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Aims Spontaneous coronary artery dissection (SCAD) is an under-recognized cause of myocardial infarction. We aimed to investigate SCAD survivors' perceptions of their quality-of-care and its relationship to quality-of-life. Methods and results An anonymous survey was distributed online to SCAD survivors involved in Australian SCAD support groups, with 172 (95.3% female, mean age 52.6 ± 9.2 years) participants in the study. The survey involved assessment of quality-of-life using a standardized questionnaire (EQ-5DTM-3L). Respondents rated the quality-of-care received during their hospital admission for SCAD with a median of 8/10 [interquartile range (IQR) 7–10]. Respondents ≤ 50 years vs. >50 years were more likely to perceive that their symptoms were not treated seriously as a myocardial infarction (χ2 = 4.127, df = 1, P < 0.05). Participants rated clinician's knowledge of SCAD with a median of 4/10 (IQR 2–8) and 7/10 (IQR 3–9) for Emergency and Cardiology clinicians, respectively (P < 0.05). The internet was the most selected source (45.4%) of useful SCAD information. The mean EQ-5DTM summary index was 0.79 (population norm 0.87). A total of 47.2% of respondents reported a mental health condition diagnosis, with 36% of these diagnosed after their admission with SCAD. Quality-of-life was significantly associated with perceived quality-of-care: EQ-5DTM index/(1-EQ-5DTM index) increased by 13% for each unit increase in quality-of-care after adjusting for age and comorbidities (P < 0.001). Conclusion While SCAD survivors rated their overall hospital care highly, healthcare providers' knowledge of SCAD was perceived to be poor, and the most common source of SCAD information was the internet. Mental health conditions were common, and a significant association was observed between perceived quality-of-care and SCAD survivors' quality-of-life. [ABSTRACT FROM AUTHOR]

Aim: To determine the reliability of hospital discharge codes for heart failure (HF), acute myocardial infarction (AMI) and stroke compared with adjudicated diagnosis, and to pilot a scalable approach to adjudicate records on a population‐based sample. Methods: A population‐based sample of 685 people with diabetes admitted (1274 admissions) to one of three Australian hospitals during 2018–2020 were randomly selected for this study. All medical records were reviewed and adjudicated. Results: Cardiovascular diseases were the most common primary reason for hospitalisation in people with diabetes, accounting for ~17% (215/1274) of all hospitalisations, with HF as the leading cause. ICD‐10 codes substantially underestimated HF prevalence and had the lowest agreement with the adjudicated diagnosis of HF (Kappa = 0.81), compared with AMI and stroke (Kappa ≥ 0.91). While ICD‐10 codes provided suboptimal sensitivity (72%) for HF, the performance was better for AMI (sensitivity 84%; specificity 100%) and stroke (sensitivity 85%; specificity 100%). A novel approach to screen possible HF cases only required adjudicating 8% (105/1274) of records, correctly identified 78/81 of HF admissions and yielded 96% sensitivity and 98% specificity. Conclusions: While ICD‐10 codes appear reliable for AMI or stroke, a more complex diagnosis such as HF benefits from a two‐stage process to screen for suspected HF cases that need adjudicating. The next step is to validate this novel approach on large multi‐centre studies in diabetes. [ABSTRACT FROM AUTHOR]

Background: Sexual activity and intimacy contribute to wellbeing throughout adult life, including after a heart attack. Providing support and information about sexual activity and intimacy after a heart attack is recognised as part of a comprehensive approach to cardiac rehabilitation. Previous research shows that patients expect health professionals to initiate discussions about sexual activity and intimacy, but that this seldom occurs. Methods: Drawing on qualitative survey responses from a range of Australian health professionals working in cardiac care and rehabilitation, this research examined their perspectives on discussing sexual activity and intimacy with their patients, and patients' partners. Using a social constructionist approach, thematic analysis was used to identify themes expressed by participants. Results: Discussions about sexual activity and intimacy after heart attack were perceived as nebulous and taboo. The predominance of an illness – rather than wellness – framing of these discussions and a tendency for health professionals to make judgement calls contributed to discussions not occurring. Health professionals also identified a range of intrapersonal, interpersonal and structural obstacles to discussions, including embarrassment, fear of patients' embarrassment, a lack of role clarity, the absence of a clear protocol or training to guide practice, and a lack of time, privacy and patient resources. Conclusions: Such discussions require normalisation, careful timing, sufficient time and adequate privacy. Staff training, a protocol and appropriate patient resources are needed to support health professionals to initiate discussions. Further research is required that investigates the impact of specific resources and training on health professionals' practice and patient outcomes. Heart attack survivors expect that health professionals will communicate with them about sexual activity and intimacy, but previous research shows that this rarely occurs. This research qualitatively examines the perspectives of a range of health professionals working in cardiac care about barriers to discussing sexual activity and intimacy with patients. Discussions about sex and intimacy were perceived as nebulous and taboo topics; themes identified lead to recommendations for developing and implementing resources, training, and a clinical protocol to improve outcomes. [ABSTRACT FROM AUTHOR]

This paper examines the role of socioeconomic status (SES) in affecting access to care and the survival of acute myocardial infarction (AMI) patients in Australia's universal health care system. We jointly model the probabilities of patients being admitted to a catheterisation-capable hospital, receiving invasive coronary angiography (ICA), and surviving 30 days post discharge as a recursive system of probit equations. We further investigate the role of capacity and whether the access gap between SES groups widens when capacity becomes limited. Our study shows that SES plays a significant role in affecting the survival of AMI patients, both directly and indirectly through healthcare access. We find that socioeconomically disadvantaged patients are less likely to gain access to crucial services like catheterisation hospitals and ICA, which indirectly affects their survival probability in addition to the adverse direct impact of SES. While healthcare capacity showed no overall effect on access, its interplay with SES exacerbates the access disparity in situations of limited capacity. Our findings suggest that, to reduce inequality in health outcomes, public health strategy needs to focus not only on enhancing access but also addressing the direct consequences of SES. [ABSTRACT FROM AUTHOR]

Background: International evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). Methods: We conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017–2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors. Results: Of 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort (n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45–0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients. Conclusion: Our findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes. [ABSTRACT FROM AUTHOR]

Background: Understanding population‐level trends in osteoarthritis (OA) is critical for planning health services and disease prevention initiatives. Aim: To examine trends in the burden of hip, knee, hand and other OA related conditions in Australia from 1990 to 2019 and consider the OA burden in the context of other common conditions associated with older age. Methods: Global Burden of Disease Study 2019 data for Australia on OA prevalence, OA‐related years lived with disability (YLDs) and OA‐related YLDs attributable to high body mass index (BMI) were sourced for 1990–2019. Age‐standardised YLD data for ischaemic heart disease, stroke, dementia, type 2 diabetes and chronic obstructive pulmonary disease were obtained for comparison. Results: Overall, 3.20 million Australians were estimated to have OA in 2019, with substantial growth in the prevalence of hip (+171%), knee (+126%), hand (+110%) and other types of OA (+130%) from 1990 to 2019. Age‐standardised prevalence rates reflect the contribution of population ageing. Concomitant growth in OA‐related YLDs was also evident; knee OA and hand OA demonstrated the highest disease burden in 2019 (59 684 and 41 893 YLDs respectively). The proportion of knee OA burden attributable to high BMI was 36% in 2019. In 2019, age‐standardised YLD rates were higher for OA (313 per 100 000 population) than other common conditions (range: 47 per 100 000 (ischaemic heart disease) to 284 per 100 000 (type 2 diabetes)). Conclusions: OA is an increasingly prevalent, impactful condition with a high non‐fatal disease burden relative to other health conditions. Growth in OA populations and OA‐related disability underscore the need for enhanced investment in prevention and management. [ABSTRACT FROM AUTHOR]

Objective: Rare coexistence of disease or pathology Background: Infectious diarrheal illnesses such as rotavirus gastroenteritis are significant contributors to childhood morbidity and mortality, especially in low socio-demographic index regions. Major advances in addressing this issue include sanitation and clean water initiatives, as well as rotavirus immunization. In Australia, a robust vaccination program has significantly reduced childhood rotavirus infections, leading to decreased hospitalizations and mortality. However, cases of adult rotavirus still occur, and although these adult patients usually do not require interventional management, it is possible for them to present critically unwell and require resuscitation. Case Report: A previously well 65-year-old man presented to the Emergency Department febrile and hypotensive with severe diarrhea attributed to rotavirus. Clinically, he presented with mixed hypovolemic and septic shock. Despite initial resuscitation, he had multiple severe acute end-organ complications, secondary to poor perfusion. He acquired an acute kidney injury, type-2 myocardial infarction, and ischemic hepatic injury. The mainstay of management was rapid fluid resuscitation, continuous renal replacement therapy, and monitoring in the Intensive Care Unit; however, it was crucial to empirically treat for other causes of shock. Conclusions: To the best of our knowledge, there is a scarcity of reports documenting the management of severe rotavirus gastroenteritis in adults. We recommend advising elderly patients to avoid contact with individuals with diarrheal illnesses, especially rotavirus gastroenteritis. Clinicians should also promote awareness regarding the potential severity of a disease that is typically managed conservatively, and be aware that intervention can be required in severe gastroenteritis. [ABSTRACT FROM AUTHOR]

