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Background: To investigated the prognosis of the most prevalent cancers (breast-, gastrointestinal-, and lung cancer), according to cancer status (i.e., active-, non-active-, history of-, and no cancer), following first-time of acute coronary syndrome (ACS)., Methods: Danish nationwide registers were used to identify patients with first-time ACS from 2000-2018. Patients were stratified according to cancer type and status. Hazard ratios (HR) estimated by adjusted Cox regression models for 1year all-cause mortality reported. Further absolute risks of 1year cardiovascular versus non-cardiovascular death and 30-day cumulative incidence of coronary angiograms (CAG) was estimated, using the Aalen-Johansen non-parametric method, with competing risk of death., Results: We identified 150,478 (95.7%) with no cancer, 2,370 (1.5%) with history of cancer, 2,712 (1.7%) with non-active cancer and 1,704 (1.1%) with active cancer. Cancer patients were older with more comorbidities than patients with no cancer. When compared with no cancer, we found HRs (95% confidence intervals) of 1.71 (1.44-2.02), 2.47 (2.23-2.73) and 4.22 (3.87-4.60) correspondingly for active breast-, gastrointestinal-, and lung cancer. Increased HRs were also found for non-active cancers, but not for history of cancer. Cardiovascular disease was the leading cause of death in all patients. Among patients with active breast-, gastrointestinal-, and lung cancer 43%, 43%, and 31% underwent CAG, correspondingly, compared with 77% of patients without cancer., Conclusions: Active- and non-active cancers were associated with an increased 1-year all-cause mortality compared with patients with history of cancer and no cancer. Cardiovascular disease was the leading cause of death; notably CAG was less frequently performed in cancer patients., Competing Interests: Conflict of interest None declared., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To better guide decisions regarding antithrombotic treatment in individual patients surviving 6 months following an acute coronary syndrome (ACS) by balancing between subsequent recurrent ischaemic and bleeding risk., Methods: Patients surviving 6 months following an ACS were followed in an Australian registry. Ischaemic (composite of cardiovascular death, myocardial infarction or stroke) and bleeding (≥BARC 2) events were collected. A dual binary outcome modelling strategy was used arriving at a common set of variables from which bleeding and ischaemic risk could be independently determined in individual patients. Patients in whom bleeding rates exceeded composite ischaemic event rates during the follow-up period were identified., Results: The cohort comprised 5,905 patients in whom 215 experienced an ischaemic event and 49 a bleeding event. The single set of variables included in both ischaemic and bleeding models (C-statistics 0.71 and 0.72 respectively) included modified TIGRIS 1 ischaemic score, mode of revascularisation, history of heart failure, anaemia, multivessel disease, readmission within 6 months of index ACS and age >75. In the majority, ischaemic events were more frequent than bleeding events. In higher risk patients post coronary artery bypass grafting (CABG), bleeding events were more frequent than recurrent ischaemic events., Conclusion: The risk of recurrent ischaemic events exceeds bleeding in most patients followed 6 to 24 months following an ACS. Post CABG patients with comorbidities have a higher risk of bleeding over this period during which time attention should be directed towards modifiable bleeding risk factors including requirement for dual antiplatelet therapy., (Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.)

Background: Many patients with atrial fibrillation (AF) do not receive oral anticoagulant (OAC) therapy. The aims of this study were to 1) document receipt of OAC among patients with a history of AF admitted with an acute coronary syndrome (ACS); and to 2) determine whether hospital admission was associated with an improvement in prescription of OAC therapy., Methods: Using Australian data from the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE) and Global Registry of Acute Coronary Events (GRACE) registries, 1,479 patients with a history of AF presenting with an ACS were separated into two groups: aspirin monotherapy/no therapy (No OAC) or oral anticoagulant ± aspirin (OAC). Clinical characteristics and in-hospital treatments and outcomes were compared., Results: Of 1,479 patients, 532 (36%) with a history of AF presented on OAC with the remainder receiving antiplatelet (n=580 [39%]) or no antithrombotic therapy (n=367 [25%]). Treatment with OAC prior to presentation increased during the 18 years of the study (27% to 56%, p=0.0002). Ninety-five per cent (95%) of the OAC group had a CHA2DS2-VA score >1 vs 88% of the No OAC group (p<0.001). Patients receiving OAC had a lower prevalence of bleeding risk factors than no OAC patients (p<0.001). Only 39% of this cohort was discharged on an OAC, although this increased during the observational period (26-61%, p≤0.0001)., Conclusion: In patients presenting with an ACS with a history of AF, receipt of OAC has improved over time but remains suboptimal. There is minimal escalation in provision of OAC therapy during hospital care, indicating missed opportunities to address this evidence practice gap., (Crown Copyright © 2021. Published by Elsevier B.V. All rights reserved.)

