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We sought to characterize presenting electrocardiographic findings in patients with acute coronary syndromes (ACSs) and out-of-hospital cardiac arrest (OHCA). In the Global Registry of Acute Coronary Events and Canadian ACS Registry I, we examined presenting and 24- to 48-hour follow-up ECGs (electrocardiogram) of ACS patients who survived to hospital admission, stratified by presentation with OHCA. We assessed the prevalence of ST-segment deviation and bundle branch blocks (assessed by an independent ECG core laboratory) and their association with in-hospital and 6-month mortality among those with OHCA. Of the 12,040 ACS patients, 215 (1.8%) survived to hospital admission after OHCA. Those with OHCA had higher presenting rates of ST-segment elevation, ST-segment depression, T-wave inversion, precordial Q-waves, left bundle branch block (LBBB), and right bundle branch block (RBBB) than those without. Among patients with OHCA, those with ST-segment elevation had significantly lower in-hospital mortality (20.9% vs 33.0%, p = 0.044) and a trend toward lower 6-month mortality (27% vs 39%, p = 0.060) compared with those without ST-segment elevation. Conversely, among OCHA patients, LBBB was associated with significantly higher in-hospital and 6-month mortality rates (58% vs 22%, p 0.001, and 65% vs 28%, p 0.001, respectively). ST-segment depression and RBBB were not associated with either outcome. Sixty-three percent of bundle branch blocks (RBBB or LBBB) on the presenting ECG resolved by 24 to 48 hours. In conclusion, compared with ACS patients without cardiac arrest, those with OHCA had higher rates of ST-segment elevation, LBBB, and RBBB on admission. Among OHCA patients, ST-segment elevation was associated with lower in-hospital mortality, whereas LBBB was associated with higher in-hospital and 6-month mortality.

Process mining is a data analytics approach which has shown promising results in healthcare including the potential to improve the management of chronic diseases such as cardiovascular disease (CVD). CVD are one of the leading causes of premature death worldwide. Helping healthcare professionals develop a better understanding of how to improve CVD care pathways may result in better outcomes for patients. This paper describes the opportunities for process mining to support such improvements and provides a summary of process mining studies undertaken in the field of cardiology. The initial search found 1,597 potentially relevant papers which, after a systematic review, identified a final set of 32 relevant studies. These studies were analyzed across five themes: process and data types; research questions; techniques, perspective and tools; methodologies; limitations and suggested future work.

BackgroundUse of the Pre-Hospital 12-lead Electrocardiogram (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS).ObjectivesTo investigate differences in mortality between those who did/did not receive PHECG.MethodsPopulation-based, linked cohort study using Myocardial Ischaemia National Audit Project (MINAP) data from 2010-2017.ResultsOf 330,713 patients, 263,420 (79.6%) had PHECG, 67,293 (20.3%) did not. 30-day mortality was 7.8% overall, 7.1% with PHECG vs 10.9% without PHECG (adjusted Odds Ratio [aOR] 0.772, 95% confidence interval [CI] 0.748-0.795, pConclusionPHECG was associated with lower mortality at 30 days and 1 year in both STEMI and non-STEMI patients.

BACKGROUND: There is a paucity of information about treatment and mortality trends after acute myocardial infarction (AMI) for cancer survivors (CS). METHODS: In this population‐based study, the authors compared temporal trends of treatments and outcomes (mortality, nonfatal cardiovascular outcomes), among CS and patients without cancer (the noncancer patient [NCP] group) with AMI in Ontario (Canada) using inverse probability treatment weight (IPTW)‐adjusted modeling. RESULTS: Of 270,089 patients with AMI (22,907 CS, 247,182 NCP, 1995‐2013; median follow‐up, 10.1 and 11.0 years, respectively), the use of invasive coronary strategies and pharmacotherapies increased and mortality declined for CS and NCP (all Ptrend

Aim: To develop a simple risk-score model for predicting in-hospital cardiac arrest (CA) among patients hospitalized with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). Methods: Using the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART), we identified patients (n = 242 303) admitted with suspected NSTE-ACS between 2008 and 2014. Logistic regression was used to assess the association between 26 candidate variables and in-hospital CA. A risk-score model was developed and validated using a temporal cohort (n = 126 073) comprising patients from SWEDEHEART between 2005 and 2007 and an external cohort (n = 276 109) comprising patients from the Myocardial Ischaemia National Audit Project (MINAP) between 2008 and 2013. Results: The incidence of in-hospital CA for NSTE-ACS and non-ACS was lower in the SWEDEHEART-derivation cohort than in MINAP (1.3% and 0.5% vs. 2.3% and 2.3%). A seven point, five variable risk score (age ≥60 years (1 point), ST-T abnormalities (2 points), Killip Class >1 (1 point), heart rate

Correction: Volume: 292 Pages: 160-162 DOI: 10.1016/j.atherosclerosis.2019.11.020 Published: JAN 2020

The past three decades have seen a steady increase in the availability of routinely collected health and social care data and the processing power to analyse it. These developments represent a major opportunity for ageing research, especially with the integration of different datasets across traditional boundaries of health and social care, for prognostic research and novel evaluations of interventions with representative populations of older people. However, there are considerable challenges in using routine data at the level of coding, data analysis and in the application of findings to everyday care. New Horizons in applying routine data to investigate novel questions in ageing research require a collaborative approach between clinicians, data scientists, biostatisticians, epidemiologists and trial methodologists. This requires building capacity for the next generation of research leaders in this important area. There is a need to develop consensus code lists and standardised, validated algorithms for common conditions and outcomes that are relevant for older people to maximise the potential of routine data research in this group. Lastly, we must help drive the application of routine data to improve the care of older people, through the development of novel methods for evaluation of interventions using routine data infrastructure. We believe that harnessing routine data can help address knowledge gaps for older people living with multiple conditions and frailty, and design interventions and pathways of care to address the complex health issues we face in caring for older people.

