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BACKGROUND Permanent pacemaker (PPM) and implantable cardioverter defibrillator (ICD) implant rates have increased in New Zealand over the past decade. This study aims to provide a contemporary analysis of regional variation in implant rates. METHOD New PPM and ICD implants in patients ≥15 years were identified for ten years (2009 to 2018) using procedure coding in the National Minimum Datasets, which collects all New Zealand public hospital admissions. Age-standardised new implant rates per million adult population were calculated for each of the four regions (Northern, Midland, Central and Southern) and the 20 district health boards (DHBs) across those regions. Trend analysis was performed using joinpoint regression. RESULTS New PPM implant rates increased nationally by 3.4%/year (p

Background Takotsubo syndrome (TS) is often triggered by an acute physical or emotional stressor. We hypothesised that medium-term prognosis may be better for TS patients with an associated emotional stressor than for those with an acute physical illness. Methods We identified consecutive TS patients presenting in New Zealand (2006–2018). The clinical presentation and outcomes of TS patients according to types of stressor (physical, emotional or no stressor) were assessed. Post-discharge survival after TS was compared with age- and gender-matched patients after myocardial infarction (MI) and people in the community without known cardiovascular disease (CVD). Results Of 632 TS patients (95.9% women, mean age 65.0±11.1 years), 27.4% had an associated acute physical stressor, 46.4% an emotional stressor and 26.2% no evident stressor. In-hospital mortality was similar for each group (1.7%, 1.2%, 0.3% respectively, p=0.29). In a median 4.4 years post-discharge there were 54 deaths (53 non-cardiac). Compared with patients without known CVD, TS patients with physical stress and those with MI were less likely to survive (HR 4.46, 95%CI 3.10–6.42; HR 4.23, 95%CI 3.81–4.70 respectively) but survival for TS patients associated with emotional stress or no stressor was similar (HR 1.11, 95%CI 0.66–1.85; HR 1.08, 95%CI 0.54–2.18, respectively). Recurrence was similar among the three groups (p=0.14). Conclusion Takotsubo syndrome associated with physical stressor has a post-discharge mortality risk as high as after MI. In contrast, prognosis for TS triggered by an emotional stressor is excellent, and similar to that of those without known CVD.

At Middlemore Hospital, acute coronary syndrome (ACS) patients are admitted under the care of one of seven cardiologists working on a weekly rotation. Between 2010 and 2018 patients under the care of three of the cardiologists were followed up in a "medical only" post-ACS follow-up clinic model where the cardiologist or registrar saw all patients. Those admitted under the other four cardiologists were seen in a "nurse-led, cardiologist-supported" follow-up model where the majority of patients were seen by a nurse specialist. The study aim was to compare quality of care and outcomes between patients managed under these two follow-up clinic models.The ANZACS-QI registry was used to identify all ACS admissions, 2010 to 2018. The ANZACS-QI records for 5296 patients, discharged alive, were anonymously linked with hospital clinic follow-up and national administrative datasets. Time to follow-up, medication dispensation and titration and one-year clinical outcomes were compared for the two follow-up models.Characteristics of patients managed under each model were similar. 4395 patients attended follow up, 74% in the nurse-led model. At one year there were no differences between the medical- and nurse-led cohorts in all-cause mortality (4.6% vs 3.9, p=0.29), rehospitalisations for myocardial infarction (MI) (9.2% vs 8.3%, p=0.31), stroke (1.2% vs 1.4% p=0.71), heart failure (5.7% vs 6.9%, p=0.15) or a combined endpoint of all-cause mortality and/or rehospitalisation for MI/stroke/HF (15.2% vs 14.8%, p=0.71). Patients were seen earlier post-discharge in the nurse-led model, (mean 83 vs 101 days). Medication dispensation one year post-discharge was similar for both models of care.The nurse-led model is associated with earlier access to follow-up, was equally as effective at maintaining secondary prevention pharmacotherapy and associated with similar survival and readmission with non-fatal ACS/stroke/heart failure.

Coronary angiography in patients with previous coronary artery bypass grafts (CABG) is technically more difficult with increased procedure time, radiation exposure and in-hospital complications. In a contemporary national registry of acute coronary syndrome (ACS) patients undergoing an invasive strategy, we compared the management and outcomes of patients with and without prior CABG.The All New Zealand ACS Quality Improvement (ANZACS-QI) registry was used to identify patients admitted to New Zealand public hospitals with an ACS who underwent invasive coronary angiography (2014-2018). Outcomes were ascertained by anonymised linkage to national datasets.Of 26,869 patients, 1,791 (6.7%) had prior CABG and 25,078 (93.3%) had no prior CABG. Prior CABG patients were older (mean age 71 years vs 65 years), more comorbid and less likely to be revascularised than those without CABG (49.8% vs 73.0%). Compared to patients without CABG, at a mean follow-up of 2.1 years, patients with prior CABG had higher all-cause mortality (HR 2.03 (1.80-2.29)), and were more likely to have recurrent myocardial infarction (HR 2.70 (2.40-3.04)), rehospitalisation with congestive cardiac failure (HR 2.36 (2.10-2.66)) and stroke (HR 1.82 (1.41-2.34)).In contemporary real-world practice, despite half of the patients with ACS and prior CABG receiving PCI, the outcomes remain poor compared with those without prior CABG.

Ethnic variation in implantable cardioverter defibrillator (ICD) implant rates have been reported internationally but have not previously been examined in New Zealand. This study examined trends in new ICD implants by ethnicity over an extended period.All patients who received a new ICD implant between 2005 and 2019 were identified using the National Minimum Dataset, which collects information on all public hospital admissions in New Zealand. Ethnicity was classified using the following standard prioritisation: Māori, Pacific, Asian and European/Other. New ICD implant rates were analysed by ethnicity and age groups.A total of 5,514 new ICDs were implanted. New ICD implant rates increased from 41.4/million in 2005 to 98.2/million in 2019, an average increase of 5.4%/year (p0.01). The highest age-standardised implant rates were among Māori, followed by Pacific, European/Other and Asian ethnicities. The largest increase was seen in Pacific people at 8.9%/year (p0.01), followed by Māori and Asian people at 4.7%/year and 4.3%/year respectively (both p0.01). In European/Other patients, ICD implant rates increased by 10.3%/year (p0.01) between 2005 to 2012, then plateaued at -0.4%/year (p=0.71) between 2012 to 2019. By 2019, the age-standardised implant rates in Māori and Pacific people were two-fold higher than European/Others.There is marked ethnic variation in ICD implant rates in New Zealand. The higher implant rates in Māori and Pacific parallel known ethnic differences in rates of underlying cardiac disease. The more rapid increase in implant rates in these ethnic groups may represent more equitable treatment over time.