Objective: To determine whether the availability of invasive coronary angiography at the hospital of presentation influences catheterisation rates for patients with acute coronary syndrome (ACS), and whether presenting to a catheterisation-capable hospital is associated with better outcomes for patients with ACS., Design, Setting: Retrospective cohort study; analysis of Cooperative National Registry of Acute Coronary Events (CONCORDANCE) data., Setting, Participants: Adults admitted with ACS to 43 Australian hospitals (including 31 catheterisation-capable hospitals), February 2009 - October 2018., Main Outcome Measures: Major adverse cardiovascular events (myocardial infarction, stroke, congestive heart failure, cardiogenic shock, cardiovascular death) and all-cause deaths in hospital and by six and 12- or 24-month follow-up., Results: The proportion of women among the 5637 patients who presented to catheterisation-capable hospitals was smaller than for the 2608 patients who presented to hospitals without catheterisation facilities (28% v 33%); the proportion of patients diagnosed with ST elevation myocardial infarction was larger (32% v 20%). The proportions of patients who underwent catheterisation (81% v 70%) or percutaneous coronary intervention (49% v 35%) were larger for those who presented to catheterisation-capable hospitals. The baseline characteristics of patients who underwent catheterisation were similar for both presentation hospital categories, as were rates of major adverse cardiovascular events and all-cause death in hospital and by 6- and 12- or 24-month follow-up., Conclusions: Although a larger proportion of patients who presented to catheterisation-capable hospitals underwent catheterisation, patients with similar characteristics were selected for the procedure, independent of the hospital of presentation. Major outcomes for patients were also similar, suggesting equitable management of patients with ACS across Australia., (© 2021 AMPCo Pty Ltd.)

Importance: Although international guidelines recommend use of the Global Registries of Acute Coronary Events (GRACE) risk score (GRS) to guide acute coronary syndrome (ACS) treatment decisions, the prospective utility of the GRS in improving care and outcomes is unproven., Objective: To assess the effect of routine GRS implementation on guideline-indicated treatments and clinical outcomes of hospitalized patients with ACS., Design, Setting, and Participants: Prospective cluster (hospital-level) randomized open-label blinded end point (PROBE) clinical trial using a multicenter ACS registry of acute care cardiology services. Fixed sampling of the first 10 patients within calendar month, with either ST-segment elevation or non-ST-segment elevation ACS. The study enrolled patients from June 2014 to March 2018, and data were analyzed between February 2020 and April 2020., Interventions: Implementation of routine risk stratification using the GRS and guideline recommendations., Main Outcomes and Measures: The primary outcome was a performance score based on receipt of early invasive treatment, discharge prescription of 4 of 5 guideline-recommended pharmacotherapies, and cardiac rehabilitation referral. Clinical outcomes included a composite of all-cause death and/or myocardial infarction (MI) within 1 year., Results: This study enrolled 2318 patients from 24 hospitals and was stopped prematurely owing to futility. Of the patients enrolled, median age was 65 years (interquartile range, 56-74 years), 29.5% were women (n = 684), and 62.9% were considered high risk (n = 1433). Provision of all 3 measures among high-risk patients did not differ between the randomized arms (GRS: 424 of 717 [59.9%] vs control: 376 of 681 [55.2%]; odds ratio [OR], 1.04; 95% CI, 0.63-1.71; P = .88). The provision of early invasive treatment was increased compared with the control arm (GRS: 1042 of 1135 [91.8%] vs control: 989 of 1183 [83.6%]; OR, 2.26; 95% CI, 1.30-3.96; P = .004). Prescription of 4 of 5 guideline-recommended pharmacotherapies (GRS: 864 of 1135 [76.7%] vs control: 893 of 1183 [77.5%]; OR, 0.97; 95% CI, 0.68-1.38) and cardiac rehabilitation (GRS: 855 of 1135 [75.1%] vs control: 861 of 1183 [72.8%]; OR, 0.68; 95% CI, 0.32-1.44) were not different. By 12 months, GRS intervention was not associated with a significant reduction in death or MI compared with the control group (GRS: 96 of 1044 [9.2%] vs control: 146 of 1087 [13.4%]; OR, 0.66; 95% CI, 0.38-1.14)., Conclusions and Relevance: Routine GRS implementation in cardiology services with high levels of clinical care was associated with an increase in early invasive treatment but not other aspects of care. Low event rates and premature study discontinuation indicates the need for further, larger scale randomized studies., Trial Registration: anzctr.org.au Identifier: ACTRN12614000550606.