Background The prevalence of atrial fibrillation (AF) in older people is increasing, as is frailty. Frailty describes an increased vulnerability to adverse outcomes, whereby the balance of risk and benefit associated with an intervention may be more nuanced. However, there are limited data from a community setting on the prevalence of AF and frailty in older people. It is important to understand the burden of AF and frailty, and the associated impact on mortality and stroke disease in order to inform shared decision making with patients, and also inform guidelines for this increasing group of older people. Purpose To estimate the prevalence of AF and the burden of frailty in patients with AF, in a large primary care dataset. To report stroke and mortality by frailty group. Methods We used electronic health records of 537,051 patients in England aged 65 years or older on 31/12/2015, with follow-up for all-cause mortality and ischaemic or unclassified stroke to 11/04/2017. Patients with a history of AF were identified using Clinical Terms Version 3 (CTV-3) codes. Frailty was identified up to the point of study entry using the electronic frailty index (eFI, the proportion of deficits out of 36 possible deficits), and categorised into robust (0–0.12), mild (>0.12–0.24), moderate (>0.24–0.36) or severe (>0.36) frailty. Median CHA2DS2-VASc and ATRIA scores for patients with frailty were compared with the robust group using Mann-Whitney. The association between frailty status, all-cause mortality and stroke was calculated using Cox proportional hazards models, adjusted for age and sex. Results Of the cohort, 61,177 patients (11.4%) had AF. Of those with AF, 27,987 (45.8%) were female, and 54,734 (89.5%) had frailty. 6,443 (10.5%) were classified as robust; 20,352 (33.3%) mildly frail; 20,315 (33.2%) moderately frail; and 14,067 (23.0%) severely frail. The median number of eFI-defined deficits among patients with AF was 9 (interquartile range [IQR] 6–12). Median stroke and bleeding scores were higher in those with frailty compared with the robust group (CHA2DS2-VASc 4 [IQR 3–5] v 2 [2–3], p≤0.001; ATRIA 4 [2–6] v 1 [0–2], p≤0.001). During 73,338 patient-years of follow-up, there were 6,805 (11.1%) deaths and 945 (1.54%) strokes. Compared with the robust group, all-cause mortality and stroke were higher with increasing frailty. Mortality: mild frailty hazard ratio 1.53 (95% confidence interval 1.29–1.80); moderate frailty 2.50 (2.13–2.94); severe frailty 4.26 (3.63–5.01). Stroke: mild frailty 1.36 (0.99–1.85); moderate frailty 1.67 (1.23–2.28); severe 1.99 (1.45–2.73). Kaplan-Meier survival curves by frailty Conclusion The prevalence of AF among those aged over 65 years in primary care in England is high, the majority of whom are frail. Increasing severity of frailty was associated with higher mortality and stroke rates. The extent to which the judicious use of oral anticoagulation may improve clinical outcomes for patients with AF and frailty is currently unknown. Acknowledgement/Funding CPG: Bayer, BMS, AstraZeneca, Novartis Vifor Pharma, Menerini

Aims 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. Methods and results 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. Conclusion 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.

Introduction For non-ST-segment elevation acute coronary syndrome (NSTEACS) there is a gap between the use of class I guideline recommended therapies and clinical practice. The Global Registry of Acute Coronary Events (GRACE) risk score is recommended in international guidelines for the risk stratification of NSTEACS, but its impact on adherence to guideline-indicated treatments and reducing adverse clinical outcomes is unknown. The objective of the UK GRACE Risk Score Intervention Study (UKGRIS) trial is to assess the effectiveness of the GRACE risk score tool and associated treatment recommendations on the use of guideline-indicated care and clinical outcomes. Methods and analysis The UKGRIS, a parallel-group cluster randomised registry-based controlled trial, will allocate hospitals in a 1:1 ratio to manage NSTEACS by standard care or according to the GRACE risk score and associated international guidelines. UKGRIS will recruit a minimum of 3000 patients from at least 30 English National Health Service hospitals and collect healthcare data from national electronic health records. The co-primary endpoints are the use of guideline-indicated therapies, and the composite of cardiovascular death, non-fatal myocardial infarction, new onset heart failure hospitalisation or cardiovascular readmission at 12 months. Secondary endpoints include duration of inpatient hospital stay over 12 months, EQ-5D-5L responses and utilities, unscheduled revascularisation and the components of the composite endpoint over 12 months follow-up. Ethics and dissemination The study has ethical approval (North East - Tyne & Wear South Research Ethics Committee reference: 14/NE/1180). Findings will be announced at relevant conferences and published in peer-reviewed journals in line with the funder’s open access policy. Trial registration number ISRCTN29731761; Pre-results.

Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition. Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.

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.

Introduction Use of the prehospital 12-lead ECG (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS). Prior research found that although PHECG use was associated with improved 30-day survival, a third of patients (typically women, the elderly and those with comorbidities) under EMS care did not receive a PHECG. The overall aim of the PHECG2 study is to update evidence on care and outcomes for patients eligible for PHECG, specifically addressing the following research questions: (1) Is there a difference in 30-day mortality, and in reperfusion rate, between those who do and those who do not receive PHECG? (2) Has the proportion of eligible patients who receive PHECG changed since the introduction of primary percutaneous coronary intervention networks? (3) Are patients that receive PHECG different from those that do not in terms of social and demographic factors, or prehospital clinical presentation? (4) What factors influence EMS clinicians’ decisions to perform PHECG? Methods and analysis This is an explanatory, mixed-method study comprising four work packages (WPs). WP1 is a population-based, linked-data analysis of a national ACS registry (Myocardial Ischaemia National Audit Project). WP2 is a retrospective chart review of patient records from three large regional EMS. WP3 comprises focus groups of EMS personnel. WP4 will synthesise findings from WP1–3 to inform the development of an intervention to increase PHECG uptake. Ethics and dissemination The study has been approved by the London-Hampstead Research Ethics Committee (ref: 18LO1679). Findings will be disseminated through feedback to participating EMS, conference presentations and publication in peer-reviewed journals. Trial registration number NCT03699137

