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The article offers information on acute coronary syndrome (ACS), its impact on Australia's health system, and the need for general practitioners to be familiar with its management. It discusses the etiology and pathophysiology of ACS, the importance of early diagnosis and investigation, and the use of risk scores and clinical assessment tools in evaluating patients with chest pain.

The prognostic role of catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) remains uncertain, with guideline recommendations largely based on a single trial. We conducted a meta‐analysis of randomized controlled trials (RCTs) assessing the prognostic impact of AF ablation in patients with HF. Electronic databases were searched for RCTs comparing ‘AF ablation’ versus ‘other care’ (medical therapy and/or atrioventricular node ablation with pacing) in patients with HF. Primary endpoints were ≥1‐year mortality, HF hospitalization and change in left ventricular ejection fraction (LVEF). Meta‐analyses were performed using random‐effects modelling. Nine RCTs (n= 1462) met inclusion criteria. Compared to ‘other care’, AF ablation significantly reduced ≥1‐year mortality (relative risk [RR] 0.65; 95% confidence intervals [CI], 0.49–0.87) and HF hospitalization (RR 0.64; 95% CI, 0.51–0.81). AF ablation demonstrated significantly greater improvement in LVEF (mean difference [MD] 5.4; 95% CI, 4.4–6.4), 6‐min walk test distance (MD 21.5 meters; 95% CI, 4.6–38.4) and quality of life as measured by Minnesota Living with Heart Failure Questionnaire score (MD 7.2; 95% CI, 2.8–11.7). Meta‐regression analyses showed the beneficial impact of AF ablation on LVEF was significantly blunted by higher prevalence of ischaemic cardiomyopathy. Our meta‐analysis demonstrates AF ablation is superior to ‘other care’ in improving mortality, HF hospitalization, LVEF and quality of life in patients with HF. However, the highly selected study populations in included RCTs and effect modification mediated by etiology of HF suggests these benefits do not uniformly apply across the HF population. This meta‐analysis of 9 RCTs demonstrates AF ablation is superior to ‘other care’ in improving mortality, HF hospitalization, LVEF and quality of life in patients with HF. However, the highly selected study populations in included RCTs and effect modification mediated by etiology of HF suggests these benefits do not uniformly apply across the HF population.

Background: Statins administered early in patients with acute coronary syndromes may lead to modest reductions in recurrent ischemic events. Objective: To examine the association between previous and early in-hospital statin therapy and the presentation and outcomes of an acute coronary syndrome. Design: Cohort study. Setting: 94 hospitals in 14 countries participating in the Global Registry of Acute Coronary Events (GRACE). Patients: 19 537 patients with an acute coronary syndrome who were enrolled from April 1999 to September 2002. Measurements: Statin use before and after presentation with an acute coronary syndrome and associated rates of myocardial infarction, hospital complications, and hospital mortality. The composite end point included death, in-hospital myocardial infarction, and stroke. Results: Patients who were already taking statins when they presented to the hospital were less likely to have ST-segment elevation (odds ratio [OR], 0.79 [95% CI, 0.71 to 0.88]) or myocardial infarction (OR, 0.78 [CI, 0.70 to 0.86]). Patients who continued to take statins in the hospital were less likely to experience complications or die than patients who never received statins (OR, 0.66 [CI, 0.56 to 0.77]). Patients not previously taking statins who began statin therapy in the hospital were less likely to die than patients who never received statin therapy (OR, 0.38 [CI, 0.30 to 0.48]). However, adjustment for the hospital of admission attenuated the association between initiation of statin therapy and the composite end point (OR, 0.84 [CI, 0.65 to 1.10]). Limitations: This observational study cannot exclude confounding by clinical and hospital factors. Conclusions: These data support the hypothesis that statin therapy can modulate early pathophysiologic processes in patients with acute coronary syndromes. A randomized trial of statin therapy in acute myocardial infarction is warranted.

To assess lipid levels in people six or 12 months after hospitalisation with acute coronary syndrome (ACS); to identify factors associated with not achieving lipid level targets. Retrospective cohort study; analysis of data from CONCORDANCE, an Australian ACS registry, 2009–2018. Adult patients who had experienced confirmed ACS of cardiovascular origin, for whom serum lipid levels had been assessed on admission and six or 12 months after discharge. Not achieving lipid targets by most recent follow‐up (in order of priority: low‐density lipoprotein cholesterol [LDL‐C] ≤ 1.8 mmol/L or total cholesterol ≤ 4 mmol/L); factors associated with not achieving target lipid levels. Lipid levels measured at 6‐ or 12‐month follow‐up were available for 2671 of 10 578 people discharged from hospital alive; 1194 (45%) had not achieved lipid targets at their most recent follow‐up, including 876 (73%) who had been prescribed intensive lipid‐lowering therapy at discharge. People under 65 years of age, those using lipid‐lowering therapy or with higher cholesterol levels on admission, patients prescribed fewer than four evidence‐based therapies or not prescribed intensive lipid‐lowering therapy on discharge, and women were more likely to not reach lipid level targets. Almost half the patients did not achieve target lipid levels within 12 months of an admission to hospital with ACS. These people are at elevated risk of recurrent cardiovascular disease, and therapy could be optimised (eg, dose escalation, drug combinations, novel therapies) to improve outcomes.