Aims Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular disease (CVD). We examined the characteristics, management and outcomes of patients with CKD in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) national registry. Methods The cohort comprised New Zealand (NZ) patients with an acute coronary syndrome undergoing coronary angiography between January 2013 and December 2016. Patients were categorized according to their stage of CKD. Outcomes included all-cause and cause-specific mortality and hospitalization with myocardial infarction (MI), stroke and major bleeding. Results Of the 20 604 patients, 20.3% had normal renal function, with 53.3%, 23.3%, 1.7% and 1.4% having CKD stages 2, 3, 4 and 5 CKD, respectively. Patients with severe CKD were more likely to be Māori or Pacific and live in an area with greater socioeconomic deprivation. Death, recurrent MI or stroke, and major bleeding all increased incrementally with each worsening stage of CKD severity. Compared with those with normal renal function, patients with stage 5 CKD had a much higher all-cause (hazard ratio [HR] 16.41, 95% CI 13.06-20.61), cardiovascular (HR 16.38, 95% CI 12.17-22.04) and non-cardiovascular mortality (HR 13.66 9, 95% CI.56-19.51). In addition, patients with stage 5 CKD were at a higher risk of recurrent MI or stroke (HR 4.73, 95% CI 3.86-5.80) and bleeding (HR 5.84, 95% CI 4.39-7.76). Conclusion CKD was associated with increased mortality and a high incidence of morbidity in patients undergoing coronary angiography in New Zealand. Initiatives to understand and improve outcomes in this group of patients are urgently needed.

Guidelines recommend angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB)/angiotensin receptor neprilysin inhibitors (ARNI); beta blockers; and mineralocorticoid receptor antagonists (MRA) in patients with symptomatic heart failure and reduced left ventricular ejection fraction before consideration of primary prevention implantable cardioverter defibrillator (ICD). This study aims to investigate dispensing rates of guideline-directed medical therapy (GDMT) before and after primary prevention ICD implantation in New Zealand.All patients receiving a primary prevention ICD between 2009 and 2018 were identified using nationally collected data on all public hospital admissions in New Zealand. This was anonymously linked to national pharmaceutical data to obtain medication dispensing. Medications were categorised as low dose (50% of target dose), 50-99% of target dose or target dose based on international guidelines.Of the 1,698 patients identified, ACEi/ARB/ARNI, beta blockers and MRA were dispensed in 80.2%, 83.6% and 45.4%, respectively, prior to ICD implant. However, ≥50% target doses of each medication class were dispensed in only 51.8%, 51.8% and 34.5%, respectively. Only 15.8% of patients were receiving ≥50% target doses of all three classes of medications. In the 1,666 patients who survived 1 year after ICD implant, the proportions of patients dispensed each class of medications remained largely unchanged.Dispensing of GDMT was suboptimal in patients before and after primary prevention ICD implantation in New Zealand, and only a minority received ≥50% target doses of all classes of medication. Interventions are needed to optimise use of these standard evidence-based medications to improve clinical outcomes and avoid unnecessary device implantation.

Background Implantable cardioverter defibrillator (ICD) implant rates in New Zealand (NZ) have increased significantly in recent years. Previous studies in NZ have demonstrated that Māori and Pacific patients had higher rates of ischaemic heart disease compared to other ethnicities. Ethnic variation in ICD implant rates have been reported internationally, but whether this trend exists in NZ is unclear. Purpose This paper aims to provide the first analysis of new ICD implants by ethnicity over an extended time period. Methods All patients who received a new ICD implant were identified for the period of 1st January 2005 to 31st December 2019 using the National Minimum Datasets, which collects information on all public hospital admissions in NZ. Ethnicity prioritisation was performed in the following order: Māori, Pacific, Asian and European. New ICD implant rates were analysed by ethnicity and age-groups. Results A total of 5,514 new ICDs were implanted over the study period. New ICD implant rates increased by 137%, from 41.4/million in 2005 to 98.2/million in 2019, at an average of 5.4%/year (p In the age groups of Conclusion There is marked ethnic variation in ICD implant rates in NZ. Implant rates have increased in ethnic minorities but have plateaued in European patients in the past 7 years. The continued difference in implant rates across ethnicities warrants further investigation. Funding Acknowledgement Type of funding sources: None.

Background Invasive coronary angiography plays a pivotal role in the management of acute coronary syndromes (ACS). Wide variability in its use has been previously documented. Our aim was to investigate whether coronary angiography is being used appropriately prior to discharge after ACS, taking into account relative contraindications of the procedure. Methods Patients presenting with ACS in 2015 to two large, demographically distinct New Zealand (NZ) District Health Boards (DHBs)—Counties Manukau (CMDHB) and Waitemata (WDHB)—were identified from the NZ Ministry of Health National Dataset using ICD-10-AM codes. Patients’ clinical data were obtained from the electronic and paper clinical records. Pre-defined relative contraindications to coronary angiography were identified. Results Of the 3,809 patient admissions coded with ACS, 600 patient admissions (300 from each DHB) were reviewed. Sixty-one (61) (10%) did not meet diagnostic criteria for ACS on review of clinical data and were excluded. Of the patients reviewed, 55% received coronary angiography, with a higher rate in WDHB than CMDHB (61% and 49%, respectively) and 37.5% had relative contraindications documented. The overall rate of angiography was appropriately high in those without a relative contraindication (90.3%) and low in those with one (7.4%). There were fewer patients with relative contraindications in WDHB than CMDHB (36.7% and 48.5%) but the rate of angiography in those with (6.9% and 7.8%) and without (92.5% and 87.5%) contraindications in the two DHBs was similar. Conclusions The decision to offer coronary angiography after ACS appears to be appropriately influenced by the presence or absence of relative contraindications. Approximately 60% of patients had no documented relative contraindication suggesting that this may be an appropriate angiography rate in New Zealand practice. However, differences between the two DHBs of around 10% appear to be clinically appropriate due to variation in contraindication rates.