ObjectiveInternational studies report a decline in mortality following ST-elevation myocardial infarction (STEMI). The extent to which the observed improvements in STEMI survival are explained by temporal changes in patient characteristics and utilisation of treatments is unknown.MethodsCohort study using national registry data from the Myocardial Ischaemia National Audit Project between first January 2004 and 30th June 2013. 232 353 survivors of hospitalisation with STEMI as recorded in 247 hospitals in England and Wales. Flexible parametric survival modelling and causal mediation analysis were used to estimate the relative contribution of temporal changes in treatments and patient characteristics on improved STEMI survival.ResultsOver the study period, unadjusted survival at 6 months and 1 year improved by 0.9% and 1.0% on average per year (HR: 0.991, 95% CI: 0.988 to 0.994 and HR: 0.990, 95% CI: 0.987 to 0.993, respectively). The uptake of primary percutaneous coronary intervention (PCI) (HR: 1.025, 95% CI: 1.021 to 1.028) and increased prescription of P2Y12inhibitors (HR: 1.035, 95% CI: 1.031 to 1.039) were significantly associated with improvements in 1-year survival. Primary PCI explained 16.8% (95% CI: 10.8% to 31.6%) and 13.2% (9.2% to 21.9%) of the temporal survival improvements at 6 months and 1 year, respectively, whereas P2Y12inhibitor prescription explained 5.3% (3.6% to 8.8%) of the temporal improvements at 6 months but not at 1 year.ConclusionsFor STEMI in England and Wales, improvements in survival between 2004 and 2013 were significantly explained by the uptake of primary PCI and increased use of P2Y12inhibitors at 6 months and primary PCI only at 1 year.Trial registration numberNCT03749694

Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist as they share multiple risk factors, including hypertension, diabetes mellitus, and coronary artery disease. Although there is irrefutable evidence supporting anticoagulation in AF in the general population, these data may not be transferable to the setting of advanced CKD, where the decision to commence anticoagulation poses a conundrum. In this cohort, there is a progressively increased risk of both ischemic stroke and hemorrhage as renal function declines, complicating the decision to initiate anticoagulation. No definitive clinical guidelines derived from randomized controlled trials exist to aid clinical decision-making, and the findings from observational studies are conflicting. In this review, the authors outline the pathophysiological mechanisms at play and summarize the limited existing data related to anticoagulation in those with concomitant CKD and AF. Finally, the authors suggest how to approach the decision of whether and how to use oral anticoagulation in these patients.

Background:High survival rates are commonly reported following primary percutaneous coronary intervention for ST-elevation myocardial infarction, with most contemporary studies reporting overall survival.Aims:The aim of this study was to describe survival following primary percutaneous coronary intervention for ST-elevation myocardial infarction corrected for non-cardiovascular deaths by reporting relative survival and investigate clinically significant factors associated with poor long-term outcomes.Methods and Results:Using the prospective UK Percutaneous Coronary Intervention registry, primary percutaneous coronary intervention cases ( n=88,188; 2005–2013) were matched to mortality data for the UK populace. Crude five-year relative survival was 87.1% for the patients undergoing primary percutaneous coronary intervention and 94.7% for patients 75 years: 4.69, 4.27–5.16). After four years, there was no excess mortality for ages 56–65 years (excess mortality rate ratio 1.27, 0.95–1.70), but persisting excess mortality for older groups (66–75 years: excess mortality rate ratio 1.72, 1.30–2.27; >75 years: 1.66, 1.15–2.41). Excess mortality was associated with cardiogenic shock (excess mortality rate ratio 6.10, 5.72–6.50), renal failure (2.52, 2.27–2.81), left main stem stenosis (1.67, 1.54–1.81), diabetes (1.58, 1.47–1.69), previous myocardial infarction (1.52, 1.40–1.65) and female sex (1.33, 1.26–1.41); whereas stent deployment (0.46, 0.42–0.50) especially drug eluting stents (0.27, 0.45–0.55), radial access (0.70, 0.63–0.71) and previous percutaneous coronary intervention (0.67, 0.60–0.75) were protective.Conclusions:Following primary percutaneous coronary intervention for ST-elevation myocardial infarction, long-term cardiovascular survival is excellent. Failure to account for non-cardiovascular death may result in an underestimation of the efficacy of primary percutaneous coronary intervention.

to investigate whether the association between blood pressure and clinical outcomes is different in older adults with and without frailty, using observational studies.MEDLINE, EMBASE and CINAHL were searched from 1st January 2000 to 13th June 2018. PROSPERO CRD42017081635. We included all observational studies reporting clinical outcomes in older adults with an average age over 65 years living in the community with and without treatment that measured blood pressure and frailty using validated methods. Two independent reviewers evaluated study quality and risk of bias using the ROBANS tool. We used generic inverse variance modelling to pool risks of all-cause mortality adjusted for age and sex.nine observational studies involving 21,906 older adults were included, comparing all-cause mortality over a mean of six years. Fixed effects meta-analysis of six studies demonstrated that in people with frailty, there was no mortality difference associated with systolic blood pressure140 mm Hg compared to systolic blood pressure140 mm Hg (HR 1.02, 95% CI 0.90 to 1.16). In the absence of frailty, systolic blood pressure140 mm Hg was associated with lower risk of death compared to systolic blood pressure140 mm Hg (HR 0.86, 95% CI 0.77 to 0.96).evidence from observational studies demonstrates no mortality difference for older people with frailty whose systolic blood pressure is140 mm Hg, compared to those with a systolic blood pressure140 mm Hg. Current evidence fails to capture the complexities of blood pressure measurement, and the association with non-fatal outcomes.

ObjectiveTo compare temporal changes in European Society of Cardiology (ESC) acute myocardial infarction (AMI) quality indicator (QI) attainment in the UK and Israel.MethodsData cross-walking using information from the Myocardial Ischaemia National Audit Project and the Acute Coronary Syndrome in Israel Survey for matching 2-month periods in 2006, 2010 and 2013 was used to compare country-specific attainment of 14 ESC AMI QIs.ResultsPatients in the UK (n=17 068) compared with Israel (n=5647) were older, more likely to be women, and had less diabetes, dyslipidaemia and heart failure. Baseline ischaemic risk was lower in Israel than the UK (Global Registry of Acute Coronary Events (GRACE) risk, 110.5 vs 121.0). Overall, rates of coronary angiography (87.6% vs 64.8%) and percutaneous coronary intervention (70.3% vs 41.0%) were higher in Israel compared with the UK. Composite QI performance increased more in the UK (1.0%–86.0%) than Israel (70.2%–78.0%). Mortality rates at 30 days declined in each country, with lower rates in Israel in 2013 (4.2% vs 7.6%). Composite QI adherence adjusted for GRACE risk score was inversely associated with 30-day mortality (OR 0.95; CI 0.95 to 0.97, pConclusionsInternational comparisons of guideline recommended AMI care and outcomes can be quantified using the ESC AMI QIs. International implementation of the ESC AMI QIs may reveal country-specific opportunities for improved healthcare delivery.

