%; adjusted hazard ratio (HR) 1.51; 1.13–2.02] and similar to timely pPCI (88.2%, adjusted HR 1.02; 0.75–1.38). Concordant results were observed in propensity score-matched cohorts and for event-free survival. Conclusion A substantial proportion of patients have pPCI beyond recommended timelines. As foreseen by the guidelines, these patients have poorer 5-year outcomes, compared with a pharmaco-invasive strategy. Open in new tab Download slide Open in new tab Download slide [ABSTRACT FROM AUTHOR]

Background: Composite measures combine data to provide a comprehensive view of patient outcomes. Despite composite measures being a valuable tool to assess post-intervention outcomes, the patient perspective is often missing. The purpose of this study was to develop a composite measure for an established cardiac outcome registry, by combining clinical outcomes following percutaneous coronary interventions (PCI) with a patient-reported outcome measure (PROM) developed specifically for this population (MC-PROM).Methods: Two studies were undertaken. Study 1: Patients who had undergone a PCI at one of the three participating registry hospital sites completed the 5-item MC-PROM. Clinical outcome data for the patients (e.g. death, myocardial infarction, repeat vascularisation, new bleeding event) were collected 30 days post-intervention as part of routine data collection for the cardiac registry. Exploratory factor analysis of clinical outcomes and MC-PROM data was conducted to determine the minimum number of constructs to be included in a composite measure. Study 2: Clinical experts participated in a Delphi technique, consisting of three rounds of online surveys, to determine the clinical outcomes to be included and the weighting of the clinical outcomes and MC-PROM score for the composite measure.Results: Study 1: Routine clinical outcomes and the MC-PROM data were collected from 266 patients 30 days post PCI. The MC-PROM score was not significantly correlated with any clinical outcomes. Study 2: There was a relatively consistent approach to the weighting of the clinical outcomes and MC-PROM items by the expert panel (n = 18) across the three surveys with the exception of the clinical outcome of 'deceased at 30 days'. The final composite measure included five clinical outcomes within 30 days weighted at 90% (new heart failure, new myocardial infarction, new stent thrombosis, major bleeding event, new stroke, unplanned cardiac rehospitalisation) and the MC-PROM score (comprising 10% of the total weighting).Conclusions: A single patient level composite score, which incorporates weighted clinical outcomes and a PROM was developed. This composite score provides a more comprehensive reported measure of individual patient wellbeing at 30 days post their PCI-procedure, and may assist clinicians to further assess and address patient level factors that potentially impact on clinical recovery. [ABSTRACT FROM AUTHOR]

Introduction: Long-term risk for recurrent cardiovascular events among myocardial infarction (MI) patients in the acute versus chronic stable phase is not well characterized. This study was conducted to evaluate risk factors associated with all-cause mortality and cardiovascular (CVD) morbidity and to determine the transition period from the acute to chronic stable phase of disease. Methods: Administrative claims data from a managed care database (2007–2012) were linked to the Social Security Death Index. Kaplan–Meier curves were generated over a 3-year period. The association between risk factors and clinical endpoints was assessed using Cox proportional hazard models. Poisson models estimated the 'transition time' from acute to chronic phase of disease. Results: On average, recurrent cardiovascular event rates were higher among acute MI patients in comparison to the chronic MI patients during the first 3 months of follow-up. Over the 3-year follow-up period, survival curves became parallel and for some outcomes (i.e., acute myocardial infarction and bleeding events), were not statistically significantly different between the two groups. In both the acute and chronic MI cohorts, diabetes, heart failure, and renal disease were consistently statistically significant and positively associated with greater risk of death and ischemic events. PAD was consistently associated with increased risk among the chronic cohort and composite endpoints among the acute patients. Conclusions: Greater understanding of differences in the CVD risk profiles and the transition from acute to chronic stable phase may help identify high-risk patients and inform clinical risk stratification and long-term disease management in MI patients. Funding: Merck & Co., Inc., Kenilworth, NJ, USA. [ABSTRACT FROM AUTHOR]