Patients with acute coronary syndromes (ACS), particularly non-ST-segment elevation ACS, represent a spectrum of patients at variable risk of short- and long-term adverse clinical outcomes. Accurate prognostic assessment in this population requires the simultaneous consideration of multiple clinical and laboratory variables which may be under-recognized by the treating physicians, leading to an observed risk-treatment paradox in the use of invasive and pharmacological therapies. The routine application of established clinical risk scores, such as the Global Registry of Acute Coronary Events risk score, is recommended by major international clinical practice guidelines for structured risk stratification at the time of presentation, but uptake remains inconsistent. This article discusses the methodology of designing, deriving, and validating clinical risk scores, reviews the major validated risk scores for assessing prognosis in ACS, and examines their role in guiding clinical decision-making in ACS management, especially the timing of invasive coronary angiography. We also discuss emerging data on the impact of the routine use of such risk scores on patient management and clinical outcomes, as well as future directions for investigation in this field.

To determine whether the availability of invasive coronary angiography at the hospital of presentation influences catheterisation rates for patients with acute coronary syndrome (ACS), and whether presenting to a catheterisation‐capable hospital is associated with better outcomes for patients with ACS. Retrospective cohort study; analysis of Cooperative National Registry of Acute Coronary Events (CONCORDANCE) data. Adults admitted with ACS to 43 Australian hospitals (including 31 catheterisation‐capable hospitals), February 2009 – October 2018. Major adverse cardiovascular events (myocardial infarction, stroke, congestive heart failure, cardiogenic shock, cardiovascular death) and all‐cause deaths in hospital and by six and 12‐ or 24‐month follow‐up. The proportion of women among the 5637 patients who presented to catheterisation‐capable hospitals was smaller than for the 2608 patients who presented to hospitals without catheterisation facilities (28% v33%); the proportion of patients diagnosed with ST elevation myocardial infarction was larger (32% v20%). The proportions of patients who underwent catheterisation (81% v70%) or percutaneous coronary intervention (49% v35%) were larger for those who presented to catheterisation‐capable hospitals. The baseline characteristics of patients who underwent catheterisation were similar for both presentation hospital categories, as were rates of major adverse cardiovascular events and all‐cause death in hospital and by 6‐ and 12‐ or 24‐month follow‐up. Although a larger proportion of patients who presented to catheterisation‐capable hospitals underwent catheterisation, patients with similar characteristics were selected for the procedure, independent of the hospital of presentation. Major outcomes for patients were also similar, suggesting equitable management of patients with ACS across Australia.

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

The aim of this study is to gain insight into the differences in demographics of ST-elevation myocardial infarction (STEMI) patients in Asia-Pacific, as well as inter-country variation in treatment and mortality outcomes. Systematic review of published studies and reports from known registries in Australia, Japan, Korea, Singapore, and Malaysia that began data collection after the year 2000. Supplementary self-report survey questionnaire on public health data answered by representative cardiologists working in these countries. Twenty studies comprising of 158 420 patients were included in the meta-analysis. The mean age was 61.6 years. Chronic kidney disease prevalence was higher in Japan, while dyslipidaemia was low in Korea. Use of aspirin, P2Y12inhibitors, and statins were high throughout, but ACEi/ARB and β-blocker prescriptions were lower in Japan and Malaysia. Reperfusion strategies varied greatly, with high rates of primary percutaneous coronary intervention (pPCI) in Korea (91.6%), whilst Malaysia relies far more on fibrinolysis (72.6%) than pPCI (9.6%). Similarly, mortality differed, with 1-year mortality from STEMI was considerably greater in Malaysia (17.9%) and Singapore (11.2%) than in Korea (8.1%), Australia (7.8%), and Japan (6.2%). The countries were broadly similar in development and public health indices. Singapore has the highest gross national income and total healthcare expenditure per capita, whilst Malaysia has the lowest. Primary PCI is available in all countries 24/7/365. Despite broadly comparable public health systems, differences exist in patient profile, in-hospital treatment, and mortality outcomes in these five countries. Our study reveals areas for improvements. The authors advocate further registry-based multi-country comparative studies focused on the Asia-Pacific region.

Haemorrhagic stroke (HS) is an important cardiovascular cause of mortality worldwide. Trends in admission rates and outcomes, and predictors of outcomes, post-HS in Australia remain unclear.

The results of the Australian Acute Coronary Syndrome Prospective Audit are employed to analyze the management of patients suffering from ST-segment-elevation myocardial infarction (STEMI) in Australia. The various effects of the use of the reperfusion therapy for the treatment of the disorder are also analyzed.