Background Bleeding risk stratification in acute coronary syndrome is of highest clinical interest but current risk scores have limitations. We sought to develop and validate a new in‐hospital bleeding risk score for patients with acute myocardial infarction. Methods and Results From the nationwide SWEDEHEART (Swedish Web‐System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) register, 97,597 patients with acute myocardial infarction enrolled from 2009 until 2014 were selected. A full model with 23 predictor variables and 8 interaction terms was fitted using logistic regression. The full model was approximated by a model with 5 predictors and 1 interaction term. Calibration, discrimination, and clinical utility was evaluated and compared with the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) and CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Ad verse Outcomes With Early Implementation of the ACC /AHA Guidelines) scores. Internal and temporal validity was assessed. In‐hospital major bleeding, defined as fatal, intracranial, or requiring surgery or blood transfusion, occurred in 1356 patients (1.4%). The 5 predictors in the approximate model that constituted the SWEDEHEART score were hemoglobin, age, sex, creatinine, and C‐reactive protein. The ACTION and CRUSADE scores were poorly calibrated in the derivation cohort and therefore were recalibrated. The SWEDEHEART score showed higher discriminative ability than both recalibrated scores, overall ( C ‐index 0.80 versus 0.73/0.72) and in all predefined subgroups. Decision curve analysis demonstrated consistently positive and higher net benefit for the SWEDEHEART score compared with both recalibrated scores across all clinically relevant decision thresholds. The original ACTION and CRUSADE scores showed negative net benefit. Conclusions The 5‐item SWEDEHEART score discriminates in‐hospital major bleeding in patients with acute myocardial infarction and has superior model performance compared with the recalibrated ACTION and CRUSADE scores.

Aims: Early and accurate diagnosis of acute myocardial infarction is central to successful treatment and improved outcomes. We aimed to investigate the impact of the initial hospital diagnosis on mortality for patients with acute myocardial infarction. Methods and results: Cohort study using data from the Myocardial Ischaemia National Audit Project of patients discharged with a final diagnosis of ST-elevation myocardial infarction (STEMI, n=221,635) and non-STEMI (NSTEMI, n=342,777) between 1 April 2004 and 31 March 2013 in all acute hospitals ( n = 243) in England and Wales. Overall, 168,534 (29.9%) patients had an initial diagnosis which was not the same as their final diagnosis. After multivariable adjustment, for STEMI a change from an initial diagnosis of NSTEMI (time ratio 0.97, 95% confidence interval 0.92–1.01) and chest pain of uncertain cause (0.98, 0.89–1.07) was not associated with a significant reduction in time to death, whereas for other initial diagnoses the time to death was significantly reduced by 21% (0.78, 0.74–0.83). For NSTEMI, after multivariable adjustment, a change from an initial diagnosis of STEMI was associated with a reduction in time to death of 10% (time ratio 0.90, 95% confidence interval 0.83–0.97), but not for chest pain of uncertain cause (0.99, 0.96–1.02). Patients with NSTEMI who had other initial diagnoses had a significant 14% reduction in their time to death (time ratio 0.86, 95% confidence interval 0.84–0.88). STEMI and NSTEMI with other initial diagnoses had low rates of pre-hospital electrocardiograph (24.3% and 21.5%), aspirin on hospitalisation (61.6% and 48.5%), care by a cardiologist (60.0% and 51.5%), invasive coronary procedures (38.8 % and 29.2%), cardiac rehabilitation (68.9% and 62.6%) and guideline indicated medications at time of discharge from hospital. Had the 3.3% of patients with STEMI and 17.9% of NSTEMI who were admitted with other initial diagnoses received an initial diagnosis of STEMI and NSTEMI, then 33 and 218 deaths per year might have been prevented, respectively. Conclusion: Nearly one in three patients with acute myocardial infarction had other diagnoses at first medical contact, who less frequently received guideline indicated care and had significantly higher mortality rates. There is substantial potential, greater for NSTEMI than STEMI, to improve outcomes through earlier and more accurate diagnosis of acute myocardial infarction.

Background The long-term excess risk of death associated with diabetes following acute myocardial infarction is unknown. We determined the excess risk of death associated with diabetes among patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) after adjustment for comorbidity, risk factors and cardiovascular treatments. Methods Nationwide population-based cohort (STEMI n=281 259 and NSTEMI n=422 661) using data from the UK acute myocardial infarction registry, MINAP, between 1 January 2003 and 30 June 2013. Age, sex, calendar year and country-specific mortality rates for the populace of England and Wales (n=56.9 million) were matched to cases of STEMI and NSTEMI. Flexible parametric survival models were used to calculate excess mortality rate ratios (EMRR) after multivariable adjustment. This study is registered at ClinicalTrials.gov (NCT02591576). Results Over 1.94 million person-years follow-up including 120 568 (17.1%) patients with diabetes, there were 187 875 (26.7%) deaths. Overall, unadjusted (all cause) mortality was higher among patients with than without diabetes (35.8% vs 25.3%). After adjustment for age, sex and year of acute myocardial infarction, diabetes was associated with a 72% and 67% excess risk of death following STEMI (EMRR 1.72, 95% CI 1.66 to 1.79) and NSTEMI (1.67, 1.63 to 1.71). Diabetes remained significantly associated with substantial excess mortality despite cumulative adjustment for comorbidity (EMRR 1.52, 95% CI 1.46 to 1.58 vs 1.45, 1.42 to 1.49), risk factors (1.50, 1.44 to 1.57 vs 1.33, 1.30 to 1.36) and cardiovascular treatments (1.56, 1.49 to 1.63 vs 1.39, 1.36 to 1.43). Conclusions At index acute myocardial infarction, diabetes was common and associated with significant long-term excess mortality, over and above the effects of comorbidities, risk factors and cardiovascular treatments.