AKI is a potential complication of intravascular iodinated contrast exposure. Contrast-associated AKI, which typically manifests as small and transient decrements in kidney function that develop within several days of contrast administration, is associated with serious adverse outcomes, including progressive kidney dysfunction and death. However, a causal link between the small increases in serum creatinine that characteristically occur with contrast-associated AKI and serious adverse outcomes remains unproven. This is important given mounting evidence that clinically indicated, potentially lifesaving radiographic procedures are underutilized in patients with CKD. This has been hypothesized to be related to provider concern about precipitating contrast-associated AKI. Intravascular gadolinium-based contrast, an alternative to iodinated contrast that is administered with magnetic resonance imaging, has also been linked with potential serious adverse events, notably the development of nephrogenic systemic fibrosis in patients with severe impairment in kidney function. Patients hospitalized in the intensive care unit frequently have clinical indications for diagnostic and therapeutic procedures that involve the intravascular administration of contrast media. Accordingly, critical care providers and others treating critically ill patients should possess a sound understanding of the risk factors for and incidence of such outcomes, the ability to perform evidence-based risk-benefit assessments regarding intravascular contrast administration, and knowledge of empirical data on the prevention of these iatrogenic complications., (Copyright © 2022 by the American Society of Nephrology.)

Background: Hospital-based registries provide a key contribution in assessing the quality of care in acute myocardial infarction (MI) patients, although some concern on selection bias of included cases has recently arisen. We investigated the feasibility of a retrospective, population-based registry of MIs in monitoring the quality of care.Methods: We identified all the hospitalizations with a diagnosis of acute MI among 35-79 years old residents in the Varese province, Northern Italy, in 2007-2008. Information needed to define performance according to the American Heart Association set was extracted from hospital case histories. To characterize our approach, we focus on data completeness for critical event times and eligibility criteria, and on the analysis of ST-elevated MI (STEMI) patients according to received reperfusion treatment.Results: Exact time of hospital admission and of percutaneous coronary angioplasty (PCI) procedure was available in 96% and 77% of MIs, with no difference between non-transferred (n = 1399) and inter-hospital transferred (n = 300) patients. Data completeness for eligibility to action/treatment criteria was >90% for each performance measure except statin prescription at discharge (76%). About 45% of STEMI experienced a delay in PCI-capable hospital arrival, and only one every three ST-elevated MI patients received primary PCI; these were more likely to be younger male cases with less comorbidities than un-treated patients.Conclusions: Complementary to clinical registries, the retrospective population-based is a feasible approach which allows monitoring the entire pattern of care of all hospitalized MI patients independent of their clinical characteristics. [ABSTRACT FROM AUTHOR]

Background: The benefits of physical activity and cardiovascular rehabilitation on the reduction of cardiovascular risk are well documented. Despite this, significant barriers and challenges remain in optimizing patient risk factors post acute coronary syndromes (ACS) and ensuring patient compliance. Consumer wearable personal activity trackers represent a cost effective and readily available technology that may aid in this endeavour.Methods: UP-STEP ACS is a prospective single-blinded, two-arm, parallel, randomized control trial with an aim to enrol 200 patients all undertaking cardiac rehabilitation. It will assess the affect that personal activity monitors have on change in exercise capacity in patients post acute coronary syndromes primarily measured by a six-minute walk test (6MWT). Secondary end points will be the improvement in other cardiovascular risk factors, namely; blood lipid and glucose levels, weight, waist circumference, along with mood, quality of life and cardiac rehabilitation adherence. Patients will be randomized to either receive a personal activity tracker or standard post hospital care during their index event. After the 8- week intervention period, patients will return for a clinical review and repeat of baseline assessments including the 6MWT.Discussion: The utility and impact on exercise capacity of personal activity trackers in patient's post-acute coronary syndrome has not been assessed. This study aims to add to the scientific evidence emerging regarding the clinical utility and validity of these devices in different patient population groups. If proven to be of benefit, these devices represent a cost effective, easily accessible technology that could aid in the reduction of cardiovascular events.Trial Registration: The trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR). The registration number is ACTRN12617000312347 (28/02/2017). [ABSTRACT FROM AUTHOR]