This study reports on a predominantly noninvasive management program for neonatal transposition of the great arteries [TGA] incorporating balloon atrial septostomy [BAS] under echocardiographic control. BAS was performed in 2S consecutive patients presenting with TGA between April 1988 and April 1990. Structural and coronary anatomy was evaluated echocardiographically with angiographic supplementation only when additional data were required. This information was correlated, where possible, with direct anatomic findings and subsequent course. BAS was performed through the umbilicus in 17 patients (85% of patients in whom this approach was attempted). Thirteen patients did not require ventilation during BAS. There were minimal complications and satisfactory septostomies in all cases. Coronary anatomy was correctly predicted in all patients where anatomic correlation was available. Without invasive investigation 9 patients underwent neonatal arterial switch procedures and 2 underwent palliative procedures. BAS under echocardiographic control proved safe, effective, minimally traumatic and mostly possible via the umbilical vein. The umbilical vein, where patent, permitted rapid safe access for BAS. Echocardiographic diagnosis of the coronary artery, and structural and functional anatomy was reliable and allowed minimally invasive preoperative management in many patients. (Am J Cardiol 1992;69:1321-1323)

A study uses data from the Acute Coronary Syndrome Prospective Audit (ACACIA) registry to investigate treatment disparities and effect on late mortality outcomes in patients with and without diabetes presenting with acute myocardial infarction (MI). Analysis reveals that patients with diabetes presenting with acute myocardial infarction have a higher risk of late mortality following an acute MI than non-diabetic patients, but receive fewer evidence-based pharmacological and early invasive treatments.

The article discusses the various approaches that can be employed for effectively implementing the guidelines that were given out by the National Australian Heart Foundation of Australia for acute coronary syndromes (ACS). The need for a proper and effective risk management and data collection system is also demonstrated.

A study was conducted to investigate the relationship between invasive management and late mortality among patients with suspected acute coronary syndrome. Results indicated that a strong relationship exists between invasive management and late mortality thereby suggesting the need for more invasive management among patients with acute coronary heart disease.

A study in Australia to assess the guidelines advocated by the National Heart Foundation (NHF) and the Cardiac Society of Australia and New Zealand (CASNZ) for management of patients manifesting chest pain was conducted. Results revealed that significant shortcomings were evident in the implementation of guidelines, which corresponded to the facilities available at the respective hospitals.

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Background: Pulse pressure is a readily available vital sign that has been shown to independently predict outcomes in several cardiovascular disease states. We investigated the prognostic significance of pulse pressure (PP) and systolic blood pressure (SBP) among patients with acute coronary syndromes (ACS).Methods: A total of 14,514 patients with ACS in the prospective, multicentre Global Registry of Acute Coronary Events (GRACE), expanded GRACE (GRACE-2) and Canadian Registry of Acute Coronary Events (CANRACE) were stratified by initial PP on presentation. Patient characteristics and in-hospital outcomes were compared by PP quartiles and the independent prognostic significance of PP for in-hospital mortality was quantified. We compared the discriminative ability (c-statistic) of models incorporating either PP or SBP.Results: Patients with higher PPs were older, more frequently female and had higher prevalence rates of conventional cardiovascular risk factors (all p< 0.01). Lower PP was associated with ST-segment elevation myocardial infarction presentation, higher GRACE risk scores and higher rates of adverse in-hospital outcomes (p< 0.001). PP was strongly correlated with SBP (Pearson’s correlation coefficient = 0.79, p< 0.001). After adjustment for other GRACE risk model predictors, lower PP was independently associated with in-hospital mortality (first vs. fourth quartile [reference]: adjusted odds ratio 2.57, 95% confidence interval 1.80–3.67). The c-statistic was slightly higher for the multivariable model incorporating SBP as compared to the model with PP (0.868 vs. 0.864, respectively, p= 0.028) for in-hospital mortality.Conclusion: Higher presenting PP is associated with increased age and more prevalent cardiovascular risk factors, whereas patients with lower PP present with worse clinical characteristics and in-hospital outcomes. Lower PP is an independent adverse prognosticator in ACS. However, PP did not improve the discriminatory performance of the GRACE risk score compared with SBP.

Patients ≥ 80 years of age are underrepresented in major implantable cardioverter-defibrillator (ICD) trials, and real-world data are lacking. In this study, we sought to assess ICD utilisation, outcomes, and their predictors, in an unselected statewide population including patients ≥ 80 years old.