The National Heart Foundation of Australia's (NHFA) Warning Signs campaign ran between 2010 and 2013. This study examines trends in Australian adults' ability to name heart attack symptoms during the campaign and in the years following. Using the NHFA's HeartWatch data (quarterly online surveys) for adults aged 30–59 years, we conducted an adjusted piecewise regression analysis comparing trends in the ability to name symptoms during the campaign period plus one year lag (2010–2014) to the post-campaign period (2015–2020) Over the study period, there were 101,936 Australian adults surveyed. Symptom awareness was high or increased during the campaign period. However, there was a significant downward trend in each year following the campaign period for most symptoms (e.g., chest pain: adjusted odds ratio [AOR] =0.91, 95%CI: 0.56–0.80; arm pain: AOR=0.92, 95%CI: 0.90–0.94). Conversely, the inability to name any heart attack symptom increased in each year following the campaign (3.7% in 2010 to 19.9% in 2020; AOR=1.13, 95%CI: 1.10–1.15); these respondents were more likely to be younger, male, have less than 12 years of education, identify as Aboriginal and/or Torres Strait Islander Peoples, speak a language other than English at home and have no cardiovascular risk factors. Awareness of heart attack symptoms has decreased in the years since the Warning Signs campaign in Australia, with 1 in 5 adults currently unable to name a single heart attack symptom. New approaches are needed to promote and sustain this knowledge, and to ensure people act appropriately and promptly if symptoms occur. [ABSTRACT FROM AUTHOR]

Background: Disparities in cardiovascular outcomes between Aboriginal and Torres Strait Islander Australians and non‐Indigenous Australians persist. This has previously been attributed to a combination of differences in burden of cardiovascular disease risk factors, and inpatient access to guideline‐recommended care. Aims: To assess differences in inpatient access to guideline‐recommended acute coronary syndrome (GR‐ACS) treatment between Aboriginal and Torres Strait Islander and non‐indigenous patients admitted to Royal Darwin Hospital (RDH) with index ACS event. Methods: This retrospective study included index ACS admissions (n = 288) to RDH between January 2016 and June 2017. Outcomes included rates of coronary angiography, percutaneous coronary intervention (PCI), surgical revascularisation, GR‐ACS medications prescribed on discharge and short‐term outcomes (30‐day mortality and ACS readmissions; 12‐month all cardiac‐related readmissions). Results: Two hundred and eighty‐eight patients, including 109 (37.85%) Aboriginal and Torres Strait Islander patients, were included. Compared with non‐indigenous patients, they were younger (median age 48 years vs 60 years; P < 0.01), with a greater burden of comorbidities, including diabetes (39% vs 19%; P < 0.01), smoking (68% vs 35%; P < 0.01) and chronic kidney disease (29% vs 5%; P < 0.01). There were no differences in rates of coronary angiography (98% vs 96%; P = 0.24) or PCI (47% vs 57%; P = 0.12), although there was a trend towards surgical revascularisation in Aboriginal and Torres Strait Islander patients (16% vs 8%; P = 0.047). There were no differences in 30‐day mortality (1.8% vs 1.7%; P = 0.72), 12‐month ACS readmissions (7% vs 4%; P = 0.20) or 12‐month cardiac‐related readmissions (7% vs 13%; P = 0.11). Conclusions: Aboriginal and Torres Strait Islander patients received similar inpatient ACS care and secondary prevention medication at discharge, with similar short‐term mortality outcomes as non‐indigenous patients. While encouraging, these outcomes may not persist long term. Further outcomes research is required, with differences compelling consideration of other primary and secondary prevention contributors. [ABSTRACT FROM AUTHOR]

Background: Climate change has resulted in an increase in ambient temperatures during the summer months as well as an increase in risk of associated air pollution and of potentially disastrous bushfires throughout much of the world. The increasingly frequent combination of elevated summer temperatures and bushfires may be associated with acute increases in risks of cardiovascular events, but this relationship remains unstudied. We evaluated the individual and cumulative impacts of daily fluctuations in temperature, fine particulate matter of less than 2.5 µm (PM2.5) pollution and presence of bushfires on incidence of acute coronary syndromes and Takotsubo syndrome.Methods: From November 1, 2019, to February 28, 2020, all admissions with acute coronary syndromes or Takotsubo syndrome to South Australian tertiary public hospitals were evaluated. Univariate and combined associations were sought among each of 1) maximal daily temperature, 2) PM2.5 concentrations, and 3) presence of active bushfires within 200 km of the hospitals concerned.Results: A total of 504 patients with acute coronary syndromes and 35 with Takotsubo syndrome were studied. In isolation, increasing temperature was associated (rs = 0.26, P = .005) with increased incidence of acute coronary syndromes, while there were similar, but nonsignificant correlations for PM2.5 and presence of bushfires. Combinations of all these risk factors were also associated with a doubling of risk of acute coronary syndromes. No significant associations were found for Takotsubo syndrome.Conclusion: The combination of high temperatures, presence of bushfires and associated elevation of atmospheric PM2.5 concentrations represents a substantially increased risk for precipitation of acute coronary syndromes; this risk should be factored into health care planning including public education and acute hospital preparedness. [ABSTRACT FROM AUTHOR]

Background: Internationally, stroke and cardiac rehabilitation clinicians agree that current cardiac rehabilitation models are a suitable secondary prevention program for people following a transient ischaemic attack (TIA) or mild stroke. There is strong evidence for exercise-based cardiac rehabilitation in people with heart disease, however, the evidence for cardiac rehabilitation post-TIA or stroke is limited. Here we will explore the effectiveness and implementation of an integrated (TIA, mild stroke, heart disease) traditional exercise-based cardiovascular rehabilitation (CVR) program for people with TIA or mild stroke over 6-months.Methods: This type 1 effectiveness-implementation hybrid study will use a 2-arm single-centre assessor-blind randomised controlled trial design, recruiting 140 participants. Adults who have had a TIA or mild stroke in the last 12-months will be recruited by health professionals from hospital and primary healthcare services. Participants will be assessed and randomly allocated (1:1) to the 6-week CVR program or the usual care 6-month wait-list control group. Distance completed in the 6-min walk test will be the primary effectiveness outcome, with outcomes collected at baseline, 6-weeks (complete CVR) and 6-months in both groups. Other effectiveness outcome measures include unplanned cardiovascular disease-related emergency department and hospital admissions, daily minutes of accelerometer moderate-to-vigorous physical activity, body mass index, waist circumference, blood pressure, quality of life, anxiety and depression. Implementation outcomes will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, including a cost-effectiveness analysis. Semi-structured interviews will be conducted with participants and CVR program health professionals, investigating the acceptability, value, and impact of the CVR program. Qualitative analyses will be guided by the Consolidated Framework for Implementation Research.Discussion: Few studies have assessed the effectiveness of cardiac rehabilitation for people with TIA and mild stroke, and no studies appear to have investigated the cost-effectiveness or implementation determinants of such programs. If successful, the CVR program will improve health outcomes and quality of life of people who have had a TIA or mild stroke, guiding future research, policy, and clinical practice, reducing the risk of repeat heart attacks and strokes for this population.Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621001586808 , Registered 19 November 2021. [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]

Background: Dual antiplatelet therapy (DAPT) is guideline therapy following acute coronary syndrome (ACS). Novel, potent P2Y12 inhibitors have been developed and studied but it is unclear how this evidence has been incorporated into patient care. We sought to describe the prescribing trends and health care costs of P2Y12therapy in Australia over the last decade.Method: The latest statistical data collected by the Pharmaceutical Benefit Scheme (PBS), Australia, was reviewed. PBS codes for coronary indications were selected. Yearly total prescriptions and cost were then compared between all three P2Y12 inhibitors. Linear trend modelling was used to observe general trends over the data collection period.Results: Total yearly P2Y12 scripts have more than doubled between 2010 (403,880 scripts) and 2020 (994,826 scripts). Clopidogrel is the most prescribed P2Y12 inhibitor and has been for the last decade. Ticagrelor represents 26.2% of total prescriptions but accounts for 75% of PBS spending. More than $30 million is spent on ticagrelor every year with a cost per MACE prevented of $72,637. Prasugrel was the least prescribed agent but was 41% cheaper per major adverse cardiac event (MACE) prevented than ticagrelor before being removed from the Australian market. Without prasugrel available, clopidogrel scripts have increased 10% and ticagrelor scripts remain stable.Conclusion: Clopidogrel remains the most prescribed P2Y12 agent in Australia, despite emergence of more potent P2Y12 inhibitors. Ticagrelor is increasingly prescribed but represents a disproportionately large burden of spending. Whilst prasugrel is the most efficacious, cheaper than ticagrelor and guideline recommended P2Y12 inhibitor after ACS, it represented the minority of scripts before being withdrawn. Rather than use of a potent P2Y12 agent, clinicians are reverting to prescribing clopidogrel. [ABSTRACT FROM AUTHOR]