Background: There are varying data on whether socioeconomic status (SES) affects the treatment in patients with acute coronary syndrome (ACS). Our aim was to obtain a reliable estimate of the effect of SES on discharge prescription of medications following an ACS through systematic review and meta-analysis. Methods: Medline, EMBASE and Global Health were searched systematically on 6th April 2016. Studies were eligible if the participants had ACS and reported the rate/odds of guideline-recommended ACS medications prescription (aspirin, antiplatelet, beta blocker, angiotensin co-enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB) and statin) at discharge stratified by SES. A meta-analysis was performed to pool the estimates, comparing the prescription ratio (PR) between the lowest and the highest SES groups. Results: Of 252 articles found from the search, seven met the eligibility criteria and it included 41,462 (20,986 from the lowest SES group) patients. We found that the individual/neighbourhood level SES did not affect the prescription of aspirin (PR (95% CI): 0.97 (0.91, 1.03)), but for beta blocker and statin, the lowest SES group were disadvantaged (0.84 (0.73, 0.94), 0.80 (0.62, 0.98), respectively). In contrast, ACEi were prescribed more often to the lowest individual/neighbourhood level SES group than the highest (1.13 (1.05, 1.22)). Although the risk of bias was low, there was considerable heterogeneity between the studies. Conclusions: Despite the recommendations to close the treatment gap, the rate of prescription of guideline-recommended medications in managing ACS is significantly different between patients with the lowest and the highest groups. A solution is needed to provide equitable care across the SES groups. PROSPERO Registry: Systematic review registration no.: CRD42016048503. Registered 28 September 2016. [ABSTRACT FROM AUTHOR]

Background: While the clinical benefits of exercise-based cardiac rehabilitation are well established, there is extensive variation in the interventions used within these trials. It is unknown whether variations in individual components of these exercise interventions provide different relative contributions to overall clinical outcomes. This study aims to systematically examine the relationship between individual components of the exercise intervention in cardiac rehabilitation (such as intensity and frequency) and clinical outcomes for people with coronary heart disease. Methods: In this systematic review, eligible trials were identified via searches of databases (PubMed, Allied and Complementary Medicine, EMBASE, PEDro, Science Citation Index Expanded, CINAHL, The Cochrane Library, SPORTDiscus) from citation tracking and hand-searching. Studies were included if they were randomised trials of a structured exercise intervention (versus usual care) for participants with coronary heart disease and reported at least one of cardiovascular mortality, total mortality, myocardial infarction or revascularisation outcomes. Each included trial was assessed using the Cochrane Risk of Bias Tool. Authors were also contacted for missing intervention details or data. Random effects meta-analysis was performed to calculate a summary risk ratio (RR) with 95% confidence interval (CI) for the effect of exercise on outcomes. Random effects meta-regression and subgroup analyses were conducted to examine the association between pre-specified co-variates (exercise components or trial characteristics) and each clinical outcome. Results: Sixty-nine trials were included, evaluating 72 interventions which differed markedly in terms of exercise components. Exercise-based cardiac rehabilitation was effective in reducing cardiovascular mortality (RR 0.74, 95% CI 0.65 to 0.86), total mortality (RR 0.90, 95% CI 0.83 to 0.99) and myocardial infarction (RR 0.80, 95% CI 0.70 to 0.92). This effect generally demonstrated no significant differences across subgroups of patients who received various types of usual care, more or less than 150 min of exercise per week and of differing cardiac aetiologies. There was however some heterogeneity observed in the efficacy of cardiac rehabilitation in reducing total mortality based on the presence of lipid lowering therapy ( I = 48%, p = 0.15 for subgroup treatment interaction effect). No single exercise component was identified through meta-regression as a significant predictor of mortality outcomes, although reductions in both total (RR 0.81, p = 0.042) and cardiovascular mortality (RR 0.72, p = 0.045) were observed in trials which reported high levels of participant exercise adherence, versus those which reported lower levels. A dose-response relationship was found between an increasing exercise session time and increasing risk of myocardial infarction (RR 1.01, p = 0.011) and the highest intensity of exercise prescribed and an increasing risk of percutaneous coronary intervention (RR 1.05, p = 0.047). Conclusions: Exercise-based cardiac rehabilitation is effective at reducing important clinical outcomes in patients with coronary heart disease. While our analysis was constrained by the quality of included trials and missing information about intervention components, there appears to be little differential effect of variations in exercise intervention, particularly on mortality outcomes. Given the observed effect between higher adherence and improved outcomes, it may be more important to provide exercise-based cardiac rehabilitation programs which focus on achieving increased adherence to the exercise intervention. [ABSTRACT FROM AUTHOR]