To determine the prevalence and identify predictors of people hospitalised with acute coronary syndrome (ACS) receiving intensive lipid‐lowering therapy during the 12 months after their discharge from hospital. Retrospective observational analysis. Data were extracted from CONCORDANCE, a prospective, Australian investigator‐initiated ACSregistry. Patients enrolled in CONCORDANCEduring January 2015 – May 2016 who survived to hospital discharge, for whom information on lipid‐lowering therapy 6 or 12 months after discharge from hospital were available. Not receiving intensive lipid‐lowering therapy (with or without ezetimibe) at the most recent follow‐up (6 or 12 months); predictors of not receiving intensive lipid‐lowering therapy. 1876 of 3441 patients (55%) were receiving intensive lipid‐lowering therapy 6 or 12 months after their hospitalisation with an ACS. Predictors of not receiving intensive lipid‐lowering therapy included not been prescribed this treatment prior to their hospital admission (odds ratio [OR], 1.53; 95% CI, 1.26–1.85) or at hospital discharge (aOR, 7.24; 95% CI, 4.37–12.0), being a woman (aOR, 1.20; 95% CI, 1.02–1.41), and not being referred for cardiac rehabilitation (aOR1.39; 95% CI, 1.09–1.78). Patients who were managed medically in hospital (not revascularised; aOR, 1.54; 95% CI, 1.25–1.91) or underwent coronary artery bypass grafting (aOR1.55; 95% CI, 1.26–1.92) were less likely to be receiving intensive lipid‐lowering therapy at follow‐up than those with a percutaneous coronary intervention. Unmeasured hospital factors accounted for 17% of the variation in the likelihood of intensive lipid‐lowering therapy. 45% of patients in Australia are not receiving intensive lipid‐lowering therapy in the 12 months after their ACS. Optimising oral lipid‐lowering therapy would reduce the recurrence of coronary events in this high risk group.

Polymer-free drug-eluting stents (PF-DES) were introduced with the aim of reducing the risk of stent thrombosis associated with durable polymer drug-eluting stents (DP-DES). The comparison of safety and efficacy profiles between these two stent platforms remains unclear.

Introduction:Atrial fibrillation (AF) is increasing in prevalence and is associated with significant morbidity and mortality. The optimal diagnostic and treatment strategies for AF are continually evolving and care for patients requires confidence in integrating these new developments into practice. These clinical practice guidelines will assist Australian practitioners in the diagnosis and management of adult patients with AF. Main recommendations:These guidelines provide advice on the standardised assessment and management of patients with atrial fibrillation regarding: screening, prevention and diagnostic work-up;acute and chronic arrhythmia management with antiarrhythmic therapy and percutaneous and surgical ablative therapies;stroke prevention and optimal use of anticoagulants; andintegrated multidisciplinary care. Changes in management as a result of the guideline: Opportunistic screening in the clinic or community is recommended for patients over 65 years of age.The importance of deciding between a rate and rhythm control strategy at the time of diagnosis and periodically thereafter is highlighted. ß-Blockers or non-dihydropyridine calcium channel antagonists remain the first line choice for acute and chronic rate control. Cardioversion remains first line choice for acute rhythm control when clinically indicated. Flecainide is preferable to amiodarone for acute and chronic rhythm control. Failure of rate or rhythm control should prompt consideration of percutaneous or surgical ablation.The sexless CHA2DS2-VA score is recommended to assess stroke risk, which standardises thresholds across men and women; anticoagulation is not recommended for a score of 0, and is recommended for a score of = 2. If anticoagulation is indicated, non-vitamin K oral anticoagulants are recommended in preference to warfarin.An integrated care approach should be adopted, delivered by multidisciplinary teams, including patient education and the use of eHealth tools and resources where available. Regular monitoring and feedback of risk factor control, treatment adherence and persistence should occur.

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.

Objective:To examine whether there are sex differences in the characteristics, management, and clinical outcomes of patients with an ST-elevation myocardial infarction (STEMI). Design, setting:Cohort study; analysis of data collected prospectively by the CONCORDANCE acute coronary syndrome registry from 41 Australian hospitals between February 2009 and May 2016. Participants:2898 patients (2183 men, 715 women) with STEMI. Main outcome measures:Rates of revascularisation (percutaneous coronary intervention [PCI], thrombolysis, coronary artery bypass grafting [CABG]), adjusted for GRACE risk score quartile. Secondary outcomes: timely vascularisation rates; major adverse cardiac event rates; clinical outcomes and preventive treatments at discharge. Results:The mean age of women with STEMI at presentation was 66.6 years (SD, 14.5 years), of men, 60.5 years (SD, 12.5 years). The proportions of women with hypertension, diabetes, prior stroke, chronic kidney disease, chronic heart failure, or dementia were larger than those of men; fewer women had histories of previous coronary artery disease or myocardial infarction, or of prior PCI or CABG. Women were less likely to have undergone coronary angiography (odds ratio, adjusted for GRACE score quartile [aOR], 0.53; 95% CI, 0.41–0.69) or revascularisation (aOR, 0.42; 95% CI, 0.34–0.52); they were less likely to have received timely revascularisation (aOR, 0.72; 95% CI, 0.63–0.83) or primary PCI (aOR, 0.76; 95% CI, 0.61–0.95). Six months after admission, the rates of major adverse cardiovascular events (aOR, 2.68; 95% CI, 1.76–4.09) and mortality (aOR, 2.17; 95% CI, 1.24–3.80) were higher for women. At discharge, significantly fewer women than men received ß-blockers, statins, and referrals to cardiac rehabilitation. Conclusion:Women with STEMI are less likely to receive invasive management, revascularisation, or preventive medication at discharge. The reasons for these persistent differences in care require investigation.