Background: Clopidogrel in combination with aspirin after acute coronary syndromes (ACS) reduces recurrent ischaemic events compared to aspirin alone. Further reductions in events have been demonstrated when clopidogrel is replaced by ticagrelor or prasugrel albeit with increases in bleeding. There are few studies documenting the patterns of use of P2Y12 inhibitors or their association with outcomes in the Australian population.Aims: To describe the patterns of use of each P2Y12 inhibitor and to determine the associations between initial P2Y12 inhibitor use and outcomes.Methods: Data were extracted from Cooperative National Registry of ACS, Guideline Adherence and Clinical Events (CONCORDANCE)-a prospective database of patients presenting to 43 sites across Australia with ACS. Patients were stratified based on first antiplatelet agent received. Baseline clinical characteristics were compared between these patient groups and hospital investigations, management as well as in-hospital and 12 months outcomes (death, a composite of cardiac-related death, myocardial infarction, and stroke, and major bleeding) were compared between the three treatment cohorts after adjustment for differences in baseline characteristics.Results: Mean ages of the clopidogrel (n=7,537), ticagrelor (n=1,878), and prasugrel (n=347) cohorts were 65, 63, and 58 yrs respectively (p<0.0001), the mean Global Registry of Acute Coronary Events (GRACE) risk scores were 107, 104, and 102 (p=0.0016). The ticagrelor and prasugrel cohorts were more likely to receive percutaneous coronary intervention (PCI) (clopidogrel 52%, ticagrelor 66%, prasugrel 88%, p<0.0001), and evidence based medications (≥4 guideline indicated medications: clopidogrel 76%, ticagrelor 82%, prasugrel 93%, p<0.0001). Patients treated with ticagrelor and prasugrel were less likely to experience in-hospital death (clopidogrel 2.5%, ticagrelor 1.4%, prasugrel 1.2%, p=0.05), major adverse cardiac events (MACE) (clopidogrel 5.1%, ticagrelor 3.0%, prasugrel 3.5% [p=0.01]), or bleeding (clopidogrel 8.4%, ticagrelor 4.6%, prasugrel 7.5% [p<0.001]) compared to clopidogrel. These differences were no longer apparent after multivariable adjustment. There was no difference in outcomes between cohorts at 12 months.Conclusions: In Australia, ticagrelor and prasugrel are used in younger patients who are more likely to undergo percutaneous coronary intervention (PCI) and receive evidence based therapy. Patients receiving clopidogrel were more likely to experience in hospital ischaemic or bleeding events but this was explained by their higher baseline risk. Selection of therapy was not associated with any difference in outcomes at 12-month follow-up, but our findings suggest there is room for improvement towards guideline-driven usage of P2Y12 inhibitors. [ABSTRACT FROM AUTHOR]

Background: International Classification of Disease (ICD) codes are central for identifying myocardial infarction (MI) in administrative hospitalisation data, however validation of MI subtype codes is limited. We measured the sensitivity and specificity of ICD-10-AM (Australian Modification) codes for ST-elevation MI (STEMI) and non-STEMI (NSTEMI).Methods: A sample of MI admissions was obtained from a dataset containing all MI hospitalisations in Western Australia (WA) for 2003, 2008 and 2013. Clinical data were collected from hospital medical records (n=799 patients). Cases were classified by ICD-10-AM codes for STEMI, NSTEMI and unspecified MI, and compared to clinical classification from review of available electrocardiographs (ECGs) and cardiac biomarkers (n=660). Sensitivity and specificity for ICD-10-AM coding versus clinical classification was measured, stratified by calendar year of discharge.Results: The majority of classifiable cases had MI recorded in the principal diagnosis field (STEMI n=293, 84.2%; NSTEMI n=202, 74.3%; unspecified MI n=20, 50.0%). Overall sensitivity of the ICD-10-AM STEMI code was 86.3% (95% CI 81.7-90.0%) and was higher when restricted to MI as a principal versus secondary diagnosis (88.8% vs 66.7%). Comparable values for NSTEMI were 66.7% (95% CI 61.5-71.6%), and 68.8% vs 61.4% respectively. Between 2003 and 2013, sensitivity for both MI subtypes increased: 80.2-89.5% for STEMI, and 51.2-73.8% for NSTEMI. Specificity was high for NSTEMI throughout (88.2% 95% CI 84.1-91.6%), although improving over time for STEMI (68.1-76.4%).Conclusions: The sensitivity and specificity of ICD-10-AM codes for MI subtypes in hospitalisation data are generally high, particularly for principal diagnosis cases. However, the temporal improvement in sensitivity in coding of MI subtypes, particularly NSTEMI, may necessitate modification to trend studies using administrative hospitalisation data. [ABSTRACT FROM AUTHOR]

Background: Heart failure is increasing in prevalence, creating a greater public health and economic burden on our health care system. With a rising proportion of hospitalisations for heart failure with preserved ejection fraction (HFpEF) compared to heart failure with reduced ejection fraction (HFrEF) and lack of proven therapies for HFpEF, patient characterisation and defining clinical outcomes are important in determining optimal management of heart failure patients. There is scarce Australian-specific data with regards to the burden of disease of patients with HFpEF which further limits our ability to appropriately manage this syndrome.Aim: To determine the characteristics, management practices and outcomes of patients with HFpEF compared to patients diagnosed with HFrEF.Method: Data was sourced from the Victorian Cardiac Outcomes Registry-Heart Failure (VCOR-HF) snapshot of patients admitted with acute heart failure to one of 16 Victorian health services between 2014-2017 over one consecutive month annually. Outcomes measured were in-hospital mortality, and 30-day readmission and mortality.Results: Of the 1,132 HF patients, 436 patients were diagnosed with HFpEF and were more likely to be female (59%) and older (81.5±9.8 vs 73.2±14.5 years). They were also more likely to have hypertension (80%), atrial fibrillation (59.9%), chronic obstructive airways disease (36.2%) and chronic kidney disease (68.8%). Patients with HFrEF were more likely to have ischaemic heart disease with a history of previous myocardial infarction (36.6%), percutaneous coronary intervention and cardiac bypass surgery (35.2%). There were no significant differences in 30-day mortality between HFpEF and HFrEF (10.2% vs 7.8%; p=0.19, respectively) and 30-day readmission rates (22.1% vs 25.9%; p=0.15, respectively).Conclusion: VCOR-HF Snapshot data provides important insight into the burden of acute heart failure. Whilst patients with HFpEF and HFrEF have differing clinical profiles, morbidity, mortality and re-admission rates are similar. [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: Examining a variety of diet quality methodologies will inform best practice use of diet quality indices for assessing all-cause and cardiovascular disease (CVD) mortality.Objectives: To examine the association between 3 diet quality indices (Australian Dietary Guideline Index, DGI; Dietary Inflammatory Index, DII; Mediterranean-DASH (Dietary Approaches to Stop Hypertension) Intervention for Neurodegenerative Delay, MIND) and risk of all-cause mortality, CVD mortality, and nonfatal CVD events ≤19 y later.Methods: Data on 10,009 adults (mean age 51.8 y; 52% female) from the Australian Diabetes, Obesity, and Lifestyle study were used. An FFQ was used to calculate DGI, DII, and MIND at baseline. Cox proportional hazard models were used to estimate HRs and 95% CI of all-cause mortality, CVD mortality, and nonfatal CVD events (stroke; myocardial infarction) according to 1 SD increase in diet quality, adjusted for age, sex, education, smoking, physical activity, energy intake, history of stroke or heart attack, and diabetes and hypertension status.Results: Deaths due to all-cause (n = 1955) and CVD (n = 520), and nonfatal CVD events (n = 264) were identified during mean follow-ups of 17.7, 17.4, and 9.6 y, respectively. For all-cause mortality, HRs associated with higher DGI, DII, and MIND were 0.94 (95% CI: 0.89, 0.99), 1.08 (95% CI: 1.02, 1.15), and 0.93 (95% CI: 0.89, 0.98), respectively. For CVD mortality, HRs associated with higher DGI, DII, and MIND were 0.93 (95% CI: 0.85, 0.99), 1.10 (95% CI: 1.00, 1.24), and 0.90 (95% CI: 0.82, 0.98), respectively. There was limited evidence of associations between diet quality and nonfatal CVD events.Conclusions: A better quality diet predicted lower risk of all-cause and CVD mortality in Australian adults, whereas a more inflammatory diet predicted higher mortality risk. These findings highlight the applicability of following Australian dietary guidelines, a Mediterranean-style diet, and a low-inflammatory diet for the reduction of all-cause and CVD mortality risk. [ABSTRACT FROM AUTHOR]

Objective: To summarize data on the prevalence/incidence, risk factors and prognosis of atrial fibrillation (AF) in patients with acute coronary syndromes (ACS). Methods: MEDLINE, Embase, and Web of Science were searched to identify all published studies providing relevant data through August 23, 2020. Random‐effects meta‐analysis method was used to pool estimates. Results: We included 109 studies reporting data from a pooled population of 8 239 364 patients. The prevalence rates were 5.8% for pre‐existing AF, 7.3% for newly diagnosed AF, and 11.3% for prevalent (total) AF, in patients with ACS. Predictors of newly diagnosed AF included age (per year increase) (adjusted odds ratio [aOR]: 1.05), C‐reactive protein (aOR: 1.49), left atrial (LA) diameter (aOR: 1.08), LA dilatation (aOR: 2.32), left ventricular ejection fraction <40% (aOR: 1.82), hypertension (aOR: 1.87), and Killip ˃ 1 (aOR: 1.85), p <.01 in all analyzes. Newly diagnosed AF was associated with an increased risk of acute heart failure (adjusted hazard ratio [aHR]: 3.20), acute kidney injury (aHR: 3.09), re‐infarction (aHR: 1.96), stroke (aHR: 2.15), major bleeding (aHR: 2.93), and mortality (aHR: 1.80) in the short term; and with an increased risk of heart failure (aHR: 2.21), stroke (aHR: 1.75), mortality (aHR: 1.67), CV mortality (aHR: 2.09), sudden cardiac death (aHR: 1.53), and a composite of major adverse cardiovascular events (aHR: 1.54) in the long term (beyond 1 month), p <.05 in all analyzes. Conclusion: One in nine patients with ACS has AF, with a high proportion of newly diagnosed AF. AF, in particular newly diagnosed AF, is associated with poor short‐term and long‐term outcomes in patients with ACS. [ABSTRACT FROM AUTHOR]