Background The ANZACS‐QI Cardiac Implanted Device Registry (ANZACS‐QI DEVICE) collects nationwide data on cardiac implantable electronic devices in New Zealand (NZ). We used the registry to describe contemporary NZ use of implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT). Methods All ICD and CRT Pacemaker implants recorded in ANZACS‐QI DEVICE between 1 January 2014 and 31 December 2017 were analyzed. Results Of 1579 ICD implants, 1152 (73.0%) were new implants, including 49.0% for primary prevention and 51.0% for secondary prevention. In both groups, median age was 62 years and patients were predominantly male (81.4% and 79.2%, respectively). Most patients receiving a primary prevention ICD had a history of clinical heart failure (80.4%), NYHA class II‐III symptoms (77.1%) and LVEF ≤35% (96.9%). In the secondary prevention ICD cohort, 88.4% were for sustained ventricular tachycardia or survived cardiac arrest from ventricular arrhythmia. Compared to primary prevention CRT Defibrillators (n = 155), those receiving CRT Pacemakers (n = 175) were older (median age 74 vs 66 years) and more likely to be female (38.3% vs 19.4%). Of the 427 (27.0%) ICD replacements (mean duration 6.3 years), 46.6% had received appropriate device therapy while 17.8% received inappropriate therapy. The ICD implant rate was 119 per million population with regional variation in implant rates, ratio of primary prevention ICD implants, and selection of CRT modality. Conclusion In contemporary NZ practice three‐quarters of ICD implants were new implants, of which half were for primary prevention. The majority met current guideline indications. Patients receiving CRT pacemaker were older and more likely to be female., This paper utilized the ANZACS‐QI Cardiac Implanted Device Registry to describe contemporary use of implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) in New Zealand. Three‐quarters of ICD implants were new implants, of which half were for primary prevention. Compared to primary prevention CRT Defibrillators, those receiving CRT Pacemakers were older and more likely to be female. The ICD implant rate was 119 per million population with regional variation in implant rates, ratio of primary prevention ICD implants, and selection of CRT modality.

The last two decades in New Zealand have seen increased availability of primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) and early invasive coronary angiography (ICA) for other high-risk acute coronary syndrome (ACS) patients. One metric to assess the clinical appropriateness of these invasive strategies is to examine the false-positive rate for the investigation (ie, the rate of non-ACS diagnoses).All patients presenting to New Zealand public hospitals with suspected ACS who underwent ICA between 2015 and 2019 were recorded prospectively in the All New Zealand Acute Coronary Syndrome Quality Improvement registry. The cohort was divided according to clinical impression at presentation: (1) suspected STEMI24h and (2) other suspected ACS. The final discharge diagnosis for each patient were obtained from the registry.There were 6,059 (20%) patients with suspected STEMI24h and 24,258 (80%) with other suspected ACS. Of the suspected STEMIs24h, 90.6% had a final diagnosis of STEMI, 3.5% non-ST segment elevation ACS (NSTEACS) and only 5.9% had a non-ACS diagnosis. Of those with other suspected ACS, 80.7% had a final ACS diagnosis. Across all New Zealand district health boards (DHBs), the proportion of non-ACS diagnoses was similar for suspected STEMI presentations. However, for other suspected ACS, the proportions were higher in DHBs with rapid access to coronary interventional facilities than in those without (17.6% vs 7.0%, p0.001).False-positive catheter laboratory activations for suspected STEMI patients are low across New Zealand. The differences in the proportion of non-ACS diagnoses according to DHB interventional capability for other suspected ACS requires further investigation.

ObjectiveStudies indicate that age-standardised heart failure (HF) incidence has been decreasing internationally; however, contrasting trends in different age groups have been reported, with rates increasing in younger people and decreasing in the elderly. We aimed to describe age-specific trends in HF incidence in New Zealand (NZ).MethodsIn this nationwide data linkage study, we used routinely collected hospitalisation data to identify incident HF hospitalisations in NZ residents aged ≥20 years between 2006 and 2018. Age-specific and age-standardised incidence rates were calculated for each calendar year. Joinpoint regression was used to compare incidence trends.Results116 113 incident HF hospitalisations were identified over the 13-year study period. Between 2006 and 2013, age-standardised incidence decreased from 403 to 323 per 100 000 (annual percentage change (APC) −2.6%, 95% CI −3.6 to −1.6%). This reduction then plateaued between 2013 and 2018 (APC 0.8%, 95% CI −0.8 to 2.5%). Between 2006 and 2018, rates in individuals aged 20–49 years old increased by 1.5% per year (95% CI 0.3 to 2.7%) and decreased in those aged ≥80 years old by 1.2% per year (95% CI −1.7 to −0.7%). Rates in individuals aged 50–79 years old initially declined from 2006 to 2013, and then remained stable or increased from 2013 to 2018. The proportion of HF hospitalisations associated with ischaemic heart disease decreased from 35.1% in 2006 to 28.0% in 2018.ConclusionHF remains an important problem in NZ. The decline in overall incidence has plateaued since 2013 due to increasing rates of HF in younger age groups despite an ongoing decline in the elderly.