We assessed the association of BMI with all-cause and cardiovascular (CV) mortality in a contemporary acute coronary syndrome cohort. Patients from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events and Global Registry of Acute Coronary Events between 2009 and 2019, were divided into BMI subgroups (underweight: <18.5, healthy: 18.5 to 24.9, overweight: 25 to 29.9, obese: 30 to 39.9, extremely obese: >40). Logistic regression was used to determine the association between BMI group and outcomes of all cause and CV death in hospital, and at 6 months. 8,503 patients were identified, mean age 64 ± 13, 72% male. The BMI breakdown was: underweight- 95, healthy- 2,140, overweight- 3,258, obese- 2,653, extremely obese- 357. Obese patients were younger (66 ± 12 vs 67 ± 13), with more hypertension, diabetes, and dyslipidemia vs healthy (all p < 0.05). Obese had lower hospital mortality than healthy: all-cause: 1% versus 4%, aOR (95% CI): 0.49(0.27, 0.87); CV: 1% versus 3%, 0.51(0.27, 0.96). At 6-month underweight had higher mortality than healthy: all-cause: 11% versus 4%, 2.69(1.26, 5.76); CV: 7% versus 1%, 3.54(1.19, 10.54); whereas obese had lower mortality: all-cause: 1% versus 4%, 0.48(0.29, 0.77); CV: 0.4% versus 1%, 0.42(0.19, 0.93). When BMI was plotted as a continuous variable against outcome a U-shaped relationship was demonstrated, with highest event rates in the most obese (>60). In conclusion, BMI is associated with mortality following an acute coronary syndrome. Obese patients had the best outcomes, suggesting persistence of the obesity paradox. However, there was a threshold effect, and favorable outcomes did not extend to the most obese., (Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the prevalence and identify predictors of people hospitalised with acute coronary syndrome (ACS) receiving intensive lipid-lowering therapy during the 12 months after their discharge from hospital., Design: Retrospective observational analysis., Setting: Data were extracted from CONCORDANCE, a prospective, Australian investigator-initiated ACS registry., Participants: Patients enrolled in CONCORDANCE during January 2015 - May 2016 who survived to hospital discharge, for whom information on lipid-lowering therapy 6 or 12 months after discharge from hospital were available., Main Outcome Measures: Not receiving intensive lipid-lowering therapy (with or without ezetimibe) at the most recent follow-up (6 or 12 months); predictors of not receiving intensive lipid-lowering therapy., Results: 1876 of 3441 patients (55%) were receiving intensive lipid-lowering therapy 6 or 12 months after their hospitalisation with an ACS. Predictors of not receiving intensive lipid-lowering therapy included not been prescribed this treatment prior to their hospital admission (odds ratio [OR], 1.53; 95% CI, 1.26-1.85) or at hospital discharge (aOR, 7.24; 95% CI, 4.37-12.0), being a woman (aOR, 1.20; 95% CI, 1.02-1.41), and not being referred for cardiac rehabilitation (aOR 1.39; 95% CI, 1.09-1.78). Patients who were managed medically in hospital (not revascularised; aOR, 1.54; 95% CI, 1.25-1.91) or underwent coronary artery bypass grafting (aOR 1.55; 95% CI, 1.26-1.92) were less likely to be receiving intensive lipid-lowering therapy at follow-up than those with a percutaneous coronary intervention. Unmeasured hospital factors accounted for 17% of the variation in the likelihood of intensive lipid-lowering therapy., Conclusions: 45% of patients in Australia are not receiving intensive lipid-lowering therapy in the 12 months after their ACS. Optimising oral lipid-lowering therapy would reduce the recurrence of coronary events in this high risk group., (© 2018 AMPCo Pty Ltd.)