Background: The influence of testosterone on risk for cardiovascular events in men is uncertain. Previous observational studies of sex hormones and incident cardiovascular disease in men have reported inconsistent findings, limited by cohort sizes and different selection criteria.Objective: To analyze associations of serum total testosterone and sex hormone-binding globulin (SHBG) with incident cardiovascular events in men.Design: Cohort study.Setting: UK Biobank prospective cohort.Participants: Community-dwelling men aged 40 to 69 years.Measurements: Testosterone and SHBG were assayed, and free testosterone was calculated. Cox proportional hazards regression was done, with outcomes of incident myocardial infarction (MI), hemorrhagic stroke (HS), ischemic stroke (IS), heart failure (HF), and major adverse cardiovascular events (MACE), adjusted for sociodemographic, lifestyle, and medical factors.Results: Of 210 700 men followed for 9 years, 8790 (4.2%) had an incident cardiovascular event. After adjustment for key variables, lower total testosterone concentrations (quintile 1 vs. quintile 5) were not associated with incident MI (fully adjusted hazard ratio [HR], 0.89 [95% CI, 0.80 to 1.00]), HS (HR, 0.94 [CI, 0.70 to 1.26]), IS (HR, 0.95 [CI, 0.82 to 1.10]), HF (HR, 1.15 [CI, 0.91 to 1.45]), or MACE (HR, 0.92 [CI, 0.84 to 1.00]). Men with lower calculated free testosterone values had a lower incidence of MACE (HR, 0.90 [CI, 0.84 to 0.97]). Lower SHBG concentrations were associated with higher incidence of MI (HR, 1.23 [CI, 1.09 to 1.38]) and lower incidence of IS (HR, 0.79 [CI, 0.67 to 0.94]) and HF (HR, 0.69 [CI, 0.54 to 0.89]), but not with HS (HR, 0.81 [CI, 0.57 to 1.14]) or MACE (HR, 1.01 [CI, 0.92 to 1.11]).Limitation: Observational study; single baseline measurement of testosterone and SHBG.Conclusion: Men with lower total testosterone concentrations were not at increased risk for MI, stroke, HF, or MACE. Calculated free testosterone may be associated with risk for MACE. Men with lower SHBG concentrations have higher risk for MI but lower risk for IS and HF, with causality to be determined.Primary Funding Source: Western Australian Health Translation Network, Medical Research Future Fund, and Lawley Pharmaceuticals. [ABSTRACT FROM AUTHOR]

Background: P2Y12 inhibitor therapy is recommended for 12 months in patients hospitalised for acute myocardial infarction (AMI) unless the bleeding risk is high. Aims: To describe real‐world use of P2Y12 inhibitor therapy following AMI hospitalisation. Methods: We used population‐level linked hospital data to identify all patients discharged from a public hospital with a primary diagnosis of AMI between July 2011 and June 2013 in New South Wales and Victoria, Australia. We used dispensing claims to examine dispensing of a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) within 30 days of discharge and multilevel models to identify predictors of post‐discharge dispensing and persistence of therapy to 1 year. Results: We identified 31 848 patients hospitalised for AMI, of whom 56.8% were dispensed a P2Y12 inhibitor within 30 days of discharge. The proportion of patients with post‐discharge dispensing varied between hospitals (interquartile range: 25.0–56.5%), and significant between‐hospital variation remained after adjusting for patient characteristics. Patient factors associated with the lowest likelihood of post‐discharge dispensing were: having undergone coronary artery bypass grafting (odds ratio (OR): 0.17; 95% confidence intervals (CI): 0.15–0.20); having oral anticoagulants dispensed 180 days before or 30 days after discharge (OR: 0.39, 95% CI: 0.35–0.44); major bleeding (OR: 0.68, 95% CI: 0.61–0.76); or being aged ≥85 years (OR: 0.68, 95% CI: 0.62–0.75). A total of 26.8% of patients who were dispensed a P2Y12 inhibitor post‐discharge discontinued therapy within 1 year. Conclusion: Post‐hospitalisation use of P2Y12 inhibitor therapy in AMI patients is low and varies substantially by hospital of discharge. Our findings suggest strategies addressing both health system (hospital and physician) and patient factors are needed to close this evidence‐practice gap. [ABSTRACT FROM AUTHOR]

Background: Estimation of influenza disease burden is necessary to monitor the impact of intervention programmes. This study aims to estimate the attributable fraction of respiratory and circulatory disease due to influenza among Australian adults 50–64 and ≥65 years of age. Methods: A semi‐parametric generalised‐additive model was used to estimate annual and average rate of influenza‐attributable hospitalisation and death per 100,000 population under the principal diagnosis of influenza/pneumonia, respiratory, circulatory and myocardial infarction (MI) from 2001 through 2017. Results: Over the study period, seasonal influenza accounted for an estimated annual average respiratory hospitalisation rate of 78.9 (95%CI: 76.3, 81.4) and 287.5 (95%CI: 279.8, 295.3) per 100,000 population in adults aged 50–64 and ≥65 years, respectively. The corresponding respiratory mortality rates were 0.9 (95%CI: 0.7, 1.2) and 18.2 (95%CI: 16.9, 19.4) per 100,000 population. The 2017 season had the highest influenza‐attributable respiratory hospitalisations in both age groups, and respiratory complications were estimated approximately 2.5 times higher than the average annual estimate in adults aged ≥65 years in 2017. For mortality, on average, influenza attributed 1,080 circulatory and 361 MI deaths in adults aged ≥65 years per year. Influenza accounted for 1% and 2.8% of total MI deaths in adults aged 50–64 and ≥65 years, respectively. Conclusion: Rates of cardiorespiratory morbidity and mortality were high in older adults, whilst the younger age group contributed a lower disease burden. Extension of influenza vaccination programme beyond the targeted population could be an alternative strategy to reduce the burden of influenza. [ABSTRACT FROM AUTHOR]

Background: Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) has been shown to be superior to angiography-guided PCI in randomized controlled studies. However, real-world data on the use and outcomes of FFR-guided PCI remain limited. Thus, we investigated the outcomes of patients undergoing FFR-guided PCI compared to angiography-guided PCI in a large, state-wide unselected cohort. Methods and results: All patients undergoing PCI between June 2017 and June 2018 in New South Wales, Australia, were included. The cohort was stratified into the FFR-guided group when concomitant FFR was performed, and the angiography-guided group when no FFR was performed. The primary outcome was a combined endpoint of death or myocardial infarction (MI). Secondary outcomes included all-cause death, cardiovascular (CVS) death, and MI. The cohort comprised 10,304 patients, of which 542 (5%) underwent FFR-guided PCI. During a mean follow-up of 12±4 months, the FFR-guided PCI group had reduced occurrence of the primary outcome (hazard ratio [HR] 0.34, 95% confidence intervals [CI] 0.20–0.56, P<0.001), all-cause death (HR 0.18, 95% CI 0.07–0.47, P = 0.001), CVS death (HR 0.21, 95% CI 0.07–0.66, P = 0.01), and MI (HR 0.46, 95% CI 0.25–0.84, P = 0.01) compared to the angiography-guided PCI group. Multivariable Cox regression analysis showed FFR-guidance to be an independent predictor of the primary outcome (HR 0.45, 95% CI 0.27–0.75, P = 0.002), all-cause death (HR 0.22, 95% CI 0.08–0.59, P = 0.003), and CVS death (HR 0.27, 95% CI 0.09–0.83, P = 0.02). Conclusions: In this real-world study of patients undergoing PCI, FFR-guidance was associated with lower rates of the primary outcome of death or MI, as well as the secondary outcomes of all-cause death and CVS death. [ABSTRACT FROM AUTHOR]

We aim to report the co-design of the implementation strategy of a telehealth-enabled cardiac rehabilitation model of care in rural and remote areas of Australia. The goal of this model of care is to increase cardiac rehabilitation attendance and completion by country patients with cardiovascular diseases.We hypothesise that a model of care co-designed with stakeholders will address patients' needs and preferences and increase participation. We applied the Model for Large Scale Knowledge Translation and engaged with patients, clinicians and health service managers across six local health networks in rural South Australia. They informed the design of a web-based cardiac rehabilitation programme and the delivery of the expanded telehealth service.The stakeholders defined face-to-face, telephone, web-based or combinations as choices of mode of delivery to patients referred to cardiac rehabilitation. A case-managed programme supported by a web portal with an interface for patients and clinicians was considered more appropriate to the local context than a self-managed programme. A business model was developed to enable the sustainability of cardiac rehabilitation clinical assessments through primary care. The impact of the model of care on cardiac rehabilitation attendance/completion, clinical outcomes, patient-reported outcomes and patient-reported experiences and cost-effectiveness will be tested in a 12-month follow-up study. [ABSTRACT FROM AUTHOR]

Acute coronary syndromes are a significant cause of morbidity and mortality in Australia. Outcomes are likely to be improved by rapid and accurate diagnosis, and early intervention. The development of high-sensitivity troponin assays has revealed previously unrecognised types of myocardial injury, for which conventional management guidelines for myocardial infarction may not confer similar benefits. The distinction between myocardial injury and myocardial infarction has therefore become increasingly important. Once the diagnosis of acute myocardial infarction has been made, individualised acute reperfusion strategies including percutaneous coronary intervention or fibrinolytic therapy should be considered. Secondary prevention strategies should be implemented before hospital discharge. [ABSTRACT FROM AUTHOR]