Prior New Zealand studies suggest that only approximately two-thirds of patients who present with an acute coronary syndrome (ACS) are adequately maintained on a statin post-discharge. This could be due to low initiation and/or poor longer-term adherence.To identify the pattern and adequacy of statin maintenance following ACS from initial prescription to one-year post-discharge.All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry data for consecutive New Zealand residents (2015-2017) who were hospitalised with ACS and managed with coronary angiography were anonymously linked to national datasets to derive a medication possession ratio (MPR) to assess medication maintenance. An MPR ≥0.8 is considered adequate maintenance and ≥1 is considered optimal.Of the 16,557 patients who survived their ACS, 15,431 (93.2%) were prescribed a statin at discharge and 89.8% were dispensed a statin within three months. 79.8% (13,219/16,557) of patients had an MPR ≥0.8 during the first year, but only 61.0% (10,096/16,557) had optimal dispensing over this period. Regression analysis identified the independent predictors of sub-optimal maintenance over the first year as age45 years, no prior statin and Māori and Pacific ethnicity.After ACS discharge, the gap between prescribing and dispensing rates was small with only minor demographic variation. One in ten patients were not initially dispensed a statin. Although eight in ten patients were adequately maintained, only six in ten had optimal maintenance with clear ethnic and age differences, which may reflect more general disparities in healthcare.

Recommendations regarding medication use after acute coronary syndrome (ACS) are dichotomised according to whether left ventricular ejection fraction (LVEF) is40% or ≥40%. In the context of heart failure (HF), a mid-range EF (mrEF, 40-49%) confers an intermediate prognosis between reduced EF (rEF,40%) and preserved EF (pEF, ≥50%). The aim of this study was to describe, in the context of ACS, the frequency of each EF subgroup and their associated outcomes.Consecutive patients presenting with ACS who underwent coronary angiography during 2015 were enrolled in the ANZACS-QI (All New Zealand Acute Coronary Syndrome-Quality Improvement) registry. Outcomes were obtained using anonymised linkage to national datasets. Cox proportional hazards models were used to adjust for confounding variables.Of the cohort of 6,216 patients, 31% did not have an LVEF assessment. Of those with a recorded LVEF, 63% had pEF, 21% had mrEF and 16% had rEF. Mean follow-up was 1.5 years. After adjusting for age, sex, clinical risk factors and post-ACS management, those with mrEF and rEF had a higher adjusted risk of all-cause mortality compared to pEF (HR 1.55, 95% CI 1.12-2.15 and HR 2.57, 95% CI 1.89-3.48, respectively). After adjustment, rEF was associated with an increased risk of subsequent HF hospitalisation (HR 2.32, 95% CI 1.75-3.08).One in five patients post-ACS have mrEF, which is associated with an intermediate risk of morbidity and mortality compared to those with pEF and rEF. Further study is warranted to determine the optimal management for these patients.

Primary percutaneous coronary intervention (PCI) is the optimal reperfusion strategy to manage ST-elevation myocardial infarction (STEMI). Where timely primary PCI cannot be achieved, an initial pharmacological reperfusion strategy is recommended with subsequent transfer to a PCI-capable hospital. The study aim was to assess STEMI outcomes according to the interventional capability of the New Zealand hospital to which patients initially present.Nine thousand four hundred and eighty-eight New Zealand patients, aged 20-79 years, admitted with STEMI to a public hospital were identified. Patients were categorised into three groups-metropolitan hospitals with all-hours access to primary PCI (routine primary PCI cohort), metropolitan hospitals without routine access to PCI, and rural hospitals. The primary outcome was all-cause mortality. Secondary outcomes were major adverse cardiac events (MACE) and major bleeding.Invasive coronary angiography was more frequent in the routine primary PCI cohort compared to metropolitan hospitals without routine access to PCI and rural hospitals (90.6 vs 83.0 vs 85.0% respectively; p0.001) and occurred more commonly on the day of admission (78.9 vs 28.7 vs 25.7% respectively; p0.001). There were no differences in multivariable adjusted all-cause mortality, MACE or major bleeding between patients admitted to any of the hospital groupings.Outcomes after STEMI in New Zealand are similar regardless of the interventional capability of the hospital where they first present.

Takotsubo syndrome (TS) mimics acute coronary syndrome but has a distinct pathophysiology. This study aimed to compare and contrast the clinical presentation, management and outcomes of patients with TS in five large New Zealand hospitals.We identified 632 consecutive patients presenting to the five major tertiary hospitals in New Zealand (Middlemore Hospital, Auckland City Hospital, North Shore Hospital, Christchurch Hospital and Dunedin Hospital) between January 2006 and June 2018 and obtained clinical, laboratory, electrocardiography, echocardiography, coronary angiography and long-term follow-up data.Six hundred and thirty-two consecutive patients with TS (606 women, mean age 65.0+11.1 years) were included. An associated stressor was identified in two-thirds of patients, and emotional triggers were more frequent than physical triggers (62.9% and 37.1%, respectively). Overall, 12.7% of patient had depression and 11.7% anxiety but this was more common in patients from Christchurch Hospital (20.4% and 23.4%, respectively). The in-hospital mortality among the five hospitals ranges between 0 to 2.0%. The mean follow-up was 4.9+3.4 years (median 4.4 years). Fifty-four people died post-discharge, all but one from a non-cardiac cause. Forty patients had recurrent TS. Mortality post-discharge (p=0.63) and TS recurrence (p=0.38) did not differ significantly among the five hospitals.In this large New Zealand TS cohort, the clinical characteristics and presentation were similar among the five hospitals. A subset of patients had a complicated in-hospital course, but late deaths were almost all from non-cardiac causes and recurrence was infrequent. Mortality post-discharge and recurrence was similar between the hospitals.