Adherence to guideline-indicated care for the treatment of non-ST-elevation myocardial infarction (NSTEMI) is associated with improved outcomes. We investigated the extent and consequences of non-adherence to guideline-indicated care across a national health system.A cohort study ( ClinicalTrials.gov identifier: NCT02436187) was conducted using data from the Myocardial Ischaemia National Audit Project ( n = 389,057 NSTEMI, n = 247 hospitals, England and Wales, 2003-2013). Accelerated failure time models were used to quantify the impact of non-adherence on survival according to dates of guideline publication.Over a period of 1,079,044 person-years (median 2.2 years of follow-up), 113,586 (29.2%) NSTEMI patients died. Of those eligible to receive care, 337,881 (86.9%) did not receive one or more guideline-indicated intervention; the most frequently missed were dietary advice ( n = 254,869, 68.1%), smoking cessation advice ( n = 245,357, 87.9%), P2Y12 inhibitors ( n = 192,906, 66.3%) and coronary angiography ( n = 161,853, 43.4%). Missed interventions with the strongest impact on reduced survival were coronary angiography (time ratio: 0.18, 95% confidence interval (CI): 0.17-0.18), cardiac rehabilitation (time ratio: 0.49, 95% CI: 0.48-0.50), smoking cessation advice (time ratio: 0.53, 95% CI: 0.51-0.57) and statins (time ratio: 0.56, 95% CI: 0.55-0.58). If all eligible patients in the study had received optimal care at the time of guideline publication, then 32,765 (28.9%) deaths (95% CI: 30,531-33,509) may have been prevented.The majority of patients hospitalised with NSTEMI missed at least one guideline-indicated intervention for which they were eligible. This was significantly associated with excess mortality. Greater attention to the provision of guideline-indicated care for the management of NSTEMI will reduce premature cardiovascular deaths.

Objective For percutaneous coronary intervention (PCI) to the unprotected left main stem (UPLMS), there are limited long-term outcome data. We evaluated 5-year survival for UPLMS PCI cases taking into account background population mortality. Methods A population-based registry of 10 682 cases of chronic stable angina (CSA), non-ST-segment elevation acute coronary syndrome (NSTEACS), ST-segment elevation myocardial infarction with (STEMI+CS) and without cardiogenic shock (STEMI−CS) who received UPLMS PCI from 2005 to 2014 were matched by age, sex, year of procedure and country to death data for the UK populace of 56.6 million people. Relative survival and excess mortality were estimated. Results Over 26 105 person-years follow-up, crude 5-year relative survival was 93.8% for CSA, 73.1% for NSTEACS, 77.5% for STEMI−CS and 28.5% for STEMI+CS. The strongest predictor of excess mortality among CSA was renal failure (EMRR 6.73, 95% CI 4.06 to 11.15), and for NSTEACS and STEMI−CS was preprocedural ventilation (6.25, 5.05 to 7.75 and 6.92, 4.25 to 11.26, respectively). For STEMI+CS, the strongest predictor of excess mortality was preprocedural thrombolysis in myocardial infarction (TIMI) 0 flow (2.78, 1.87 to 4.13), whereas multivessel PCI was associated with improved survival (0.74, 0.61 to 0.90). Conclusions Long-term survival following UPLMS PCI for CSA was high, approached that of the background populace and was significantly predicted by co-morbidity. For NSTEACS and STEMI−CS, the requirement for preprocedural ventilation was the strongest determinant of excess mortality. By contrast, among STEMI+CS, in whom survival was poor, the strongest determinant was preprocedural TIMI flow. Future cardiovascular cohort studies of long-term mortality should consider the impact of non-cardiovascular deaths.

BackgroundInternational guidelines for the management of acute coronary syndromes (ACS) recommend use of the prehospital 12-lead electrocardiogram (PHECG). Research conducted before the primary PCI era suggested that PHECG is not always performed for those receiving a hospital diagnosis of ACS, with the patient’s gender and ethnicity speculated as influential.AimAs part of a mixed methods study investigating the use and impact of the PHECG in the primary PCI era, we explored the factors emergency medical services (EMS) clinicians report as influencing their decision to perform a PHECG.MethodsWe conducted a qualitative phenomenological study, in six focus groups with a semi structured topic guide, in three UK regions involving 47 EMS clinicians with experience ranging from nine months to 31 years. We recorded, transcribed and anonymised each focus group; familiarised ourselves with the data including notes and reflections; formed and iterated a coding framework; and constructed themes with the study team, including patient and public representatives.ResultsAll participants expressed a desire to perform a prehospital ECG in patients suspected with ACS but described a setting characterised by uncertainty and ‘messy’ context. We drew out three themes of influence on the decision to perform an ECG: surface characteristics (age, sex, ethnicity, privacy, presenting condition of the patient); pattern recognition (training, experience of atypical presentations, equipment availability, confidence in interpretation); and tensions/external pressures (distance to PCI, guidelines, organisational pressures). These were interwoven by the concept of clinical autonomy.ConclusionFactors identified as influencing clinicians’ decision to perform a PHECG ranged from straightforward to complex and were difficult to unpick. Whilst qualitatively clinicians reported performing 12 lead PHECG wherever possible in suspected ACS, the reported multifaceted influences on the decision reinforce the need for the quantitative arm of this study to examine this nationally, alongside its association with patient outcomes.

Background despite a large and growing population of older people with frailty and atrial fibrillation (AF), there is a lack of guidance on optimal AF management in this high-risk group. Objective to synthesise the existing evidence base on the association between frailty, AF and clinical outcomes. Methods a systematic review of studies examining the association between validated measures of frailty, AF and clinical outcomes, and meta-analysis of the association between frailty and oral anticoagulation (OAC) prescription. Results twenty studies (30,883 patients) were included, all observational. Fifteen were in hospital, four in the community, one in nursing care. Risk of bias was low-to-moderate. AF prevalence was 3%–38%. In people with AF, frailty was associated with increased stroke incidence, all-cause mortality, symptom severity and length of hospital stay. Meta-analysis of six studies showed frailty was associated with decreased OAC prescription at hospital admission (pooled adjusted OR 0.45 [95%CI 0.22–0.93], three studies), but not at discharge (pooled adjusted OR 0.40 [95%CI 0.13–1.23], three studies). A community-based study showed increased OAC prescription associated with frailty (OR 2.33 [95%CI 1.03–5.23]). Conclusion frailty is common, and associated with adverse clinical outcomes in patients with AF. There is evidence of an association between frailty status and OAC prescription, with different direction of effect in community compared with hospital cohorts. Despite the majority of care for older people being provided in the community, there is a lack of evidence on the association between frailty, AF, anticoagulation and clinical outcomes to guide optimal care in this setting.