Objective: Tourism to regional and remote Australia is increasing. Its impact on regional critical care services is incompletely understood. We describe tourist admissions and their impact on critical care resources relative to the local population. Design: Single‐centre retrospective study using prospectively collected data from January 2009 to December 2018. Setting: Australian regional intensive care unit. Participants: All critical care admissions for patients aged over 18 years for whom postcode data were available were included. Outcome measures: Primary outcome was hospital mortality. Secondary outcomes examined resource use (intensive care unit and hospital length of stay, mechanical ventilation, interhospital transfer) and admission diagnosis. Results: Tourists comprise 6.1% of critical care admissions, occupying 5.7% of intensive care unit bed days. They were less likely to be Indigenous (6.3% vs 72.7%), but older (61.5 vs 49.2 years) and male (65.4% vs 52.6%). They were more frequently admitted following acute myocardial infarction (14.2% vs 8.9%) or trauma (20.0% vs 5.0%). There was no difference in hospital mortality (2.9% vs 4.0%) or intensive care unit mortality (2.4% vs 1.8%); however, tourists were more than twice as likely to require interhospital transfer (31.7% vs 14.0%). These findings persisted after adjustment for illness severity. Conclusion: Tourists are an appreciable caseload of this regional intensive care unit and are more likely to require interhospital transfer. There was no difference in mortality. Further research is required across regional and rural Australia to better understand the epidemiology and impact of tourism on critical care resources, and the economic implications of becoming unwell in a regional area. [ABSTRACT FROM AUTHOR]

Background: The phenomenon of the "weekend effect", whereby patient outcomes are significantly worse for those admitted to hospital on the weekend as compared to weekdays, is well-documented in systematic reviews and meta-analyses in the literature. We sought to assess the effect of the time of a patient's admission on outcomes across an entire cardiology admissions cohort and explore other factors that have been previously identified or proposed to influence these outcomes, including admissions out-of-hours, and patient transfers from other facilities.Methods: We conducted a retrospective cohort study involving cardiology admissions at a large tertiary referral centre across a 6-year period from 1 January 2012 to 31 December 2017. Outcomes were in-hospital, 30-day and 1-year mortality rates as well as length-of-stay, and readmission rate. 14,078 patients admitted under a cardiologist across the 6-year period were identified, with 3,029 elective patients excluded. Patients were stratified into weekday (n=8,951) or weekend (n=2,098) categories.Results: In-hospital mortality for weekend admissions was noted to be significantly higher compared to weekday admissions (adj OR 1.78, 95% CI 1.40-2.28; p<0.001). Mortality for weekend admissions was also higher at 30-days (adj OR 1.74, 95% CI 1.39-2.17; p<0.001) and at 1-year (adj OR 1.33 95% CI 1.14-1.55; p<0.001). Adjusted for diagnosis, there was a significant increase in in-hospital, 30-day and 1-year mortality seen only for weekend admissions with the final diagnosis of acute myocardial infarction.Conclusion: We have identified an association between weekend admissions and higher in-hospital, 30-day and 1-year mortality for the final diagnosis of acute myocardial infarction in our cardiology admissions data over an extended period of time, although confounders cannot be completely discounted. Any steps to reduce the weekend effect need to move to a system where weekend practices are not substantially different to a usual business day. The question of whether changes in organisation practice and the increased costs incurred would reduce mortality in this high-risk group needs to be addressed by further directed research. [ABSTRACT FROM AUTHOR]

Background: The condition onset flag (COF) variable was introduced into the hospitalization coding practice in 2008 to help distinguish between the new and pre-existing conditions. However, Australian datasets collected prior to 2008 lack the COF, potentially leading to data waste. The aim of this study was to determine if an algorithm to lookback across the previous admissions could make this distinction.Methods: All patients requiring kidney replacement therapy (KRT) identified in the Australia and New Zealand Dialysis and Transplant Registry in New South Wales, South Australia and Tasmania between July 2008 and December 2015 were linked with hospital admission datasets using probabilistic linkage. Three different lookback periods entailing either one, two or three admissions prior to the index admission were investigated. Conditions identified in an index admission but not in the lookback periods were classified as a new-onset condition. Conditions identified in both the index admission and the lookback period were deemed to be pre-existing. The degrees of agreement were determined using the kappa statistic. Conditions examined for new onset were myocardial infarction, pulmonary embolism and pneumonia. Conditions examined for prior existence were diabetes mellitus, hypertension and kidney failure. Secondary analyses evaluated whether the conditions identified as pre-existing using COF were captured consistently in the subsequent admissions.Results: 11 140 patients on KRT with 69 403 admissions were analysed. Lookback over a single admission interval (Period 1) provided the highest rates of true positives with COF for all three new-onset conditions, ranging from 89% to 100%. The levels of agreement were almost perfect for all conditions (k = 0.94-1.00). This was consistent across the different time eras. All lookback periods identified additional new-onset conditions that were not classified by COF: Lookback Period 1 picked up a further 474 myocardial infarction, 84 pulmonary embolism and 1092 pneumonia episodes. Lookback Period 1 had the highest percentage of true positives when identifying the pre-existing conditions (64-80%). The level of agreement was moderate to strong and was similar across the time eras. Secondary analysis showed that not all pre-existing conditions identified using COF carried forward to the subsequent admission (61-82%) but increased when looking forward across >1 admission (87-95%).Conclusion: The described algorithm using a lookback period is a pragmatic, reliable and robust means of identifying the new-onset and pre-existing patient conditions, thereby enriching the existing datasets predating the availability of the COF. The findings also highlight the value of concatenating a series of hospital patient admissions to more comprehensively adjudicate the pre-existing conditions, rather than assessing the index admission alone. [ABSTRACT FROM AUTHOR]

Homozygous familial hypercholesterolaemia (FH) causes severe cardiovascular disease from childhood. Conventional drug therapy is usually ineffective; lipoprotein apheresis (LA) is often required. Liver transplantation (LT) can correct the metabolic defect but is considered a treatment of last resort. Newer drugs including lomitapide and evinacumab might reduce the need for apheresis and LT. We sought to determine the long-term outcomes following LT in Australia and New Zealand. We analysed demographic, biochemical and clinical data from all patients in Australia and New Zealand who have received LT for homozygous FH, identified from the Australia and New Zealand Liver and Intestinal Transplant Registry. Nine patients (five female; one deceased; seven aged between 3 and 6 years at the time of LT and two aged 22 and 26 years) were identified. Mean follow-up was 14.1 years (range 4–27). Baseline LDL-cholesterol off all treatment was 23 ± 4.1 mmol/L. Mean LDL-cholesterol on medical therapy (including maximal statin therapy in all patients, ezetimibe in three and LA in five) was 11 ± 5.7 mmol/L (p < 0.001). After LT, mean LDL-cholesterol was 2.6 ± 0.9 mmol/L (p = 0.004) with three patients remaining on statin therapy and none on LA. One patient died from acute myocardial infarction (AMI) three years after LT. Two patients required aortic valve replacement, more than 10 years after LT. The remaining six patients were asymptomatic after eight to 21 years of follow-up. No significant adverse events associated with immunosuppression were reported. LT for homozygous FH was highly effective in achieving substantial long-term reduction in LDL-cholesterol concentrations in all nine patients. LT remains an option for severe cases of homozygous FH where drug therapy combined with apheresis is ineffective or unfeasible. [Display omitted] • Liver transplantation has low morbidity in experienced centres. • Modern immunosuppression facilitates long-term graft survival. • Liver transplantation lowers LDL-cholesterol more than any other treatment. • Aortic stenosis can progress despite liver transplantation. • Post-transplant familial hypercholesterolaemia cardiovascular guidelines are needed. [ABSTRACT FROM AUTHOR]

To describe trends in hospitalisation for subtypes of cardiovascular diseases among people with diabetes. The data sources included the Australian diabetes registry, admitted hospitalisation datasets, and death registry from 2011 to 2019. The outcomes comprised hospital admissions for: all CVD; all cerebrovascular diseases, ischaemic and haemorrhagic stroke; angina and ischaemic heart disease (AIHD); non-ST elevation myocardial infarction (NSTEMI), ST-elevation myocardial infarction (STEMI); atrial fibrillation and flutter (AFF). Data were analysed using Stata and Joinpoint regression software. Rates were standardised for age and sex. Annual percentage change (APC) was reported. In type 1 diabetes, there were increases in hospitalisation for all cerebrovascular diseases (APC 4.5, 95 % CI: 1.2, 7.9) and ischaemic stroke (2.3, 95 % CI: 1.6, 3.0). There were declines in STEMI (-2.6, 95 % CI: −5.0, −0.1) and AIHD (-3.1, 95 % CI: −5.5, −0.7). In type 2 diabetes, hospitalisation for all CVD declined (-0.9, 95 % CI: −1.4, −0.3). Hospitalisation rates for ischaemic stroke increased (4.1, 95 % CI: 3.1, 5.1). There were declines in NSTEMI (-2.5, 95 % CI: −3.2, −1.8) and AIHD (-4.2, 95 % CI: −4.8, −3.5). In type 1 and 2 diabetes, hospitalisation for ischaemic stroke increased while coronary diagnoses declined. [ABSTRACT FROM AUTHOR]