Ischaemic heart disease (IHD) mortality rates after myocardial infarction (MI) are higher in Māori and Pacific compared to European people. The reasons for these differences are complex and incompletely understood. Our aim was to use a contemporary real-world national cohort of patients presenting with their first MI to better understand the extent to which differences in the clinical presentation, cardiovascular (CVD) risk factors, comorbidity and in-hospital treatment explain the mortality outcomes for Māori and Pacific peoples.New Zealand residents (≥20 years old) hospitalised with their first MI (2014-2017), and who underwent coronary angiography, were identified from the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. All-cause mortality up to one year after the index admission date was obtained by linkage to the national mortality database.There were 17,404 patients with a first ever MI. European/other comprised 76% of the population, Māori 11.5%, Pacific 5.1%, Indian 4.3% and Other Asian 2.9%. Over half (55%) of Māori, Pacific and Indian patients were admitted with their first MI before age 60 years, compared with 29% of European/other patients. Māori and Pacific patients had a higher burden of traditional and non-traditional cardiovascular risk factors, and despite being younger, were more likely to present with heart failure and, together with Indian peoples, advanced coronary disease at presentation with first MI. After adjustment for age and sex, Māori and Pacific, but not Indian or Other Asian patients had significantly higher all-cause mortality at one year compared with the European/other reference group (HR 2.55 (95% CI 2.12-3.07), HR 2.98 (95% CI 2.34-3.81) for Māori and Pacific respectively). When further adjusted for differences in clinical presentation, clinical history and cardiovascular risk factors, the excess mortality risk for Māori and Pacific patients was reduced substantially, but a differential persisted (HR 1.77 (95% CI 1.44-2.19), HR 1.42 (95% CI 1.07-1.83)) which was not further reduced by adjustment for differences in in-hospital management and discharge medications.In New Zealand patients after their first MI there is a three-fold variation in one-year mortality based on ethnicity. At least half of the inequity in outcomes for Māori, and three-quarters for Pacific people, is associated with differences in preventable or modifiable clinical factors present at, or prior to, presentation.

Background: Countries with a high incidence of coronavirus 2019 (COVID-19) reported reduced hospitalisations for acute coronary syndromes (ACS) during the pandemic. This study describes the impact of a nationwide lockdown on ACS hospitalisations in New Zealand (NZ), a country with a low incidence of COVID-19. Methods: All patients admitted to a NZ Hospital with ACS who underwent coronary angiography in the All NZ ACS Quality Improvement registry during the lockdown (23 March – 26 April 2020) were compared with equivalent weeks in 2015–2019. Ambulance attendances and regional community troponin-I testing were compared for lockdown and non-lockdown (1 July 2019 to 16 February 2020) periods. Findings: Hospitalisation for ACS was lower during the 5-week lockdown (105 vs. 146 per-week, rate ratio 0•72 [95% CI 0•61–0•83], p = 0.003). This was explained by fewer admissions for non-ST-segment elevation ACS (NSTE-ACS; p = 0•002) but not ST-segment elevation myocardial infarction (STEMI; p = 0•31). Patient characteristics and in-hospital mortality were similar. For STEMI, door-to-balloon times were similar (70 vs. 72 min, p = 0•52). For NSTE-ACS, there was an increase in percutaneous revascularisation (59% vs. 49%, p

INTRODUCTION Implant rates for cardiac implantable electronic devices (CIED), including permanent pacemakers (PPM) and implantable cardioverter defibrillators (ICD), have increased globally in recent decades. This is the first national study providing a contemporary analysis of national CIED implant trends by sex-specific age groups over an extended period. METHODS Patient characteristics and device type were identified for ten years (2009 to 2018) using procedure coding in the National Minimum Datasets, which collects all New Zealand (NZ) public hospital admissions. CIED implant rates represent implants/million population. RESULTS New PPM implant rates increased by 4.6%/year (p

Concomitant atrial fibrillation (AF) and acute coronary syndrome (ACS) present the difficult therapeutic dilemma of balancing bleeding, cardio-embolic and coronary thrombotic risks with appropriate combinations of antithrombotic medications. We aim to evaluate current New Zealand practice by identifying the incidence of AF in ACS; describe the population characteristics; and assess our antithrombotic management.Consecutive patients ≥18y presenting with ACS who had coronary angiography (2017-2018) were identified from the All New Zealand ACS Quality Improvement (ANZACS-QI) registry. The cohort was divided into three groups: 1) patients with pre-existing AF; 2) new-onset AF; and 3) no AF. Antithrombotic regimens included dual antiplatelet therapy (DAPT), dual antithrombotic therapy (DAT-single antiplatelet plus an oral anticoagulant (OAC)) and triple antithrombotic therapy (TAT).There were 9,489 patients, 9.6% with pre-existing AF, 4.4% new AF and 86% without AF. Both AF groups were older (median 74 vs 71 vs 65y, p=0.001), had poorer renal function, were more likely to present with heart failure (16% vs 19% vs 8%, p=0.001) and have left ventricular ejection fraction40% (22% vs 28% vs 13%, p0.001). They received less percutaneous coronary intervention (PCI) (53% vs 59% vs 70%, p=0.001). In the cohort, 25 different combinations of antithrombotic agents were utilised. Ninety-six percent of patients with any AF had a CHA2DS2VASC stroke risk score of ≥2, of whom 48% did not receive OAC. Twenty-four percent received TAT and 19% DAT. OAC use increased slightly with increasing stroke risk but were independent of CRUSADE bleeding risk. Of patients with AF treated with PCI, 53% received DAPT, 11% DAT and 35% TAT. 51% of those at high stroke risk were discharged on DAPT only. In contrast, 19% at low stroke risk received TAT.In New Zealand, one in seven patients presenting with ACS have AF, a third being new-onset AF. Antithrombotic management is inconsistent, with underutilisation of anticoagulants, particularly the DAT regimen, and is inadequately informed by stroke and bleeding risk scores.

A key pillar in the medical management of patients after an acute coronary syndrome (ACS) is the early initiation and maintenance of "high-intensity" statin therapy to lower low-density lipoprotein cholesterol (LDL-C) and to improve clinical outcomes. The aim of this study was to describe the New Zealand utilisation of high-intensity statin therapy in the first year post-ACS.19,867 New Zealand patients (≥20 years), discharged post-ACS event (2015-2017) were identified from the All New Zealand ACS Quality Improvement (ANZACS-QI) registry and anonymously linked with the national pharmaceutical dataset to identify statin dispensing early (0-3 months) and late (9-12 months) post-discharge. "High intensity" statin was subdivided into the New Zealand guidelines recommended dose (80mg atorvastatin) and "other high-intensity" statin (atorvastatin 40mg, simvastatin 80mg). All other statin doses were classified as "low/medium dose".Seventy-nine percent were initially dispensed high-intensity statins. Thirty-six percent of the overall cohort received 80mg atorvastatin and 43% a lower "other high-intensity" statin. A further 13% received a medium/low dose and 8% no statin. By 12 months, 29% were dispensed atorvastatin 80mg, 36% another high dose, 14% a low/medium dose and 21% no statin. Only 14% of those initially on 80mg atorvastatin had a statin dose reduction. After multivariable adjustment, the risk of discontinuation was the same for those started on atorvastatin 80mg compared with "other high dose", and lower than for those started on a low/medium dose. Few patients (6.2%) had statins started, or dose up-titrated post-discharge. There is clinically unexplained variation in the use of the highest atorvastatin 80mg dose between district health boards (range 15% to 65%).Eight in 10 ACS patients were dispensed a high-intensity statin at discharge, but only 36% received the guidelines-recommended dose of 80mg of atorvastatin. By one year, one in five patients discharged on a statin were not receiving it. There are opportunities to improve longer-term LDL-C reduction and clinical outcomes through dosage optimisation and improved medication maintenance.