Background: There is a paucity of data on the complex interaction between chronic kidney disease, age and its impact on management and outcomes in acute myocardial infarction.Methods: A state based claims dataset that collects data on all hospitalizations (representing 32.3% of the Australian population) was used to identify all patients admitted with a principal diagnosis of acute myocardial infarction (ICD10 codes: I21.0–I21.4) over a four-year period. Patients were linked to the state death registry and followed until death or end of follow-up (31 December 2009). Chronic kidney disease was defined as the presence of any of 65 ICD10 diagnostic codes for chronic kidney disease. The primary outcomes were receipt of revascularization, length of hospital stay and mortality adjusted for age, comorbidities and prior revascularization at presentation.Results: Of the 40,472 patients with acute myocardial infarction, chronic kidney disease was present in 4814 patients (11.9%). Median follow-up was 2.8 years (range 0–5.5 years). In the multivariable model, there was a marked interaction between chronic kidney disease and age (p<0.001). Chronic kidney disease was a powerful marker of lower revascularization rates (median age group of 70–79 years: odds ratio 0.68; 95% confidence interval 0.59–0.78; p<0.001), especially in those over the age of 50 years. The impact of chronic kidney disease on length of stay (median age group of 70–79 years vs. referent age group 18–39 years: incidence rate ratio 1.41; 95% confidence interval 1.32–1.51; p<0.001) and long-term mortality (median age group of 70–79 years: hazard ratio 2.19; 95% confidence interval 2.01–2.39; p<0.001) was mitigated with increasing age.Conclusion: Chronic kidney disease is an important deterrent for the receipt of revascularization in older patients, but age is the primary determinant of length of stay and mortality.

Despite being recommended in acute coronary syndrome (ACS) guidelines, the use of invasive management within specific risk groups continues to be debated. This study examines the change in the use of invasive management in ACS by patient risk and the associated change in mortality within Australia over the last 17 years.

ObjectiveWhether revascularisation is superior to medical therapy in older populations presenting with non-ST-elevation acute coronary syndromes (NSTEACS) remains contentious, with inconclusive evidence from randomised trials. We aimed to compare routine invasive therapy with initial medical management in the elderly presenting with NSTEACS.MethodsMEDLINE, EMBASE and Cochrane Controlled Trial Register were searched for studies comparing routine invasive therapy with initial medical management in patients ≥75 years old presenting with NSTEACS. Endpoints included long-term mortality, myocardial infarction (MI), revascularisation, rehospitalisation, stroke and major bleeding reported as ORs.ResultsFour randomised trials and three observational studies met inclusion criteria, enrolling a total of 20 540 patients followed up from 6 months to 5 years. Routine invasive therapy reduced mortality (OR 0.67, CI 0.61 to 0.74), MI (OR 0.56, CI 0.45 to 0.70) and stroke (OR 0.53, CI 0.30 to 0.95). Analyses restricted to randomised controlled trials (RCTs) confirmed a reduction in MI (OR 0.51, CI 0.40 to 0.66), revascularisation (OR 0.27, CI 0.13 to 0.56) and a trend to reduced mortality (OR 0.84, CI 0.66 to 1.06) at the expense of major bleeding (OR 2.19, CI 1.12 to 4.28). Differences in major bleeding were unapparent in more recent studies.ConclusionRoutine invasive therapy reduces MI and repeat revascularisation and may reduce mortality at the expense of major bleeding in elderly patients with NSTEACS. Our findings highlight the need for further RCTs to better determine the effect on mortality and contemporary bleeding risk.

ObjectivesTo quantify contemporary differences in cardiovascular disease (CVD) risk factor assessment and management between women and men in Australian primary healthcare services.MethodsRecords of routinely attending patients were sampled from 60 Australian primary healthcare services in 2012 for the Treatment of Cardiovascular Risk using Electronic Decision Support study. Multivariable logistic regression models were used to compare the rate of CVD risk factor assessment and recommended medication prescriptions, by gender.ResultsOf 53 085 patients, 58% were female. Adjusting for demographic and clinical characteristics, women were less likely to have sufficient risk factors measured for CVD risk assessment (OR (95% CI): 0.88 (0.81 to 0.96)). Among 13 294 patients (47% women) in the CVD/high CVD risk subgroup, the adjusted odds of prescription of guideline-recommended medications were greater for women than men: 1.12 (1.01 to 1.23). However, there was heterogeneity by age (p <0.001), women in the CVD/high CVD risk subgroup aged 35–54 years were less likely to be prescribed the medications (0.63 (0.52 to 0.77)), and women in the CVD/high CVD risk subgroup aged ≥65 years were more likely to be prescribed the medications (1.34 (1.17 to 1.54)) than their male counterparts.ConclusionsWomen attending primary healthcare services in Australia were less likely than men to have risk factors measured and recorded such that absolute CVD risk can be assessed. For those with, or at high risk of, CVD, the prescription of appropriate preventive medications was more frequent in older women, but less frequent in younger women, compared with their male counterparts.Trial registration number12611000478910, Pre-results.