Ankle-brachial pressure index (ABPI) is commonly measured in people referred to vascular specialists. This study aimed to assess the association of high ABPI (≥ 1.4) with cardiovascular events in people with peripheral artery disease (PAD). 1533 participants with PAD diagnosed by a vascular specialist were prospectively recruited from four out-patient clinics in Australia. ABPI was measured at recruitment and the occurrence of myocardial infarction (MI), stroke or cardiovascular death (major cardiovascular events; MACE) and any amputation were recorded over a median (inter-quartile range) follow-up of 3.3 (1.0–7.1) years. The association of high, compared to normal, low (0.5–0.9) or very low (<0.5), ABPI with clinical events was estimated using Cox proportional hazard analyses, adjusting for traditional risk factors and reported as hazard ratio with 95% confidence intervals. 596 (38.9%), 676 (44.1%), 157 (10.2%) and 104 (6.8%) participants had normal, low, very low and high ABPI, respectively. Participants with high ABPI had increased risk of MACE, MI and death by comparison to those with either normal ABPI [1.69 (1.07, 2.65), 1.93 (1.07, 3.46) and 1.67 (1.09, 2.56)] or either low or very low ABPI [1.51 (1.02, 2.23), 1.92 (1.16, 3.19) and 1.47 (1.02, 2.14)] after adjusting for other risk factors. Findings were similar in a sensitivity analysis excluding people with ABPI only measured in one leg (n = 120). Participants with high ABPI also had an increased risk of MACE and MI compared to those with very low ABPI alone. High ABPI is a strong indicator of excess risk of cardiovascular events amongst people with PAD. [ABSTRACT FROM AUTHOR]

Background: The association between preterm delivery (PTD) and maternal risk of cardiovascular disease (CVD) was demonstrated, but the economic burden of CVD in these women was unknown. Methods: A Markov microsimulation model, comprising no event, postacute coronary event (ACE, including acute myocardial infarction and unstable angina), poststroke, post-ACE and stroke, postheart failure, and death, was constructed to quantify the CVD burden in women with PTD from 2017 to 2066 using the Australian health care system perspective. Both first-ever and recurrent CVD events were accounted for in the model. Population with PTD histories was sourced from Australian Bureau of Statistics and costs of acute hospitalization and longterm management from government websites. Nonmonetary burden as years of life lost (YLL) was compared between women with and without PTD histories. Both dynamic (i.e., new cohort added every cycle) and static (i.e., population was stabilized) approaches were used to measure the CVD burden, with sensitivity analyses examining the robustness of results. Results: The dynamic model showed the total CVD burden caused by PTD as AUD11.4 billion for the next 50 years and the YLL as 0.34/capita, while the static model generated a cost of AUD4.5 billion and the YLL as 0.52/capita. Long-term management cost was the primary cost determinant (AUD9.4 billion and AUD3.7 billion, respectively) in the two models, with the results most sensitive to the discount rate and time horizon. Conclusions: Considering the substantial economic burden, recognizing PTD as a potential risk factor and encouraging women with PTD histories to participate in primary prevention programs would potentially curb the ever-increasing CVD burden. [ABSTRACT FROM AUTHOR]

Cardiac rehabilitation (CR) programs are effective in reducing cardiovascular mortality and readmissions. However, most patients are denied the benefits of CR due to low referral rates. Of those patients referred, commencement rates vary from 28.4% to 60%. This paper quantifies the scale of health loss in Australia due to poor engagement with the program, and estimates how much public funding can be justifiably reallocated to address the problem. Economic decision modelling was undertaken to estimate the expected lifetime health loss and costs to Medicare. Key parameters were derived from Australian databases, CR registries and meta-analyses. Population health gains associated with uptake rates of 60%, and 85% were calculated. CR was associated with a 99.9% probability of being cost-effective, even at a cost-effectiveness threshold lower than conventionally applied. Importantly, an average of 0.52 years of life expectancy are lost due to national uptake being below 60% achieved in some best performing programs in Australia, equivalent to 0.28 quality adjusted life years. The analysis indicates that $12.9 million/year could be justifiably reallocated from public funds to achieve a national uptake rate of 60%, while maintaining cost-effectiveness of CR due to the large health gains that would be expected. CR is a cost-effective service for patients with coronary heart disease. In Australia, less than a third of patients commence CR, potentially resulting in avoidable patient harm. Additional investment in CR is vital and should be a national priority as the health gains for patients far outweigh the costs. • Cardiac rehabilitation (CR) is effective in reducing mortality and readmissions. • Most patients are denied the benefits of CR due to low referral rates. • In this economic analysis, CR was cost-effective with a mean ICER of $6096/QALY. • Patients in CR programs experience greater health benefits over a lifetime. • 60% uptake of CR will lower readmissions by 823 events and 536 deaths over 10 years. [ABSTRACT FROM AUTHOR]

Background: Bioresorbable scaffolds (BRS) are a novel technology in coronary intervention. However, recent trials demonstrate higher rates of device failure compared to contemporary drug-eluting stents. This study sought to utilise a clinical quality registry to assess the medium-term safety of the Abbott Absorb BRS (Abbott Vascular, Santa Clara, CA, USA), in an Australian context.Methods: A prospective, observational study of 192 BRS percutaneous coronary interventions (PCI) compared to 31,773 non-BRS PCIs entered in the Victorian Cardiac Outcomes Registry from 2013 to 2017. The main outcome measure was patient-oriented composite endpoint (POCE) events comprising all-cause mortality, any myocardial infarction (MI), and any revascularisation.Results: Bioresorbable scaffolds patients (mean age 61.6±10.5 years, 79% male) were younger, had less comorbidity, less prior PCI, fewer ST elevation myocardial infarction (STEMI) presentations, lower rates of multi-lesion disease and more adjuvant devices compared to non-BRS PCI (all p<0.01). All-cause mortality was 2.1%, myocardial infarction (MI) 2.1%, scaffold thrombosis 3.1% and any revascularisation 14.1% (mean follow-up 27.4±8.9 months). POCE events occurred in 11.5% at 1 year and 16.9% at 2 years, comparable to pooled-trial data. Multivariate predictors of POCE were >1 scaffold used (odds ratio [OR] 4.6, 95% confidence interval [CI] 1.9-11.4, p<0.01) and scaffold diameter ≤2.5 mm (OR 3.3, 95% CI 1.4-7.6, p=0.02). Over 95% guideline adherence was achieved in six of eight patient selection criteria and four of six device deployment criteria.Conclusion: In an Australian setting, BRS were used in non-complex patients. Most guidelines for use were adhered to and outcomes were comparable to pooled trial data. Clinical quality registries are effective in assessing novel treatments and technologies when potential safety concerns develop. [ABSTRACT FROM AUTHOR]

Background: Stent thrombosis (ST) is an uncommon but serious complication of percutaneous coronary intervention (PCI). The reported rate of definite ST with new generation drug-eluting stents ranges from 0.5 to 1% at 30 days. We aimed to examine the incidence and outcomes of ST in a real-world setting.Methods: The Victorian Cardiac Outcomes Registry was established in 2012 as a state-wide clinical quality registry, with all PCI capable centres contributing in 2017. Data were collected on 41,137 consecutive PCI procedures from 2013 to 2017. We describe the patient characteristics and clinical outcomes in definite and probable ST at 30 days.Results: Stent thrombosis occurred in 225 patients (0.55%). Compared to patients without ST, these patients were more likely to be female (32.0% vs 23.4%, p≤0.01) and have a history of diabetes (28.6% vs 21.9%, p=0.02). ST was more common in patients with severely reduced left ventricular ejection fraction (14.9% vs 4.6%, p<0.001) and in patients presenting with ST-elevation myocardial infarction, cardiogenic shock and cardiac arrest for their index PCI (all p<0.001). Dual antiplatelet therapy at 30 days was less frequent in patients with ST (84.8% vs 92.0%, p<0.001), while 30-day mortality was more common: 23.6% versus 2.0% (p<0.001).Conclusions: Even with contemporary stents and adjunctive medications, ST still occurs following 1 in 200 PCIs, and is associated with increased mortality at 30 days. [ABSTRACT FROM AUTHOR]

Background: Women experience less appropriate implantable cardioverter-defibrillator (ICD) interventions and are underrepresented in randomised ICD trials. Sex-differences in inducible and spontaneous ventricular tachycardia/fibrillation (VT/VF), cardiac arrest and sudden cardiac death (SCD) early post-myocardial infarction (MI) require further study.Methods: Consecutive ST-elevation MI patients with left ventricular ejection fraction (LVEF)≤40% underwent electrophysiology study (EPS) to target early prevention of SCD. An ICD was implanted for a positive (inducible monomorphic VT) but not a negative (no arrhythmia or inducible VF) EPS. The combined primary endpoint of VT/VF (spontaneous or ICD-treated), cardiac arrest or SCD was assessed using competing risk survival analysis in women versus men with adjustment for confounders. Logistic regression was used to determine independent predictors of inducible VT at EPS.Results: A total of 403 patients (16.9% female) underwent EPS. Women were significantly older than men but with similar LVEF (31.5 ± 6.3 versus 31.6 ± 6.4%, p = 0.91). Electrophysiology study was positive for inducible VT in 22.1% and 33.4% (p = 0.066) and an ICD implanted in 25.0% and 33.4% (p = 0.356) of women versus men. Appropriate ICD activations (VT/VF) occurred in 5.9% of women and 36.6% of men (p = 0.012). The adjusted cumulative primary endpoint incidence was significantly lower in women than men (1.6% versus 26.5%, p = 0.03). Female sex was not an independent predictor of inducible VT at EPS (HR 0.63, 95% CI 0.33-1.23, p = 0.178).Conclusions: Women with early post-MI cardiomyopathy had lower VT/VF, cardiac arrest and SCD, compared to men. In ICD recipients the rate of appropriate activations was six-fold less in women compared to men. [ABSTRACT FROM AUTHOR]