ObjectiveThe medium-term outcome and cause of death in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) is not well characterised. The aim of this study was to compare mortality and rates of recurrent events in post myocardial infarction (MI) patients with obstructive coronary artery disease (CAD) and in patients with MINOCA compared with an age and sex-matched cohort without cardiovascular disease (CVD).MethodsWe performed a national cohort study of consecutive patients undergoing coronary angiography for MI during 2 years between 2013 and 2015 from the All New Zealand Acute Coronary Syndrome—Quality Improvement (ANZACS QI) registry. MI patient registry data were linked anonymously to national hospitalisation and mortality records. Age and sex matched patients without known CVD formed the comparison group.ResultsOf the 8305 patients with MI, 897 (10.8%) were classified as MINOCA. Compared with those without known CVD, the adjusted HRs for the primary outcome (all-cause death or recurrent non-fatal MI) were 7.81 (95% CI 6.64 to 9.19, pConclusionsMINOCA is common and has an adverse outcome rate approximately half than that of those with obstructive CAD. The predominant contributor to mortality is non-CVD death. The rate of events in MINOCA is significantly greater than the population without CVD.

Non-obstructive coronary artery disease (CAD) on coronary angiography after myocardial infarction (MI) is associated with a lower risk of adverse outcomes, but the prognosis may not be benign. Our aim was to assess outcomes in MI with and without obstructive CAD, and in an age and sex matched comparison cohort without known cardiovascular disease.We performed a single centre analysis of consecutive patients undergoing coronary angiography for MI between 2007 and 2012. Patients were classified into those with obstructive CAD (≥50% epicardial coronary artery stenosis) and those without obstructive CAD (50%). Myocardial infarction patient data was collected in an electronic registry and linked anonymously to national hospitalisation and mortality records. Age and sex matched patients without known CVD were identified from the community PREDICT cohort.Of the 2070 patients with MI, 302 (15%) had non-obstructive CAD. Compared to patients with obstructive disease they were younger (mean 57 v 61 years, p0.001), more likely to be women (50% vs 23%, p0.001), to be of Maori or Pacific vs. European ethnicity (p0.001), more likely to be lifelong non-smokers (46% v 38%, p=0.02), non-diabetic (80v 73%, p0.01), have no ST-segment deviation (78% v 46%, p0.001), and have a low risk Global Registry of Acute Coronary Events acute coronary syndrome (GRACE ACS) score (54 v 35%, p0.001). They were also less likely to receive 'triple therapy' secondary prevention medications (81% v 94%, p0.0001). The cumulative two-year Kaplan-Maier composite outcome of mortality or non-fatal MI was 14.3% for MI with obstructive CAD, 4.6% for MI without obstructive disease, and 2.2% for patients without prior CVD (p0.001).Myocardial infarction without obstructive coronary disease is common (∼1 in 7 patients) and is not clinically benign, with an adverse outcome rate double that of age and sex matched patients without CVD.

BACKGROUND Patients with reduced left ventricular ejection fraction (EF

The ANZACS-QI Cardiac Implanted Device Registry (ANZACS-QI DEVICE) collects data on cardiac implantable electronic devices inserted in New Zealand. We evaluated completeness of data capture and quality of ANZACS-QI DEVICE in 2016.Complete datasets within ANZACS-QI DEVICE, comprising DEVICE-PPM (permanent pacemakers) and DEVICE-ICD (implantable cardioverter defibrillators), from 1 January 2016 to 31 December 2016 were linked with the National Hospitalisation dataset (all New Zealand public hospital admissions). The total number of implants included procedures captured in either dataset. Variables assessed included age, gender, ethnicity, procedure type, implanting centre, admission and procedure date.DEVICE-PPM captured 85.9% of all PPM procedures (n=2,512). This was similar regardless of age, sex and ethnicity. In the 84.4% of procedures captured in both datasets, agreement was97% for all variables except admission date (90.1%). DEVICE-ICD captured 81.3% of all ICD procedures (n=690). Capture was similar across age, sex and ethnicity groups. In the 76.8% of procedures captured in both datasets, agreement was96% for all variables except admission date (90.6%).The ANZACS-QI DEVICE registry had a good capture rate and excellent agreement with the national dataset. This high concordance supports the use of both datasets for future research.

Prompt access to cardiac defibrillation and reperfusion therapy improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The study aim was to describe the 'patient' and 'system' delay in patients who receive acute reperfusion therapy for ST-elevation myocardial infarction (STEMI) in New Zealand.In 2015-17, 3,857 patients who received acute reperfusion therapy were captured in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. 'Patient delay' is the time from symptom onset to first medical contact (FMC), and 'system delay' the time from FMC until reperfusion therapy (primary percutaneous coronary intervention (PCI) or fibrinolysis).Seventy percent of patients received primary PCI and 30% fibrinolysis. Of those receiving fibrinolysis, 122 (10.5%) received pre-hospital fibrinolysis. Seventy-seven percent were transported to hospital by ambulance. After adjustment, people who were older, male and presented to a hospital without a routine primary PCI service were less likely to travel by ambulance. Patient delay: The median delay was 45 minutes for ambulance-transported patients and 97 minutes for those self-transported to hospital, with a quarter delayed by2 hours and3 hours, respectively. Delay1 hour was more common in older patients, Māori and Indian patients and those self-transported to hospital. System delay: For ambulance-transported patients who received primary PCI, the median time was 119 minutes. For ambulance-transported patients who received fibrinolysis, the median system delay was 86 minutes, with Māori patients more often delayed than European/Other patients. For patients who received pre-hospital fibrinolysis the median delay was 46 minutes shorter. For the quarter of patients treated with rescue PCI after fibrinolysis, the median needle-to-rescue time was prolonged-four hours.Nationwide implementation of the NZ STEMI pathway is needed to reduce system delays in delivery of primary PCI, fibrinolysis and rescue PCI. Ongoing initiatives are required to reduce barriers to calling the ambulance early after symptom onset.