Acute coronary syndrome (ACS) is a costly condition for health service provision yet variation in the delivery of care between hospitals persists. A composite measure of adherence with evidence-based clinical-process indicators (CPIs) could better inform hospital performance reporting and clinical outcomes in the management of ACS.

Introduction: The prognostic significance of prior heart failure in acute coronary syndromes has not been well studied. Accordingly, we evaluated the baseline characteristics, management patterns and clinical outcomes in patients with acute coronary syndromes who had prior heart failure.Methods and results: The study population consisted of acute coronary syndrome patients in the Global Registry of Acute Coronary Events, expanded Global Registry of Acute Coronary Events and Canadian Registry of Acute Coronary Events between 1999 and 2008. Of the 13,937 eligible patients (mean age 66±13 years, 33% female and 28.3% with ST-elevation myocardial infarction), 1498 (10.7%) patients had a history of heart failure. Those with prior heart failure tended to be older, female and had lower systolic blood pressure, higher Killip class and creatinine on presentation. Prior heart failure was also associated with significantly worse left ventricular systolic function and lower rates of cardiac catheterization and coronary revascularization. The group with previous heart failure had significantly higher rates of acute decompensated heart failure, cardiogenic shock, myocardial (re)infarction and mortality in hospital. In multivariable analysis, prior heart failure remained an independent predictor of in-hospital mortality (odds ratio 1.48, 95% confidence interval 1.08–2.03, p=0.015).Conclusions: Prior heart failure was associated with high risk features on presentation and adverse outcomes including higher adjusted in-hospital mortality in acute coronary syndrome patients. However, acute coronary syndrome patients with prior heart failure were less likely to receive evidence-based therapies, suggesting potential opportunities to target more intensive treatment to improve their outcome.

ObjectiveTo determine the effectiveness of risk stratification using the Global Registry of Acute Coronary Events (GRACE) risk score (GRS) for patients presenting to hospital with suspected non-ST elevation acute coronary syndrome.DesignParallel group cluster randomised controlled trial.SettingPatients presenting with suspected non-ST elevation acute coronary syndrome to 42 hospitals in England between 9 March 2017 and 30 December 2019.ParticipantsPatients aged ≥18 years with a minimum follow-up of 12 months.InterventionHospitals were randomised (1:1) to patient management by standard care or according to the GRS and associated guidelines.Main outcome measuresPrimary outcome measures were use of guideline recommended management and time to the composite of cardiovascular death, non-fatal myocardial infarction, new onset heart failure hospital admission, and readmission for cardiovascular event. Secondary measures included the duration of hospital stay, EQ-5D-5L (five domain, five level version of the EuroQoL index), and the composite endpoint components.Results3050 participants (1440 GRS, 1610 standard care) were recruited in 38 UK clusters (20 GRS, 18 standard care). The mean age was 65.7 years (standard deviation 12), 69% were male, and the mean baseline GRACE scores were 119.5 (standard deviation 31.4) and 125.7 (34.4) for GRS and standard care, respectively. The uptake of guideline recommended processes was 77.3% for GRS and 75.3% for standard care (odds ratio 1.16, 95% confidence interval 0.70 to 1.92, P=0.56). The time to the first composite cardiac event was not significantly improved by the GRS (hazard ratio 0.89, 95% confidence interval 0.68 to 1.16, P=0.37). Baseline adjusted EQ-5D-5L utility at 12 months (difference −0.01, 95% confidence interval −0.06 to 0.04) and the duration of hospital admission within 12 months (mean 11.2 days, standard deviation 18 days v11.8 days, 19 days) were similar for GRS and standard care.ConclusionsIn adults presenting to hospital with suspected non-ST elevation acute coronary syndrome, the GRS did not improve adherence to guideline recommended management or reduce cardiovascular events at 12 months.Trial registrationISRCTN 29731761