Background: Patients with non-ST elevation acute coronary syndrome complicated by left ventricular dysfunction (LVEF) are a poor prognosis group. The aim of our study was to assess the short and long term LEVF prognostic value in a cohort of NSTE-ACS patients undergoing surgical revascularization. Methods: We performed elective and isolated CABG on a cohort of 206 consecutive patients with LVEF≤0.40 complicating acute coronary syndrome. The case cohort was compared with a cohort of controls (LVEF>0.40) randomly selected (2:1) among patients who underwent the procedure during this period. Results: The Kaplan-Meier 5-year estimated survival rates for patients in the low and normal LVEF groups were 70.8% (95% confidence interval CI: 64.2–77.4) and 81.7% (95%CI: 77.8–85.6), respectively. A low LVEF was associated with both a higher all-cause (HR [95%CI] = 1.84[1.18–2.86]) and a higher cardiovascular mortality (HR = 2.07 [1.27–3.38]) during the first 12 months of follow-up. After adjustment for potential confounders, a low LVEF remained associated with a higher cardiovascular mortality only (1.87[1.03–3.38]) during the first 12 months of follow-up. After 12 months of follow-up, a low LVEF was no more associated with all-cause, nor cardiovascular mortality. Conclusion: Patients with low LVEF might require more intensive care than patients with normal LVEF during the year after the surgical procedure, but once the first postoperative year over, the initial low LVEF was no more associated with long term mortality. [ABSTRACT FROM AUTHOR]

Purpose: Discontinuation of anti-platelet therapy increases the risk of thrombotic complications whereas its continuation is believed to increase the risk of prolonged post-extraction bleeding. We therefore, performed this study to evaluate the risk of significant bleeding following dental extractions and also to assess the necessity of discontinuing anti-platelet therapy. Patients and methods: Three hundred patients requiring dental extraction were included in the study in which 200 patients were on anti-platelet therapy. Patients were divided into three groups of 100 patients each. Group 1 consisted of patients continuing their anti-platelet therapy, Group 2 consisted of patients whose anti-platelet therapy was interrupted and Group 3 comprised of healthy patients not on anti-platelet therapy. Preoperative bleeding and clotting time were determined for all patients. The procedure involved single or multiple teeth (>3 teeth) extractions under local anesthesia with a vasoconstrictor. Pressure pack was given in all cases as in routine dental extractions and bleeding was checked after 15, 30 min, 1, 24, 48 h and 1 week. Immediate post-extraction bleeding was considered to be prolonged if it continued beyond 30 min in spite of the pressure pack. Late and very late bleeding was considered to be clinically significant if it extended beyond 12 and 24 h respectively. Results: The mean bleeding time in Groups 1, 2, and 3 were 1 min and 32 s, 1 min and 25 s, and 1 min and 27 s, respectively. Prolonged immediate post-extraction bleeding (bleeding after 30 min) was present among 9 patients in Group 1 (9 %) and 15 patients in Group 2 (15 %) whereas it was not seen in any patient of Group 3. Bleeding after 1 h was present in 9 patients of Group 2 (9 %) and was controlled with gelatin sponge within half an hour thereafter. None of the patients in any group reported with bleeding after 24, 48 h and 1 week. Conclusion: Dental extractions can be safely carried out in patients on anti-platelet therapy without the risk of significant post-extraction bleeding thus averting the risk of thromboembolic events that might take place on temporary discontinuation of antiplatelet therapy. [ABSTRACT FROM AUTHOR]

Introduction: Many studies have now demonstrated the efficacy of text messaging in positively changing behaviours. We aimed to identify features and factors that explain the effectiveness of a successful text messaging program in terms of user engagement, perceived usefulness, behavior change and program delivery preferences. Methods: Mixed methods qualitative design combining four data sources; (i) analytic data extracted directly from the software system, (ii) participant survey, (iii) focus groups to identify barriers and enablers to implementation and mechanisms of effect and (iv) recruitment screening logs and text message responses to examine engagement. This evaluation was conducted within the TEXT ME trial—a parallel design, single-blind randomized controlled trial (RCT) of 710 patients with coronary heart disease (CHD). Qualitative data were interpreted using inductive thematic analysis. Results: 307/352 (87% response rate) of recruited patients with CHD completed the program evaluation survey at six months and 25 participated in a focus group. Factors increasing engagement included (i) ability to save and share messages, (ii) having the support of providers and family, (iii) a feeling of support through participation in the program, (iv) the program being initiated close to the time of a cardiovascular event, (v) personalization of the messages, (vi) opportunity for initial face-to-face contact with a provider and (vii) that program and content was perceived to be from a credible source. Clear themes relating to program delivery were that diet and physical activity messages were most valued, four messages per week was ideal and most participants felt program duration should be provided for at least for six months or longer. Conclusions: This study provides context and insight into the factors influencing consumer engagement with a text message program aimed at improving health-related behavior. The study suggests program components that may enhance potential success but will require integration at the development stage to optimize up-scaling. Trial Registration: Australia and New Zealand Clinical Trials Registry, . [ABSTRACT FROM AUTHOR]