The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry was designed to collect data on all coronary angiograms and percutaneous coronary interventions (PCI) in New Zealand, and all acute coronary syndromes (ACS) associated with these procedures. This study compares the completeness of capture in ANZACS-QI of coronary procedures and ACS admissions with those recorded in the National Hospitalisation Dataset and evaluates data quality by assessing agreement in ACS diagnoses and coronary procedures between datasets.The national dataset, which included all New Zealand public hospital admissions in 2015 (n=962,700 episodes), was anonymously linked with the ANZACS-QI CathPCI (n=14,649 coronary angiogram episodes) and ACS cohorts (n=8,141 episodes) for 2015. Total numbers of coronary angiogram, PCI and ACS admissions were used as denominators and calculated by combining unique episodes from both data sources.Of all coronary angiogram episodes (n=15,377) and all PCI episodes (n=5,711), 92% were captured in both datasets, 5% in the national dataset only and 3% in ANZACS-QI only. Overall, 95% of coronary angiogram and PCI episodes were captured in ANZACS-QI. Of ACS episodes with associated coronary angiography (n=8,237), 85% were captured. Overall, 54% of all ACS episodes (n=15,167) were captured, including 71% in70-year-olds. Seventy-five percent of all ST-elevation myocardial infarctions (STEMI) were captured. Ninety percent of ACS diagnoses in ANZACS-QI had a matching diagnosis in the national dataset. There was excellent agreement in recorded gender, date of birth and ethnicity (99%). Sub-type of ACS was also highly concordant for STEMI and non-STEMI diagnoses (92% and 89% agreement, respectively).Consistent with its aim, the ANZACS-QI registry captured almost all New Zealand public hospital coronary angiography and PCI procedures including those associated with an ACS diagnosis. The high level of agreement between the registry and national dataset supports the use of both datasets for ongoing quality improvement reporting and research.

Acute heart failure (HF) associated with an acute coronary syndrome (ACS) predicts adverse outcome. There have been important recent improvements in ACS management. Our aim was to describe the management and outcomes in those with and without HF in a contemporary ACS cohort.Consecutive patients presenting with ACS between 2007 and 2011 were enrolled in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. Outcomes and medication dispensing were obtained using anonymised linkage to national data sets. A summary pharmacotherapy measure of "quadruple therapy" was defined as dispensing of at least one agent from each of the four evidence-based classes - anti-platelet, statin, angiotensin converting enzyme inhibitor/angiotensin receptor blocker and beta blocker.Of 3743 ACS patients 14% had acute HF. Acute heart failure patients were older (69.2±12.6 vs 62.3±12.8 years, p0.001), less likely to have coronary angiography (66% vs 86%, p0.001) and revascularisation (46% vs 62%, p0.001). Immediate post-discharge quadruple therapy was higher for those with than without HF (61% vs 55%, p=0.02) but fell to similar levels by one-year (45% vs 53%, p=0.55). At four years follow-up nearly half of those presenting with ACS and HF had died. After adjustment, HF remained a strong predictor of death within 28 days (OR 2.9, 95%CI 1.5 - 5.5) and beyond 28 days (HR 1.8, 95%CI 1.5 - 2.3).Acute heart failure complicating ACS is associated with heightened risk of short-term and long-term mortality. One in three ACS patients with HF did not have coronary angiography and less than half received quadruple therapy a year after presentation.

Chest pain is a common symptom that creates significant anxiety for patients until a diagnosis can be offered. However, hospital cardiology services can struggle to cope with referral demands from primary care. The aim of this paper is to describe the development and implementation of a nurse-led chest pain service, its care processes and clinical outcomes to show feasibility, safety and sustainability.We retrospectively analysed referral, demographic, cardiovascular risk, management and clinical outcome data relating to patients assessed in the nurse-led chest pain clinic in a large metropolitan district health board.Between January 2010 to December 2016, 3,587 patients attended the clinic, median 2.6 weeks (IQR 2-3) from referral to attendance. 1,921 (54%) were male and 2,059 (57%) were less than 60 years old. Most patients, 3,059 (85%), had an exercise tolerance test (ETT) and of those, 294 (10%) were positive, 572 (18%) non-diagnostic and 2,193 (72%) negative. Cardiovascular disease (CVD) prevention medication was added or modified for 1,150 (32%) patients, all patients who smoked were offered cessation support and all patients were provided with tailored lifestyle advice depending on their absolute CVD risk. Of the 319 (9%) referred for a diagnostic coronary angiogram, 205 (64%) had important coronary disease. The majority of patients, 2,088 (58%) were able to be discharged without any further investigation planned. Over a median follow-up period of 3.6 years, we identified 14 (0.4%) cardiac-related deaths, median (IQR) 2 (1-4) years from review to death.The nurse-led clinic offers an enhanced prevention focus that is sustainably managing large numbers of patients with outcomes similar to international studies and within recommended local timeframes.

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): 1. Five-drug-class indicator: aspirin, a second antiplatelet agent, statin, ACEI/ARB and a beta blocker. 2. An indicator based on the 2016 National Heart Foundation of Australia & Cardiac Society of NZ and Australia recommendations (NHFA/CSANZ indicator): aspirin, a second antiplatelet agent and a statin. Those with high-risk features (LVEF 3. ANZACS-QI modified NHFA/CSANZ indicator: aspirin, a second antiplatelet agent, statin and an ACEI/ARB (four classes), and those with LVEF 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.

