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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: 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]

Objective: To compare two methods of risk stratification for suspected acute coronary syndrome (ACS) in the ED. Methods: A prospective observational multicentre study was undertaken of patients undergoing evaluation in the ED for possible ACS. We compared the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHF/CSANZ) guideline and the Thrombolysis in Myocardial Infarction (TIMI) risk score for differentiating high- and low-risk patients. Composite outcome was all cause death, myocardial infarction or coronary revascularisation within 30 days. Results: Of 1758 enrolments, 223 (13%) reached the study outcome. Area under the receiver operator characteristic (ROC) curve was 0.79 (95% CI 0.76-0.81) for the NHF/CSANZ group and 0.71 (0.68-0.75) for TIMI score based on initial troponin result ( P < 0.001), and 0.82 (95% CI 0.80-0.84) and 0.76 (0.73-0.79) respectively when the 8-12 h troponin result is included ( P = 0.001). Thirty day event rates were 33% for NHF/CSANZ high-risk vs 1.5% for combined low/intermediate risk ( P < 0.001). For TIMI score, 30 day event rates were 23% for a score ≥2 and 4.8% for TIMI < 2 ( P < 0.001). The NHF/CSANZ guideline identified more patients as low risk compared with the TIMI risk score (61% vs 48%, P < 0.001). Conclusions: The NHF/CSANZ guideline is superior to the TIMI risk score for risk stratification of suspected ACS in the ED. [ABSTRACT FROM AUTHOR]

Question In patients with chest pain, how well do the NICE algorithms, based on high-sensitivity troponin (hsTn) I and T assays, rule out acute myocardial infarction (AMI)? Methods Design 3 cohort studies for post hoc validation of the recommended National Institute for Health and Care Excellence (NICE) algorithms. ACTRN12611001069943, NCT00470587. Setting 3 tertiary emergency departments (EDs) in Europe, Australia, and New Zealand. Patients 3580 patients ࣙ 18 years of age (mean age 55 to 65 y, 67% men) who presented to the ED with ࣙ 5 min of possible cardiac symptoms (acute chest, epigastric, neck, jaw or arm pain; or discomfort or pressure without an apparent noncardiac source) and received orders for serial biomarker testing (2 cohorts); or presented with symptoms of AMI (acute chest pain and angina pectoris), with onset or peak in the previous 12 hours (1 cohort). Exclusion criteria included ST elevation on electrocardiogram at presentation. Description of prediction guides hsTnI algorithm: AMI was ruled out if baseline hsTnI was ࣘ 2 ng/L (limit of detection) or if baseline and hsTnI repeated at 3 hours was < 26 ng/L (99th percentile of a healthy reference population, coefficient of variation [CV] < 5%). hsTnT algorithm: AMI was ruled out if baseline hsTnT was < 3 ng/L (limit of blank) or hsTnT repeated at 2 hours was < 14 ng/L (99th percentile, CV 10% at 13 ng/L) and absolute change within 2 hours was < 20%. Outcomes Primary outcome was cardiac death or AMI within 24 hours of presentation. Secondary outcome was major adverse cardiac events (MACE) comprising cardiac death, cardiac arrest, acute coronary syndromes (AMI or unstable angina), cardiogenic shock, or coronary revascularization at 30 days and sensitivity, specificity, and negative predictive value of the assays. Main results 15% of patients had AMI at presentation. 51 of 2506 (2.0%) patients ruled out by hsTnI and 7 of 1794 (0.4%) ruled out by hsTnT had AMI. 267 (11%) and 153 (8.5%) patients ruled out by hsTnI and hsTnT, respectively, had MACE at 30 days. Accuracy of the algorithms for ruling out AMI are shown in the Table. Conclusions In patients presenting with chest pain, the NICE algorithms, based on baseline and serial high-sensitivity troponin I and T assays, had > 89% sensitivity and 62% to 93% specificity for detecting acute myocardial infarction (AMI). > 8.5% of patients with AMI "ruled out" had major adverse cardiac events. [ABSTRACT FROM AUTHOR]