Background: Socioeconomic status (SES) is a social determinant of both health and receipt of health care services, but its impact is under-studied in acute coronary syndrome (ACS). The aim of this study was to examine the influence of SES on in-hospital care, and clinical events for patients presenting with an ACS to public hospitals in Australia., Methods: Data from 9064 ACS patient records were collected from 41 public hospitals nationwide from 2009 as part of the Cooperative National Registry of Acute Coronary Syndrome Care (CONCORDANCE) registry. For this analysis, we divided the cohort into four socioeconomic groups (based on postcode of usual residence) and compared the in-hospital care provided and clinical outcomes before and after adjustment for both patient clinical characteristics and hospital clustering., Results: Patients were divided into four SES groups (from the most to the least disadvantaged: 2042 (23%) vs. 2104 (23%) vs. 1994 (22%) vs. 2968 (32%)). Following adjustments for patient characteristics, there were no differences in the odds of receiving coronary angiogram, revascularisation, prescription of recommended medication, or referral to cardiac rehabilitation across the SES groups (p=0.06, 0.69, 0.89 and 0.79, respectively). After adjustment for clinical characteristics, no associations were observed for in-hospital and cumulative death (p=0.62 and p=0.71, respectively). However, the most disadvantaged group were 37% more likely to have a major adverse cardiovascular event (MACE) than the least disadvantaged group (OR (95% CI): 1.37 (1.1, 1.71), p=0.02) driven by incidence of in-hospital heart failure., Conclusions: Although there may be gaps in the delivery of care, this delivery of care does not differ by patient's SES. It is an encouraging affirmation that all patients in Australian public hospitals receive equal in-hospital care, and the likelihood of death is comparable between the SES groups., (Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Aims: There is little information on clinical risk stratification (CRS) compared to objective risk tools in patients with non-ST elevation acute coronary syndromes (NSTEACS). We quantified CRS use, its agreement with Global Registry of Acute Coronary Events (GRACE) risk scores (GRS), and association with outcomes., Methods and Results: Data were extracted from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE), a multi-centre NSTEACS registry. From February 2009 to December 2015, 4512 patients from 41 sites were included. Predictors of CRS use and association with treatment were identified, CRS-GRS agreement determined and prediction of in-hospital and 6-month mortality compared. Clinical risk stratification was documented in 21% of patients. Family history of coronary disease was the only independent predictor of CRS use [odds ratio (OR) 1.23, 95% confidence interval (95% CI) 1.04-1.45]; electrocardiogram changes (OR 0.8, 95% CI 0.68-0.96), elevated biomarkers (OR 0.59, 95% CI 0.48-0.73), dementia (OR 0.56, 95% CI 0.36-0.84), and an urban hospital setting (OR 0.41, 95% CI 0.19-0.89) were independent negative predictors. A treatment-risk paradox was observed: high CRS risk patients received less anticoagulation (79% vs. 88%, P = 0.001) and angiography (83% vs. 71%, P < 0.001). CRS-GRS agreement was poor (kappa coefficient = 0.034) and CRS less predictive for in-hospital (c-statistic 0.54 vs. 0.87, P < 0.001) and 6-month (c-statistic 0.55 vs. 0.74, P < 0.01) mortality., Conclusion: In Australia, CRS does not guide treatment, correlate with GRS or predict outcomes. This study suggests the need for greater awareness and integration of validated tools such as the GRACE score to optimally direct treatment and potentially improve outcomes.