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: Delivering reperfusion therapy to patients with ST‐segment elevation myocardial infarction (STEMI) in regional areas without access to tertiary cardiology care remains challenging. The systems of care in Hunter New England Health, New South Wales, Australia (area covered = 130 000 km2) to provide reperfusion to patients with STEMI involve a 12‐lead electrocardiogram in the ambulance, discussion between cardiologist and paramedic, followed by pre‐hospital thrombolysis (PHT) delivered in ambulance to appropriate patients >60 min from the cardiac catheterisation laboratories. Patients who can access the cardiac catheterisation laboratories within 60 min are treated with primary percutaneous coronary intervention (PCI). Aims: We have previously reported excellent 12‐month outcomes for patients receiving PHT and the aim of the current analysis is to look at the long term outcomes. Methods: We assessed long‐term all‐cause mortality and major adverse cardiovascular events of STEMI patients undergoing PHT in our health district from August 2008 to August 2013 and compared with the primary PCI group. Results: One hundred and fifty (mean age: 62 ± 13 years, males: 76%, n = 114) patients were administered PHT and 334 patients (mean age: 65 ± 13 years, males: 75%, n = 251) underwent primary PCI during the study period. During a median follow up of 6.2 years (interquartile range: 4.8–7.4 years) all‐cause mortality was 16% and 19% in the PHT and primary PCI groups respectively (P = 0.4). Conclusion: Our real‐world experience shows that PHT followed by early transfer to a primary PCI‐capable centre is an effective reperfusion strategy, with comparable results to primary PCI, and mortality benefits are sustained to more than 6 years. [ABSTRACT FROM AUTHOR]

• Application of self-controlled case series design in Australian primary care setting. • Use of novel primary care data source (MedicineInsight) for vaccine safety. • No new safety concerns identified for live attenuated herpes zoster vaccine. • Expected increased risk of injection site reaction supports the methodology. • No increased risk of myocardial infarction or stroke following vaccination. Australia introduced a funded shingles vaccination program for older adults in November 2016, administered predominantly in primary care clinics. MedicineInsight, a nationally representative primary care database, was used to investigate the risk of pre-specified outcomes following live attenuated herpes zoster vaccine (ZVL) in Australia. Individuals aged 70–79 years who received ZVL between 1 November 2016 and 31 July 2018 were identified from MedicineInsight. The self-controlled case series (SCCS) method was used to estimate the seasonally-adjusted relative incidence (RI) of seven pre-specified outcome events (injection site reaction (ISR) [positive control], burn [negative control], myocardial infarction (MI), stroke, rash, rash with an antiviral prescription, and clinical attendance) during a plausible post-vaccination at-risk window compared with times distant from vaccination. Sensitivity analyses examined the effect of common concomitant vaccinations and restriction to first outcome events. A total of 332,988 vaccination encounters among 150,054 individuals were identified during the study period; over 2 million clinical attendances were observed. There was an increased RI of ISR in the seven days following ZVL (RI = 77.4, 95% CI 48.1–124.6); the RI of clinical attendance (RI = 0.94, 95% CI 0.94–0.95) and stroke (RI = 0.58, 95% CI 0.44–0.78) were lower in the 42 days following administration of ZVL compared to control periods. There was no evidence of a change in the RI of MI (RI = 0.74, 95% CI 0.41–1.33), rash (RI = 0.97, 95% CI 0.88–1.08), or rash with antiviral prescription (RI = 0.83, 95% CI 0.62–1.10) in the 42 days following ZVL compared to control periods. No new safety concerns were identified for ZVL in this study based on a novel, Australian primary care data source. An expected increased risk of ISR was identified; findings in relation to cardiovascular disease were reassuring but require confirmation using additional data, including hospital records. [ABSTRACT FROM AUTHOR]

Aim: Out-of-hospital cardiac arrest (OHCA) is frequently associated with ST-elevation myocardial infarction (STEMI) and has a high mortality. We aimed to identify differences in characteristics and very long-term outcomes for STEMI patients with and without OHCA managed with percutaneous coronary intervention (PCI).Methods: We analysed data from 12,637 PCI patient procedures for STEMI in the multi-centre Melbourne Interventional Group registry between January 2005 and December 2018. Multivariable models examined associations with OHCA presentation and 30-day mortality. Long-term outcomes were assessed through linkage with the Australian National Death Index.Results: Compared with patients without OHCA (N = 11,580), patients with OHCA (N = 1057) were younger, more often male, had less cardiovascular risk factors, and more often presented with cardiogenic shock. OHCA preceded an increasing proportion of STEMI PCI cases from 2005 to 2018 (2.4% vs. 9.2%). Factors independently associated with OHCA presentation were younger age, male gender, prior valve surgery, multi-vessel disease, LAD culprit, small vessel diameter, and renal impairment on presentation. Patients with OHCA had lower procedural success, higher rates of bleeding and stroke, larger infarct size (measured by peak CK), and higher 30-day mortality (37% vs. 5%; all p < 0.05). Cardiogenic shock, renal impairment and lower ejection fraction were independently associated with 30-day mortality. Long-term mortality was 44% vs. 20% (median follow-up 4.6 years), with Cox regression analysis demonstrating no difference in survival if patients survived beyond 30 days (HR 1.18, 95% CI 0.95-1.47).Conclusions: OHCA has a high short-term mortality and precedes an increasing proportion of STEMI PCI cases. Thirty-day survivors have an excellent long-term prognosis. [ABSTRACT FROM AUTHOR]

Introduction: Health disparities among immigrants exist across socioecological domains. While Chinese immigrants face increased risk for coronary heart disease (CHD) after migration, the reasons are not well understood. Method: This descriptive qualitative study collected 18 semistructured interviews with Chinese immigrants with CHD and family carers from two Australian hospitals. Analysis was guided by the social–ecological model. Results: Poor knowledge and limited English proficiency increased CHD risk and difficulty navigating health care systems/resources. Interpersonal and family factors positively influenced health-seeking behaviors, acceptance of cardiac procedures, adoption of secondary preventive behaviors and information acquisition through social networks. A lack of culturally specific health information and programs in Chinese languages was described. Ethnic concordance between Chinese doctors and patients improved health literacy and engendered trust. Discussion: Culturally specific interventions could include health promotion materials in Chinese, inclusion of family in educational programs, and Chinese-focused public health campaigns about warning signs of heart attack. [ABSTRACT FROM AUTHOR]

Background: There is a long‐held belief in the association between the full moon and extremes of human behaviour and adverse health consequences. Small‐scale studies are conflicting; however, most suggest no clear association between lunar phase and occurrence of acute coronary syndromes. Aims: To evaluate the impact of the lunar phase, and in particular, the full moon phase, on the incidence and outcomes among ST‐elevation myocardial infarction (STEMI) cases undergoing percutaneous coronary intervention (PCI). Methods: We conducted a multi‐centre retrospective study from the Melbourne Interventional Group registry, including 7570 STEMI cases from six tertiary centres over a 12‐year study period in Victoria, Australia, and performed statistical analysis using Stata software. Primary outcomes studied were the incidence of STEMI, the occurrence of major adverse cardiac and cerebrovascular events and mortality at 1 and 5 years in cases of STEMI undergoing primary or rescue percutaneous coronary intervention during the full moon between 2005 and 2017 in Victoria, Australia. Results: This study demonstrated neither significant difference in STEMI incidence (P = 0.61) nor of major adverse cardiovascular events across all lunar phases. Subgroup analysis confirmed no difference in outcomes during the full moon compared to a composite of other lunar phases.Kaplan–Meier survival estimates showed similar 30‐day outcomes across lunar phases (P = 0.35) and when comparing full moon to a composite of other lunar phases (P = 0.45). Similarly, there was no significant difference in survival at 1 and 5 years between lunar phases (P = 0.68) or compared to the full moon phase (P = 0.51). Conclusions: This study showed no significant difference in the incidence or cardiovascular outcomes and survival in patients with STEMI undergoing primary or rescue percutaneous coronary intervention during the lunar phases. [ABSTRACT FROM AUTHOR]