Background: Myonecrosis provoked by illness unrelated to unstable coronary plaque is common, but uncertainty about a cause-effect relationship with future events challenges the appropriateness of initiating therapies known to be effective in cardiac conditions. We examined the causal relationship between troponin elevation in non-coronary diagnoses and late cardiac events using the Bradford Hills criteria for causality.Methods and results: Patients presenting acutely to South Australian public hospitals receiving at least one troponin between September 2011–September 2012 were included. Diagnoses were classified as coronary, non-coronary cardiac and non-cardiac using the International Classification of Diseases, version 10 Australian Modified, codes. The relationship between peak in-hospital troponin, using a high-sensitivity troponin T assay and adjudicated cardiac and non-cardiac mortality, and subsequent myocardial infarction (MI) was assessed using competing-risk flexible parametric survival models. Troponin results were available for 38,161 patients of whom, 12,645 (33.6%), 3237 (8.5%), and 22,079 (57.9%) patients were discharged with coronary, non-coronary cardiac and non-cardiac diagnoses, respectively. Troponin >14 ng/l was observed in 43.6%. The relationship between troponin and cardiac mortality was stronger among the non-coronary diagnosis group (troponin 1000 ng/l: coronary hazard ratio: 5.1 (95% confidence interval (CI) 4.0–6.6) vs non-coronary hazard ratio: 16.3 (95% CI 12.6–22.4)). The temporal hazard for cardiac death was marked within 30 days in both groups. Among non-coronary diagnoses, the hazard for recurrent MI was higher but did not vary with time.Conclusions: Consistency with causal criteria between secondary myonecrosis and cardiac events suggest the potential benefit for extending cardiac specific interventions to this population if supported in trials appropriately designed to address competing risks. Troponin elevation precipitated by non-coronary events is common and demonstrates an associations with late mortality that are analogous to spontaneous MI resulting from unstable coronary plaque. These observations help inform the design of randomized clinical trials exploring the benefits and risk of therapies with established benefits in other cardiac conditions. Such studies will need to appropriately account for competing risks in this population of patients.

Introduction:Infective endocarditis (IE) after cardiac valve surgery is associated with high morbidity and mortality. Nosocomial exposure is a growing cause of IE in general. We investigated the risk of post valve surgery endocarditis (PVE) in patient who had any hospitalization and specific nosocomial exposures after open heart valve surgery.Methods:We identified all ≥18yo patients who had their first open heart cardiac valve surgery between 2001-2017 in New South Wales, Australia from the Admitted Patient Data Collection (APDC) registry. Patients with prior/current IE diagnosis at time of index valve surgery were excluded. Follow up was until 31 Dec 2018 with mortality and morbidity tracked from the respective death and APDC registries. Analyses based on Cox regression modelling included age, sex, background diagnoses and features of index valve surgery as time independent covariates, with any hospitalization (separately for specific invasive procedures) post index valve surgery as time dependent exposure covariates for risk of PVE within 6 months of exposure.Results:In total 23747 patients (median age [IQR] 73yo [65-79yo, 63% male) had cardiac valve surgery: 60% isolated aortic valve (n=15065), 28% isolated mitral valve (n=6702), 10% multiple valves (n=2385) and 1.5% right sided valves (n=357). 5.4% (n=1293) of patients experienced PVE at a median 2.9 years (IQR 0.7-6.2) after index valve surgery, with 65% (n=838) occurring within 6 months of any hospitalization. Any hospitalization exposure was associated with an adjusted hazard ratio of 4.0 for developing PVE (95% confidence interval 3.5-4.5). In addition, specific invasive procedures including repeat valve surgery were associated with an elevated risk for PVE (Figure).Conclusions:PVE is significantly more common after any hospitalization with specific invasive procedures carrying differential risk. Care should be taken to avoid unnecessary hospitalizations and procedures in these patients.

Introduction:Mitral valve (MV) repair (MVr) has superior survival outcomes to MV replacement (MVR) for primary MV diseases. MVr cases has increased in other developed nations but is unknown in Australia. We assessed temporal trends in the total and relative MVr volume and compared MVr and MVR outcomes over 17 years.Method:Patients who had isolated MV surgery (MVSx) between 2001-2017 were identified from the New South Wales statewide Admitted Patient Data Collection registry. Mortality outcome was tracked to Dec 2018.Results:A total of 5693 patients (MVr: n=2020 [35%]; mechanical MVR: n=1656 [29%]; bioprosthetic MVR: n=2017 [35%]) were identified; median age [interquartile range] were 67y [59-75y] vs 64y [55-71y] vs 75y [68-80y], respectively (all P<0.001). Median follow-up for the cohort was 6.3yrs. Annual MVSx cases increased over the study period but relative use of MVr declined from 44% (110/252 MVSx) in 2002 to 27% (165/601 MVSx) in 2017 (Fig1). Crude in-hospital and 1-yr mortality steadily declined for all groups between 2001 and 2017. MVr had the best outcome, with 1.2% in-hospital, 2.5% 1-yr, and 21.6% total cumulative mortality. Compared to MVr, after adjusting for age, sex, referral source, and comorbidities, the adjusted hazard ratios for long-term mortality were 1.41 (95% confidence interval [CI]=1.24-1.61) for mechanical MVR and 1.73 (95% CI=1.53-1.95) for bioprosthetic MVR (Fig 2).Conclusion:In this statewide Australian cohort study, relative use of MVr decreased over 17 years and are lower than reported by other international studies, despite having superior outcome compared to MVR. Factors driving the relatively low use of MVr should be explored.