The health burden of acute coronary syndrome (ACS) and frailty is high, but the impact of frailty on ACS treatment and outcomes is uncertain. In this structured literature review, we investigated the relationship between frailty, ACS treatment and outcomes. Between 2000 and 2016, we identified only a small number of primary research studies investigating frailty and ACS care ( n = 10). Frailty was independently associated with increased mortality following ACS (adjusted all-cause mortality hazard ratios for patients with frailty ranged from 1.54 to 5.39). Older people with frailty were significantly less likely to receive guideline-indicated ACS care, including percutaneous coronary intervention (PCI) (rates ranged from 6.7% to 43.7% vs. from 30.4% to 69.5%). Available data for PCI indicated a gap between treatment recommended by international guidelines and clinical practice. Further research is warranted in order to investigate methods for identifying frailty in the acute setting and opportunities for improving care among older people with frailty presenting with ACS.

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

To determine whether changing patterns of anticoagulant use in atrial fibrillation (AF) have impacted on stroke rates in England.English national databases, 2006-2016, were interrogated to assess stroke admissions and oral anticoagulant use. The number of patients with known AF increased linearly from 692 054 to 983 254 (prevalence 1.29% vs. 1.71%). Hospital episodes of AF-related stroke/100 000 AF patients increased from 80/week in 2006 to 98/week in 2011 and declined to 86/week in 2016 (2006-2011 difference 18.0, 95% confidence interval (CI) 17.9-18.1, 2011-2016 difference -12.0, 95% CI -12.1 to -11.9). Anticoagulant use amongst patients with CHA2DS2-VASc ≥2 increased from 48.0% to 78.6% and anti-platelet use declined from 42.9% to 16.1%; the greatest rate of change occurred in the second 5 year period (for anticoagulants 2006-2011 difference 4.8%, 95% CI 4.5-5.1%, 2011-2016 difference 25.8%, 95% CI 25.5-26.1%). After adjustment for AF prevalence, a 1% increase in anticoagulant use was associated with a 0.8% decrease in the weekly rate of AF-related stroke (incidence rate ratio 0.992, 95% CI 0.989-0.994). Had the use of anticoagulants remained at 2009 levels, 4068 (95% CI 4046-4089) more strokes would have been predicted in 2015/2016.Between 2006 and 2016, AF prevalence and anticoagulant use in England increased. From 2011, hospitalized AF-related stroke rates declined and were significantly associated with increased anticoagulant uptake.

Frailty is increasingly seen among patients with acute cardiovascular disease. A combination of an ageing population, improved disease survival, treatable long-term conditions as well as a greater recognition of the syndrome has accelerated the prevalence of frailty in the modern world. Yet, this has not been matched by an expansion of research. National and international bodies have identified acute cardiovascular disease in the frail as a priority area for care and an entity that requires careful clinical decisions, but there remains a paucity of guidance on treatment efficacy and safety, and how to manage this complex group. This position paper from the Acute Cardiovascular Care Association presents the latest evidence about frailty and the management of frail patients with acute cardiovascular disease, and suggests avenues for future research.

Measuring the quality of care provided to patients by a healthcare system is not a novel innovation. However, the methods used to measure and assess this quality have changed over time and indeed in the last 15 years have undergone a revolution with the introduction of quality indicators. The aims of this article are to explore the history of quality indicators and how they now form an integral part of the evaluation method of the quality of care provided for acute myocardial infarction patients.

Background There is growing evidence that sleep duration and quality may be associated with cardiovascular harm and mortality. Methods and Results We conducted a systematic review, meta‐analysis, and spline analysis of prospective cohort studies that evaluate the association between sleep duration and quality and cardiovascular outcomes. We searched MEDLINE and EMBASE for these studies and extracted data from identified studies. We utilized linear and nonlinear dose‐response meta‐analysis models and used DerSimonian–Laird random‐effects meta‐analysis models of risk ratios, with inverse variance weighting, and the I 2 statistic to quantify heterogeneity. Seventy‐four studies including 3 340 684 participants with 242 240 deaths among 2 564 029 participants who reported death events were reviewed. Findings were broadly similar across both linear and nonlinear dose‐response models in 30 studies with >1 000 000 participants, and we report results from the linear model. Self‐reported duration of sleep >8 hours was associated with a moderate increased risk of all‐cause mortality, with risk ratio , 1.14 (1.05–1.25) for 9 hours, risk ratio, 1.30 (1.19–1.42) for 10 hours, and risk ratio, 1.47 (1.33–1.64) for 11 hours. No significant difference was identified for periods of self‐reported sleep , 1.44; 95% confidence interval, 1.09–1.90), but no difference in mortality and other outcomes. Conclusions Divergence from the recommended 7 to 8 hours of sleep is associated with a higher risk of mortality and cardiovascular events. Longer duration of sleep may be more associated with adverse outcomes compared with shorter sleep durations.

Background: To investigate the impact of early, within 24 hours, percutaneous coronary intervention (PCI) compared with only routine medical treatment on clinical outcomes in a large international cohort of patients with non-ST elevation acute coronary syndrome (NSTE-ACS) and diabetes. Methods: Cohort study using a population- based registry (International Survey of Acute Coronary Syndromes in Transitional Countries [ISACS-TC]) enrolled in 41 hospitals participating in the ISACS-TC in 12 European countries between October 2010 and April 2016. We identified 1,250 patients with diabetes and NSTE-ACS. The primary endpoint was 30-day all-cause mortality. The secondary endpoint was the composite outcome of 30-day all-cause mortality and left ventricular dysfunction (ejection fraction < 40%). We undertook analyses to explore the heterogeneity of treatment effects using meta-classification (MC) algorithms followed by propensity score matching and inverse probability-of-treatment weighting (IPTW) from a landmark of 24 hours from hospitalization. Findings: Of 1,250 NSTE-ACS first-day survivors with diabetes (median age 67 year; 59%, men), 470 (38%) received early PCI and 780 routine medical treatment. The overall 30-day all-cause mortality rates were higher in the routine medical treatment than the early PCI group (6·3% vs. 2·5%). The prediction results of the MC algorithms accounted for only one interaction term that was statistically significant: age ≥ 65 years. After propensity-matched analysis as well as IPTW, early PCI was associated with reduced 30-day all-cause mortality in the older age (OR: 0·35; 95%CI: 0·14 to 0·92 and 0·43; 95%CI: 0·21 to 0·86, respectively), whereas younger age had no association with the primary endpoint. Similar results were also obtained for the secondary endpoint. Interpretation: Among patients with diabetes hospitalized for NSTE-ACS, an early, within 24 hours, PCI strategy is associated with reduced odds of 30-day mortality only for patients aged 65 years or over. MC algorithms provide accurate identification of treatment effect modifiers. Funding Statement: None Declaration of Interests: No competing interest exist. Ethics Approval Statement: The study was approved by the local research ethics committee from each hospital.