Background: Most patients are recommended secondary prevention pharmacotherapies following an acute coronary syndromes (ACS)., Aim: To identify predictors of adherence at 6 months and strategies to improve adherence to these therapies., Methods: Patients in the CONCORDANCE registry who were discharged on evidence-based medications were stratified into those receiving ≥75% ('adherent') or <75% ('non-adherent') of indicated medications at 6 months. Baseline characteristics, hospital and post-discharge care were compared between groups. Multivariable logistic analysis identified independent predictors of adherence. The relative contribution of each clinical or treatment factor to 'adherence' was determined using an adequacy measure method., Results: Follow-up data were available for 6595 patients, 4492 (68.1%) of whom were 'adherent'. Clinical factors predictive of adherence included previous stroke, percutaneous coronary intervention (PCI) and hypertension (odds ratios (OR) 1.36-1.56); factors predictive of non-adherence included discharge diagnosis of non-ST-segment elevation myocardial infarction (vs unstable angina) (OR 0.51) and atrial fibrillation (OR 0.59). Discharge on ≥75% of indicated medications was a strong predictor of adherence at 6 months (OR 10.23, 95% confidence interval 7.89-13.27); in-hospital management factors predicting non-adherence were medical management alone (OR 0.34) and coronary artery bypass graft (OR 0.50) (both vs PCI). Post-discharge predictors of adherence included cardiac rehabilitation (OR 1.36) and general practitioner attendance (OR 1.40)., Conclusion: Failure to discharge patients on indicated therapies is the most important modifiable predictor of adherence failure 6 months after an ACS. Implementing protocols to automate prescription of indicated discharge therapies, has the potential to reduce non-adherence dramatically in the 6 months following discharge., (© 2018 Royal Australasian College of Physicians.)

Background: Despite guideline recommendation of dual antiplatelet therapy (DAPT) in treating ACS, DAPT is underutilized. Our objective was to determine independent predictors of DAPT non-prescription in ACS and describe pattern of DAPT prescription over time., Methods: Patients presenting to 41 Australian hospitals with an ACS diagnosis between 2009 and 2016 were stratified according to discharge prescription with DAPT and single antiplatelet therapy (SAPT) or no antiplatelet therapy. Multiple stepwise logistic regression, accounting for within hospital clustering, was used to determine the independent predictors of DAPT non-prescription, defined as discharge with SAPT alone or no antiplatelet agent., Results: 8939 patients survived to discharge with an ACS diagnosis. Of these, 6294 (70.4%) patients were discharged on DAPT, 2154 (24.1%) on SAPT and 491 (5.5%) on no antiplatelet agent. Independent predictors of DAPT non-prescription in the overall cohort were: in-hospital CABG (OR 0.09, 95%CI 0.05-0.14), discharge with warfarin (0.10 (0.07-0.14)), in hospital major bleeding (0.48 (0.34-0.67), diagnosis of unstable angina (0.35, (0.27-0.45)), non-ST-elevation myocardial infarction (0.67 (0.57-0.78)) [both vs. ST-segment elevation myocardial infarction], in hospital atrial arrhythmia (0.72 (0.60-0.86)), history of hypertension (0.83 (0.73-0.94)) and GRACE high risk (0.83 (0.71-0.98)). There was an increase in prescription of DAPT and a shift towards ticagrelor over clopidogrel for ACS from 2013 to 2016 (p<0.0001), but no overall change in the frequency of DAPT prescription over the entire study period., Conclusion: This study revealed high-risk ACS subgroups who do not receive optimal DAPT. Strategies are necessary to bridge the treatment gap in ACS antiplatelet management., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