INTRODUCTION:Haemorrhagic stroke (HS) is an important cardiovascular cause of mortality worldwide. In Australia, long term temporal trends in HS hospitalisation rates and predictors of mortality are unknown.Methods:All New South Wales residents with first-ever HS from 2002-2017 were identified from the Centre-for-Health-Record-Linkage statewide databases. Mortality tracked to 31 Dec 2018 via the death registry were adjusted for age, sex, admission year, referral source, surgical evacuation of HS status, and comorbidities in multivariable regression analyses.Results:There were 35433 patients (51% male) admitted for HS. Age-adjusted mean (±SD) admission rates were higher for males than females (63.6±6.2 vs 49.9±4.4 admissions-per-100,000-persons-per-annum respectively, p<0.001). Annual admission rates declined for both sexes from 2002-2017 (male: 74.4 to 52.5 vs female: 55.2 to 43.6 admissions-per-100,000-persons, both p<0.001 for linear trend). Admission rates were highest in patients ≥60yo but significantly declined from 2002-2017 in both sexes, while admission rates for <60yo patients remained static. Crude in-hospital and 1-year mortality post-HS were 22.5% and 38.2% respectively. Adjusted in-hospital and 1-year mortality post-HS were lower in 2017 compared to 2002 (adjusted odds ratio [aOR]=0.56, 95% confidence interval [CI]=0.49-0.65; adjusted hazard ratio [aHR]=0.73, 95%CI=0.66-0.80, respectively) (all p<0.001). Annual rates of surgical evacuation were static during study period (10.4% per year). Surgical evacuation was associated with better in-hospital and 1-year mortality (aOR=0.47, 95%CI=0.42-0.53; aHR=0.49, 95%CI=0.45-0.53, both p<0.001 respectively). Increasing age and higher Charlson comorbidity index independently predicted greater in-hospital and 1-year mortality. Male sex was associated with lower in-hospital mortality (aOR=0.88, 95%CI=0.83-0.93, p<0.001) but not at 1-year.Conclusion:Age-adjusted admission rates for HS fell between 2002-2017 for both sexes, driven mostly by ≥60 age groups, with adjusted in-hospital and 1-year mortality improving by 43% and 27% respectively. Strategies to improve survival including greater access to surgical evacuation should be further explored.

Registries are becoming an increasingly important component of clinical practice through the collection of clinical data including outcomes on representative populations of patients. An understanding of registry structure and function is important for practicing cardiovascular clinicians. Clinical populations may be identified on the basis of procedures they undergo (procedural registries), or their clinical condition (disease registries). Registries provide opportunities to document and improve quality of care. They also provide insights into the nature of disease and the benefit of treatments in subgroups of patients, and poorly resourced environments, that are not well represented in randomized clinical trials.

Improving timely access to reperfusion is a major goal of ST-segment–elevation myocardial infarction care. We sought to compare the population impact of interventions proposed to improve timely access to reperfusion therapy in Australia.

The prognostic impact of atrial fibrillation (AF) in the setting of acute coronary syndrome (ACS) is controversial. Furthermore, there are limited real-world data on the management of ACS patients with history of AF.

Recent in vitro studies have shown that shear stress can cause platelet activation by agonist-independent pathways. However, no studies have assessed the extent of shear-induced platelet activation within human coronary arteries. We sampled blood from the coronary arteries proximal and distal to coronary lesions and from the coronary sinus in humans with stable coronary disease who were taking both aspirin and clopidogrel. A novel, computationally based technique for estimating shear stress from 3-dimensional coronary angiographic images of these arteries was developed, and the effect of stenosis severity and calculated shear stress on in vivo platelet and related leukocyte activation pathways were determined. We provide evidence of intracoronary up-regulation of platelet P-selectin, platelet-monocyte aggregation, and monocyte CD11b without platelet glycoprotein IIb-IIIa activation or soluble P-selectin up-regulation. This correlates with intracoronary stenosis severity and calculated shear stress and occurs despite the concurrent use of aspirin and clopidogrel. Our results show for the first time shear-related platelet and monocyte activation in human coronary arteries and suggest this as a potential therapeutic target that is resistant to conventional antiplatelet agents.

Investigar la incidencia de hemorragias graves y la mortalidad hospitalaria en pacientes con infarto de miocardio y elevación del segmento ST (IAMCEST) en relación con la administración de tienopiridinas con o sin tratamiento trombolítico asociado.

Patients presenting with acute coronary syndromes without ST elevation on their electrocardiogram continue to contribute an important healthcare burden. Medical treatments to control symptoms include nitrates and β-blockers. Morphine is a very effective analgesic although its use may be associated with adverse outcomes. Oral antiplatelet therapies including aspirin and clopidogrel form a cornerstone of prognostically modifying therapy. Similarly, the intravenous IIb/IIIa antagonists have emerged as having an important role in patients undergoing coronary intervention. Low molecular weight heparins are more convenient to use than unfractionated heparin and may be more effective. Care should be taken to avoid mixing the two antithrombins as this contributes to increased bleeding risk. Statins can impact on short-term outcomes when given during the acute admission; and this benefit is augmented if high doses are used.