Aims: Genome-wide association studies have identified a number of SNPs associated with complex disease. The longitudinal significance of these variants is uncertain and clinical genomic studies are required to elucidate what clinical value these variants have. Linking DNA to clinical health information databases is a powerful and potentially low-cost means of performing such research. Here, we describe a proof-of-principle study demonstrating the potential of this method. Materials & methods: A total of 376 individuals presenting to a hospital with severe coronary artery disease were enrolled into a prospective cohort study. DNA, demographic data, ethnicity and other clinical information was collected in an electronic database. Genotyping for SNPs rs2383207 and rs10757278 was performed using Sequenom® (CA, USA) matrix-assisted laser desorption/ionisation-time of flight mass spectrometry. Health outcomes were tracked from when patients were discharged from the hospital using the New Zealand Health Information Service (Wellington, New Zealand). Results: A total of 253 (67%) patients were of New Zealand European descent, 47 (13%) patients were of Maori descent and 21 (6%) were of Pacific Island ancestry. The Maori and Pacific Island group were younger at presentation (63 ± 11 vs 70 ± 9 years of age; p < 0.0001) and had a higher prevalence of cardiovascular risk factors. The frequency of the at-risk rs2383207 G allele in the Maori and Pacific group was 70%, compared with 54% in Europeans (p = 0.002). Similarly, the rs10757278 G allele was also present at a higher frequency (68 vs 52%; p = 0.003). No association was seen between the rs10757278 SNP and cardiovascular risk factors or markers of disease severity. GA and GG individuals had a higher rate of cardiovascular (p = 0.04) and all-cause death (p = 0.02). Conclusion: The linking of genetic data to electronic medical databases is an effective tool to assess the longitudinal effect of gene variants on health outcomes and will aid in the implementation of personalized medicine. Larger sample sizes with longer study duration may yield clinically useful information that aids preventative healthcare.

ABSTRACT INTRODUCTION Prior New Zealand studies suggest that only approximately two-thirds of patients who present with an acute coronary syndrome (ACS) are maintained on a statin/aspirin post-discharge. This could be due to sub-optimal initiation or poor longer-term adherence. AIM To identify the pattern of statin/aspirin maintenance following ACS from initial prescription to 3 years post-discharge. METHODS All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry data for consecutive New Zealand residents (2007–2011), who were hospitalised with ACS, were anonymously linked to national datasets to derive a medication possession ratio (MPR) to assess medication maintenance. An MPR ≥ 0.8 is considered adequate maintenance. RESULTS Of the 1846 patients discharged alive, 95% were prescribed a statin at discharge and 92% were dispensed a statin within 3 months, but only 75% had a MPR ≥ 0.8 in the first year, and 67% in year 3. In the same cohort, 98% were prescribed aspirin and 88% were dispensed aspirin within the 3 months of discharge. In the first year, 72% had an aspirin MPR ≥ 0.8 and 71% maintained this in year 3. Fifty-nine percent were maintained on both aspirin and a statin in the third year, but 20% were maintained on neither. Regression analysis identified the independent predictors of inadequate maintenance in the third year as age < 45 years, no prior statin, and Māori and Pacific ethnicity. CONCLUSION Longer-term maintenance of evidenced-based secondary prevention medications after ACS is suboptimal despite high levels of initial prescribing and dispensing. Understanding the barriers to longer-term maintenance is required to improve patient outcomes.

The incidence of myocardial infarction (MI) is characterised by seasonal variation, with a winter peak and summer trough. Takotsubo syndrome (TS) mimics MI, but is thought to have a distinct aetiology and may exhibit a reversed pattern of seasonal variation. This study investigated the seasonal variation in the incidence of TS in comparison to MI.Two hundred and sixty consecutive patients with TS (95% women, median age 66 years) admitted between March 2004 and December 2016 in the Auckland region of New Zealand were identified. The study population was grouped into three-month intervals (seasons) according to the date of admission to analyse for potential seasonal variations in the incidence. The TS cohort was compared with 36,376 patients who presented with acute MI in the Auckland region (40% women, median age 71 years) between March 2004 and December 2016.The onset of TS differed as a function of season (p=0.02), with the events most frequent in summer (n=77, 30%) and least so in winter (n=46, 18%). In contrast, incidence of MI also varied by season (p=0.0003), with highest events in winter and lowest in summer.The pattern of seasonal variation in TS is reversed compared with MI, with peaks during summer.

Stress echocardiography is recommended for the assessment of asymptomatic patients with severe valvular heart disease (VHD) when there is discrepancy between symptoms and resting markers of severity. The aim of this study is to determine the prognostic value of exercise stress echocardiography in patients with common valve lesions. One hundred and fifteen patients with VHD (aortic stenosis (n=28); aortic regurgitation (n=35); mitral regurgitation, (n=26); mitral stenosis (n=26)), and age- and sex-matched controls (n=39) with normal ejection fraction underwent exercise stress echocardiography. The primary endpoint was a composite of death or hospitalization for heart failure. Asymptomatic VHD patients had lower exercise capacity than controls and 37% of patients achieved 60 mmHg) was associated with an increased risk of death or hospital admission (14% vs 1%, P

One major characteristic of bonded structures is the highly localised nature of deformation near sharp corners, ply-terminations, and ends of joints where load transfer occurs. This paper presents an investigation of the use of a cohesive zone model in predicting the strong effects of stress concentration due to varying adherend thickness on the pull-off strength measured by the Pneumatic Adhesion Tensile Testing Instrument. A comparison is made with the point-strain-at-a-distance criterion, where the plastic deformation of the adhesive is analysed using a modified Drucker–Prager/cap plasticity material model. The fracture properties of the cohesive zone model were determined using double-cantilever and end-notch flexural specimens, and the cohesive strengths were measured using tensile and lap shear tests. Comparisons with experimental results reveal that the cohesive zone model with perfectly plastic (or non-strain-softening) cohesive law provides accurate predictions of joint strengths.