Survival after non-ST-elevation myocardial infarction (NSTEMI) is high and non-cardiovascular death has become more frequent. Observational studies typically quantify quality of care and clinical outcomes using all-cause mortality, which nowadays may not reflect the impact of index NSTEMI. We review and investigate relative survival for quantifying longer term outcomes after NSTEMI. National cohort study of hospitalized NSTEMI (Myocardial Ischaemia National Audit Project; patients: n = 346 546, hospitals: n = 243, countries: England and Wales). Mortality rates derived from two relative survival techniques were compared with all-cause mortality, and the impact of relative survival adjusted patient characteristics compared with those from Cox proportional estimates. Cox proportional hazards models provide lower survival estimates because they include deaths from all causes, overestimate the impact of increasing age on survival, and underestimate temporal improvements in care. The Royston–Parmar model allows more accurate estimation of relative survival because it is flexible to the high early hazard of death after hospitalized NSTEMI. All-cause mortality gives an overall assessment of survival for a cohort of patients. Relative survival provides a more accurate and informed estimation of the impact of an index cardiovascular event and, if necessary, patient characteristics on survival.

Summary Background The contemporary associations of type 2 diabetes with a wide range of incident cardiovascular diseases have not been compared. We aimed to study associations between type 2 diabetes and 12 initial manifestations of cardiovascular disease. Methods We used linked primary care, hospital admission, disease registry, and death certificate records from the CALIBER programme, which links data for people in England recorded in four electronic health data sources. We included people who were (or turned) 30 years or older between Jan 1, 1998, to March 25, 2010, who were free from cardiovascular disease at baseline. The primary endpoint was the first record of one of 12 cardiovascular presentations in any of the data sources. We compared cumulative incidence curves for the initial presentation of cardiovascular disease and used Cox models to estimate cause-specific hazard ratios (HRs). This study is registered at ClinicalTrials.gov (NCT01804439). Findings Our cohort consisted of 1 921 260 individuals, of whom 1 887 062 (98·2%) did not have diabetes and 34 198 (1·8%) had type 2 diabetes. We observed 113 638 first presentations of cardiovascular disease during a median follow-up of 5·5 years (IQR 2·1–10·1). Of people with type 2 diabetes, 6137 (17·9%) had a first cardiovascular presentation, the most common of which were peripheral arterial disease (reported in 992 [16·2%] of 6137 patients) and heart failure (866 [14·1%] of 6137 patients). Type 2 diabetes was positively associated with peripheral arterial disease (adjusted HR 2·98 [95% CI 2·76–3·22]), ischaemic stroke (1·72 [1·52–1·95]), stable angina (1·62 [1·49–1·77]), heart failure (1·56 [1·45–1·69]), and non-fatal myocardial infarction (1·54 [1·42–1·67]), but was inversely associated with abdominal aortic aneurysm (0·46 [0·35–0·59]) and subarachnoid haemorrhage (0·48 [0·26–0.89]), and not associated with arrhythmia or sudden cardiac death (0·95 [0·76–1·19]). Interpretation Heart failure and peripheral arterial disease are the most common initial manifestations of cardiovascular disease in type 2 diabetes. The differences between relative risks of different cardiovascular diseases in patients with type 2 diabetes have implications for clinical risk assessment and trial design. Funding Wellcome Trust, National Institute for Health Research, and Medical Research Council.

Despite substantial advances in the management of cardiovascular disease, it remains a major cause of morbidity and mortality worldwide. Globally, cardiovascular disease is expected to account for over 23 million deaths by the year 2030, mostly attributable to an increasing incidence in low and middle income countries. Within the World Health Organisation European Region, cardiovascular disease accounts for over 4 million deaths per year. However, this rate varies considerably between European countries with evidence from observational databases to suggest that mortality rates from cardiovascular disease are higher in countries of Central and Eastern Europe, Central Asia, Finland and Malta.

This editorial refers to ‘Consequences of implementing a cardiac troponin assay with improved sensitivity at Swedish coronary care units: an analysis from the SWEDEHEART registry’[†][1], by K.M. Egger et al ., on page 2417. Cardiac troponins play a central role in the diagnosis of acute myocardial infarction (AMI) and the management of non-ST-segment elevation acute coronary syndromes (NSTEACS). The third universal definition bases the diagnosis of AMI on the ‘detection of a rise and/or fall of cardiac biomarker values (preferably cardiac troponin) with at least one value above the 99th percentile upper reference limit’.1 The European Society of Cardiology (ESC) guidelines for the management of NSTEACS recommend an urgent invasive strategy, i.e. within 24 h, in patients with high-risk criteria, including those with a rise or fall in cardiac troponin compatible with MI.2 The early and accurate diagnosis of AMI is a key function of emergency departments. Delayed diagnosis may result in substandard initiation of AMI treatments, inadequate rule out of alternative diagnoses, and the failure to discharge very low risk patients—each being associated with the potential for increased costs and adverse clinical outcomes. Moreover, ‘negative’ cardiac troponin values may lead to patients with ACS who have small, but measureable, cardiac damage being inappropriately discharged from hospital. Such imperfections in ACS diagnostics triggered a race to develop higher sensitivity cardiac … [1]: #fn-2

Randomised clinical trials are the gold standard for testing the effectiveness of clinical interventions. However, increasing complexity and associated costs may limit their application in the investigation of key cardiovascular knowledge gaps such as the re-evaluation of generic pharmacotherapies. The registry-based randomised clinical trial (RRCT) leverages data sampling from nationwide quality registries to facilitate high participant inclusion rates at comparably low costs and, therefore, may offer a mechanism by which such clinical questions may be answered. To date, a number of studies have been conducted using such trial designs, but uncritical use of the RRCT design may lead to erroneous conclusions. The current review provides insights into the strengths and weaknesses of the RRCT, as well as provides an exploratory example of how a trial may be designed to test the long-term effectiveness of beta blockers in patients with myocardial infarction who have preserved left ventricular systolic function.

