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The Myocardial Ischaemia National Audit Project (MINAP) collects data from admissions in England, Wales, and Northern Ireland with Type 1 myocardial infarction (T1 MI). The project aims to improve clinical care through the audit process and to provide powerful high-resolution data for research.MINAP collects data spanning 130 data fields covering the course of patient care, from the moment the patient calls for professional help through to hospital discharge and rehabilitation. Data are entered by clinicians and clerical staff within hospitals, and pseudonymized records are uploaded centrally to the National Institute for Cardiovascular Outcomes Research (NICOR), hosted by Barts Health NHS Trust, London, UK. Two hundred and six hospitals submit over 92 000 new cases to MINAP annually. Approximately 1.5 million patient records are currently held in the database. Patient demographics, medical history, clinical assessment, investigations, treatments, drug therapy prior to admission, during hospital stay, and at discharge are collected. Data completeness of three key data fields (age, admission blood pressure, and heart rate) is over 91%. Vital status following hospital discharge is obtained via linkage to data from the United Kingdom Office for National Statistics. An annual report is compiled using these data, with individual hospital summary data included. Datasets are available to researchers by application to NICOR.MINAP is the largest single healthcare system heart attack registry, and includes data from hospitalizations with T1 MI in England, Wales, and Northern Ireland. It includes high-resolution data across the patient pathway and is a powerful tool for quality improvement and research.

Quality of Care and Clinical Outcomes is the 14th addition to the European Heart Journal 's family of subspecialty journals.1 Its title speaks to the heart of what matters to patients and reflects a shift in cardiological focus away from a past when the emphasis was on disease diagnosis towards a future in which disease outcomes are increasingly taking centre stage.2 It was only in the second half of the last century that drugs became available to modify the progression of cardiovascular diseases and improve patient outcomes by lowering blood pressure and LDL-cholesterol, protecting against coronary heart disease and stroke, reducing the severity of myocardial infarction and its major complications, and slowing the progression of heart failure. To these pharmacological innovations, we can add an exciting range of surgical, interventional, and device strategies that have further benefitted patients with coronary and valvular heart disease and cardiac rhythm disorders, not to mention the huge contribution that strategies to modify lifestyle factors have made to disease development and prognosis. The 21st century cardiologist is spoilt for choice in the treatments that are available and it is important that the choice is made wisely, considering not only the evidence base but also the costs at a time … [↵][1]*Corresponding author: a.d.timmis{at}qmul.ac.uk [1]: #xref-corresp-1-1

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

This editorial refers to ‘The Contribution of the Composite of Clinical Process Indicators as a Measure of Hospital Performance in the Management of Acute Coronary Syndromes-insights from the CONCORDANCE Registry ’, by B. Aliprandi-Costa et al ., on page 37. Evidence for between and within country variation in mortality from cardiovascular disease has made the measurement and reporting of quality of cardiac care and its outcomes increasingly relevant to clinical practice. The European Society of Cardiology has recognized the importance of this through a number of ventures including the EurObservational Research Programme and the European Atlas of Cardiology, each collecting information from member countries about processes and outcomes relating to cardiovascular disease and its treatment. In 1910, Dr Ernest Codman suggested that surgeons track and publish their patient’s outcomes.1 Nowadays, outcomes reporting has become central to the evaluation of clinical care across a number of healthcare systems. For example, the National Health Service of England and Wales transparently reports operator-level standardized mortality rates for percutaneous coronary intervention, which includes all publically funded procedures performed by all operators. Yet, many argue that we should concentrate on the measurement of adherence to guideline-indicated care, ‘the process’ rather than mortality, ‘the outcome’.2 There … [↵][1]* Corresponding author. Tel: +44(0) 113 3438905, Fax: 44(0) 113 343 4877, Email: c.p.gale{at}leeds.ac.uk [1]: #xref-corresp-1-1

Aims To examine long-term healthcare utilization and costs of patients with stable coronary artery disease (SCAD). Methods and results Linked cohort study of 94 966 patients with SCAD in England, 1 January 2001 to 31 March 2010, identified from primary care, secondary care, disease, and death registries. Resource use and costs, and cost predictors by time and 5-year cardiovascular disease (CVD) risk profile were estimated using generalized linear models. Coronary heart disease hospitalizations were 20.5% in the first year and 66% in the year following a non-fatal (myocardial infarction, ischaemic or haemorrhagic stroke) event. Mean healthcare costs were £3133 per patient in the first year and £10 377 in the year following a non-fatal event. First-year predictors of cost included sex (mean cost £549 lower in females), SCAD diagnosis (non-ST-elevation myocardial infarction cost £656 more than stable angina), and co-morbidities (heart failure cost £657 more per patient). Compared with lower risk patients (5-year CVD risk 3.5%), those of higher risk (5-year CVD risk 44.2%) had higher 5-year costs (£23 393 vs. £9335) and lower lifetime costs (£43 020 vs. £116 888). Conclusion Patients with SCAD incur substantial healthcare utilization and costs, which varies and may be predicted by 5-year CVD risk profile. Higher risk patients have higher initial but lower lifetime costs than lower risk patients as a result of shorter life expectancy. Improved cardiovascular survivorship among an ageing CVD population is likely to require stratified care in anticipation of the burgeoning demand.