Background: High-sensitivity cardiac troponin assays enable myocardial infarction to be ruled out earlier, but the optimal approach is uncertain. We compared the European Society of Cardiology rule-out pathway with a pathway that incorporates lower cardiac troponin concentrations to risk stratify patients., Methods: Patients with suspected acute coronary syndrome (n=1218) underwent high-sensitivity cardiac troponin I measurement at presentation and 3 and 6 or 12 hours. We compared the European Society of Cardiology pathway (<99th centile at presentation or at 3 hours if symptoms <6 hours) with a pathway developed in the High-STEACS study (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary S yndrome) population (<5 ng/L at presentation or change <3 ng/L and <99th centile at 3 hours). The primary outcome was a comparison of the negative predictive value of both pathways for index type 1 myocardial infarction or type 1 myocardial infarction or cardiac death at 30 days. We evaluated the primary outcome in prespecified subgroups stratified by age, sex, time of symptom onset, and known ischemic heart disease., Results: The primary outcome occurred in 15.7% (191 of 1218) patients. In those less than the 99th centile at presentation, the European Society of Cardiology pathway ruled out myocardial infarction in 28.1% (342 of 1218) and 78.9% (961 of 1218) at presentation and 3 hours, respectively, missing 18 index and two 30-day events (negative predictive value, 97.9%; 95% confidence interval, 96.9-98.7). The High-STEACS pathway ruled out 40.7% (496 of 1218) and 74.2% (904 of 1218) at presentation and 3 hours, missing 2 index and two 30-day events (negative predictive value, 99.5%; 95% confidence interval, 99.0-99.9; P <0.001 for comparison). The negative predictive value of the High-STEACS pathway was greater than the European Society of Cardiology pathway overall ( P <0.001) and in all subgroups, including those presenting early or known to have ischemic heart disease., Conclusions: Use of the High-STEACS pathway incorporating low high-sensitivity cardiac troponin concentrations rules out myocardial infarction in more patients at presentation and misses 5-fold fewer index myocardial infarctions than guideline-approved pathways based exclusively on the 99th centile., Clinical Trial Registration: URL: http://clinicaltrials.gov. Unique identifier: NCT01852123., (© 2016 The Authors.)

Background: There is wide variation in the use of radial over femoral access for patients with ACS. This study evaluates the factors associated with the selection of radial versus femoral angiography in Australia and New Zealand and the effect of access site on clinical events in acute coronary syndrome (ACS) patients., Methods: An analysis of the SNAPSHOT ACS audit was conducted during May 2012 across 286 hospitals in Australia and New Zealand. Data collected included baseline patient characteristics, hospital site details, treatment received, clinical events in-hospital and mortality at 18 months. Univariate and multivariable analyses were performed., Results: Of the 1621 patients undergoing coronary angiography, access was through the femoral artery in 1043 (63%), and the radial in 578 (36%) patients. Radial access dominated in New Zealand (241 out of 327, 73.7%), compared to Australia (337 out of 1293, 26.1%, p=<0.001), with interstate variation (6% to 54%, p=<0.001). Independent predictors of access site included country of admission (Odds of radial, Aus v NZ OR 0.14, 95% CI 0.08-0.24, p=<0.0001), prior CABG surgery (OR 0.16, 95% CI 0.09-0.31, p=<0.0001), high GRACE score (90 th decile) (OR 0.44, 95% CI 0.21-0.91, p=0.026) and admission to a centre with high annual PCI volume (>209 cases per year) (OR 1.86, 95% CI 1.06-3.26, p=0.03). After adjustment, there was no difference in clinical events in-hospital or mortality at 18 months CONCLUSION: Coronary angiography in New Zealand rather than Australia is the strongest predictor of radial access in ACS patients. There was no difference in outcomes according to access site in this population based cohort study., (Copyright © 2016. Published by Elsevier B.V.)