Objective: The Deepening our Understanding of Quality in Australia (DUQuA) project is a multisite, multi-level, cross-sectional study of 32 of the largest hospitals in Australia. This overview examines relationships between (i) organization-level quality management systems and department-level quality management strategies and (ii) patient-level measures (clinical treatment processes, patient-reported perceptions of care and clinical outcomes) within Australian hospitals.Design: We examined hospital quality improvement structures, processes and outcomes, collecting data at organization, department and patient levels for acute myocardial infarction (AMI), hip fracture and stroke. Data sources included surveys of quality managers, clinicians and patients, hospital visits, medical record reviews and national databases. Outcomes data and patient admissions data were analysed. Relationships between measures were evaluated using multi-level models. We based the methods on the Deepening our Understanding of Quality Improvement in Europe (DUQuE) framework, extending that work in parts and customizing the design to Australian circumstances.Setting, Participants and Outcome Measures: The 32 hospitals, containing 119 participating departments, provided wide representation across metropolitan, inner and outer regional Australia. We obtained 31 quality management, 1334 clinician and 857 patient questionnaires, and conducted 2401 medical record reviews and 151 external assessments. External data via a secondary source comprised 14 460 index patient admissions across 14 031 individual patients. Associations between hospital, Emergency Department (ED) and department-level systems and strategies and five patient-level outcomes were assessed: 19 of 165 associations (11.5%) were statistically significant, 12 of 79 positive associations (15.2%) and 7 of 85 negative associations (8.2%).Results: We did not find clear relationships between hospital-level quality management systems, ED or department quality strategies and patient-level outcomes. ED-level clinical reviews were related to adherence to clinical practice guidelines for AMI, hip fracture and stroke, but in different directions. The results, when considered alongside the DUQuE results, are suggestive that front line interventions may be more influential than department-level interventions when shaping quality of care and that multi-pronged strategies are needed. Benchmark reports were sent to each participating hospital, stimulating targeted quality improvement activities.Conclusions: We found no compelling relationships between the way care is organized and the quality of care across three targeted patient-level outcome conditions. The study was cross-sectional, and thus we recommend that the relationships studied should be assessed for changes across time. Tracking care longitudinally so that quality improvement activities are monitored and fed back to participants is an important initiative that should be given priority as health systems strive to develop their capacity for quality improvement over time. [ABSTRACT FROM AUTHOR]

Objective: Little is known about the influence that hospital quality systems have on quality at department level, in Australia and elsewhere. This study assessed the relationships between organizational-level quality management systems, and the extent to which hospital-level quality management systems and department-level quality management strategies are related.Design: A multi-level, cross-sectional, mixed-method study.Setting and Participants: As part of the Deepening our Understanding of Quality in Australia (DUQuA) project, we invited all large hospitals in Australia (~200 or more beds) which provided acute myocardial infarction (AMI), hip fracture and stroke care. The quality managers of these hospitals were the respondents for one of seven measures of hospital quality management systems and strategies. Data across the six remaining measures were collected through site visits by external surveyors assessing the participating hospitals.Main Outcome Measures: Relationships were assessed between three organization-level quality management system measures: a self-report measure assessing organization-level quality activities (quality management systems index, QMSI); externally assessed organization-level compliance to procedures used to plan, monitor and improve quality of care (quality management compliance index, QMCI); and externally assessed implementation of quality systems (clinical quality implementation index, CQII). Associations were also assessed between organization-level quality management systems and department-level quality management strategies: how clinical responsibilities are assigned for a particular condition; whether department organization processes are organized to facilitate evidence-based care recommendations; compliance with selected recommendations of international agencies; and whether clinical reviews are performed systematically.Results: Of 78 invited hospitals, 32 participated in the study. QMSI was positively associated with QMCI and CQII, but after controlling for QMSI, no relationship was found between QMCI and CQII. There appears to be a cluster of relationships between QMSI and department-level measures, but this was not consistent across all departments.Conclusion: This is the first national study undertaken in Australia to assess relationships within and between organization-level and department-level quality management systems. These quality management system tools align with many components of accreditation standards and may be useful for hospitals in continuously monitoring and driving improvement. [ABSTRACT FROM AUTHOR]

Background: This research estimates the broader socioeconomic impacts of reducing pre-hospital delay times across Australia in patients with heart attack symptoms.Methods: A cost benefit analysis (CBA) was undertaken to demonstrate the costs and benefits of a public awareness/education campaign to reduce pre-hospital delay time from 5.2hours (Base Case) to 4.1hours (Scenario 1) and 2.0hours (Scenario 2). All assumptions underlying the CBA are supported by academic literature. Financial impacts considered include campaign/public education costs, direct inpatient costs and long-term health care costs. Socioeconomic impacts considered include burden of disease, productivity losses, informal care costs and net deadweight loss.Results: The campaign is expected to generate an additional net benefit of $41.2-139.1 million in comparison to the Base Case, resulting in a benefit cost ratio (BCR) of 3.23-5.06. Disability Adjusted Life Years (DALYs) reduced by 6,046-7,575 years.Conclusion: This research illustrates that an investment in public awareness/education campaign can generate considerable benefits, more than offsetting the costs associated with the campaign and keeping people living longer such as ongoing health care costs. However, significant effort, supplementary strategies and sustained investment will be required to ensure the impact and benefit is sustained over the long term. [ABSTRACT FROM AUTHOR]

Background: Increased access to reperfusion for ST elevation myocardial infarction (STEMI) has contributed to reduced mortality internationally. We describe temporal trends in pre-hospital care, in-hospital management and outcomes of the STEMI population in Australia.Methods: Temporal trends with multiple regression analysis on the management and outcomes of STEMI patients enrolled across 46 Australian hospitals in the Australian cohort of the Global Registry of Acute Coronary Events (GRACE) and the Cooperative National Registry of Acute Coronary Care Guideline Adherence and Clinical Events (CONCORDANCE) between February 1999 and August 2016.Results: 4,110 patients were treated for STEMI, mean age 62.5±13.7years (SD). The median door-to-balloon time of primary percutaneous coronary intervention (PPCI) decreased by 11minutes (p<0.01) although there was no increase in rates of PPCI (p=0.35). Access to non-primary PCI increased by 39% (p<0.01), provisioning of fibrinolysis decreased by 13% (p<0.01) and the median door-to-needle time of 35minutes remained unchanged (p=0.09). Prescription of medical therapies in-hospital remained high, and at discharge there was an increase in prescription of statins (p<0.01); aspirin including antiplatelets (p<0.01), beta blockers (p=0.023) and ACE/ARB (p=0.02). The occurrence of any in-hospital adverse clinical events declined by 78% (p<0.01) albeit, there was no reduction in mortality in-hospital (p=0.84) or within 6 months (p=0.81).Conclusions: Over time, there has been increased access to non-primary PCI; shorter door-to-balloon times for PPCI; less adverse events in-hospital and fewer readmissions for unplanned revascularisation without the realisation of reduced mortality in-hospital or at 6 months.Trial Registration: CONCORDANCE Registry ACTRN: 12614000887673. [ABSTRACT FROM AUTHOR]

Background For patients in whom statins are not tolerated or effective as monotherapy, proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) represent a new class of lipid lowering therapies that may reduce low-density lipoprotein cholesterol (LDL-C) levels by up to 50% and lower cardiovascular events. While an important treatment option, the cost-effectiveness of PCSK9i in Australia remains unknown. This study aimed to determine the cost-effectiveness of PCSK9i compared to placebo in the prevention of atherosclerotic cardiovascular disease (CVD). Methods and results A Markov cohort state-transition model was developed in Microsoft Excel. A hypothetical sample of 1000 individuals based on subjects in the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) trial populated the model. With each five-year cycle, model subjects could have non-fatal CVD events (myocardial infarction and/or stroke), or die from CVD or other causes. Follow-up was simulated for 25 years. CVD risk reduction, cost and utility data were gathered from published sources. At current acquisition prices (AU$8174 per person per year), the incremental cost effectiveness ratio (ICER) was AU$308,558 per quality-adjusted life year (QALY) saved. Acquisition prices would need to be reduced to approximately AU$1500 per person per annum for PCSK9i to reach the arbitrary cost-effectiveness threshold of AU$50,000 per QALY saved. Conclusion(s) PCSK9i are an effective alternative for those with existing CVD or at high risk of CVD in whom statin therapy alone is ineffective, but are not cost-effective to the Australian healthcare system based on current prices. [ABSTRACT FROM AUTHOR]

Context • Type 2 diabetes mellitus is an independent precipitating factor for cardiovascular disease (CVD). Heart disease is one of the leading causes of mortality in patients with diabetes, mainly due to macrovascular complications, such as atherosclerosis. Although aspirin is a frequently used therapy for the inhibition of platelet hyperactivity, many studies suggest that aspirin resistance is rising. Objective • The study intended to investigate the benefits of anthocyanin (AC) as an antioxidant with inhibitory effects on platelets and, consequently, its potential usefulness as complementary antiplatelet therapy to attenuate the negative effects of atherosclerosis and CVD in patients with diabetes. Design • The research team performed a literature review. The team conducted a database search from 2007 to 2017 using Library of Congress, LISTA, PubMed, and Web of Science Core Collection databases, using the following keywords: anthocyanins, platelet, cardiovascular disease, and diabetes. Setting • The study took place at the School of Medical Sciences at Griffith University's Gold Coast campus (Southport, Australia). Results • Platelets have a major pathophysiological role of atherosclerosis and consequently CVD in diabetes. Antiplatelet drugs have a potent inhibitory effect of thrombotic and CVD risks in diabetes. Dietary antioxidants including ACs have a potential platelet inhibitory effect. Hence, ACs may act as complementary therapy to reduce CVD in diabetes. Conclusions • Although antiplatelet drugs such as aspirin provide significant action in the management of CVD, aspirin has limited benefits in diabetes. An AC antioxidant has a potential effect as an antiplatelet agent that subsequently can prevent atherosclerosis and CVD and, therefore, AC may be an alternative to other antiplatelet drugs such as aspirin. However, more interventional studies and large-scale clinical trials are necessary to prove the efficiency of AC as an alternative to other platelet-inhibitory drugs. [ABSTRACT FROM AUTHOR]