In acute heart failure (AHF) syndromes significant respiratory failure (RF) is essentially seen in patients with acute cardiogenic pulmonary oedema (ACPE) or cardiogenic shock (CS). Non-invasive ventilation (NIV), the application of positive intrathoracic pressure through an interface, has shown to be useful in the treatment of moderate to severe RF in several scenarios. There are two main modalities of NIV: continuous positive airway pressure (CPAP) and pressure support ventilation (NIPSV) with positive end expiratory pressure. Appropriate equipment and experience is needed for NIPSV, whereas CPAP may be administered without a ventilator, not requiring special training. Both modalities have shown to be effective in ACPE, by a reduction of respiratory distress and the endotracheal intubation rate compared to conventional oxygen therapy, but the impact on mortality is less conclusive. Non-invasive ventilation is also indicated in patients with AHF associated to pulmonary disease and may be considered, after haemodynamic stabilization, in some patients with CS. There are no differences in the outcomes in the studies comparing both techniques, but CPAP is a simpler technique that may be preferred in low-equipped areas like the pre-hospital setting, while NIPSV may be preferable in patients with significant hypercapnia. The new modality 'high-flow nasal cannula' seems promising in cases of AHF with less severe RF. The correct selection of patients and interfaces, early application of the technique, the achievement of a good synchrony between patients and the ventilator avoiding excessive leakage, close monitoring, proactive management, and in some cases mild sedation, may warrant the success of the technique.

Aims\ud To determine patient and health service factors associated with variation in hospital mortality among resuscitated cases of out-of-hospital cardiac arrest (OHCA) with acute coronary syndrome (ACS).\ud \ud Methods\ud In this cohort study, we used the Myocardial Ischaemia National Audit Project database to study outcomes in patients hospitalised with resuscitated OHCA due to ACS between 2003 and 2015 in the United Kingdom. We analysed variation in inter-hospital mortality and used hierarchical multivariable regression models to examine the association between patient and health service factors with hospital mortality.\ud \ud Results\ud We included 17604 patients across 239 hospitals. Overall hospital mortality was 28.7%. In 94 hospitals that contributed at least 60 cases, mortality by hospital ranged from 10.7% to 66.3% (median 28.6%, IQR 23.2% to 39.1%)). Patient and health service factors explained 36.1% of this variation.\ud \ud After adjustment for covariates, factors associated with higher hospital mortality included increasing serum glucose, ST-Elevation myocardial infarction (STEMI) diagnosis, and initial admission to a primary percutaneous coronary intervention (pPCI) capable hospital. Hospital OHCA volume was not associated with mortality. The key modifiable factor associated with lower mortality was early reperfusion therapy in STEMI patients.\ud \ud Conclusion\ud There was wide variation in inter-hospital mortality following resuscitated OHCA due to ACS that was only partially explained by patient and health service factors. Hospital OHCA volume and pPCI capability were not associated with lower mortality. Early reperfusion therapy was associated with lower mortality in STEMI patients.

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

Background Transcatheter aortic valve implantation (TAVI) is indicated for patients with aortic stenosis who are intermediate‐high surgical risk. Although all‐cause mortality rates after TAVI are established, survival attributable to the procedure is unclear because of competing causes of mortality. The aim was to report relative survival (RS) after TAVI, which accounts for background mortality risks in a matched general population. Methods and Results National cohort data (n=6420) from the 2007 to 2014 UK TAVI registry were matched by age, sex, and year to mortality rates for England and Wales (population, 57.9 million). The Ederer II method related observed patient survival to that expected from the matched general population. We modelled RS using a flexible parametric approach that modelled the log cumulative hazard using restricted cubic splines. RS of the TAVI cohort was 95.4%, 90.2%, and 83.8% at 30 days, 1 year, and 3 years, respectively. By 1‐year follow‐up, mortality hazards in the >85 years age group were not significantly different from those of the matched general population; by 3 years, survival rates were comparable. The flexible parametric RS model indicated that increasing age was associated with significantly lower excess hazards after the procedure; for example, by 2 years, a 5‐year increase in age was associated with 20% lower excess mortality over the general population. Conclusions RS after TAVI was high, and survival rates in those aged >85 years approximated those of a matched general population within 3 years. High rates of RS indicate that patients selected for TAVI tolerate the risks of the procedure well.

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

Background Acute myocardial infarction (AMI) remains the largest cause of hospitalisation and death in Europe. Long term conditions (LTC) are common in people with AMI and patients with LTCs also experience lower survival. The effect of LTCs on treatment receipt has not been investigated. Methods Myocardial Ischaemia National Audit Project (MINAP) data for 6 93 388 patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) were used to investigate associations between LTCs (including diabetes, chronic heart failure, chronic renal failure, COPD, peripheral vascular disease, and cerebrovascular disease) and treatment receipt. Poisson and binomial models were fitted to determine the association between LTCs and receipt of care, with treatment receipt as a count and a binary optimal care vs. sub-optimal care variable (receipt of all eligible care components vs. missing one or more) as the outcome and individual as well as cumulative LTCs as exposures. Model adjustments were informed by directed acyclic graphs. Flexible parametric survival models were fitted to investigate the interaction of LTCs and optimal care, and the impact on survival. Results Receipt of optimal care was 11.3% (n=78,376), with patients receiving on average 67% of all care opportunities (Mean 0.67, SD 0.23; Median 0.7, IQR 0.5–0.86). In those with a LTC (n=257,929), 11% (n=28,357) received optimal care. Patients with ≥one LTC received 2.7% fewer treatments compared with no LTC (IRR 0.97, 95% CI 0.97–0.98); larger differences of 7.3% and 6.1% were evident, respectively, in patients with chronic heart failure (0.93, 0.92–0.93) and chronic renal failure (0.94, 0.93–0.94). The odds of receiving suboptimal care were not significantly different in patients with ≥one LTC than those with no LTC (OR 1.01, 95% CI 0.89,1.13), however the odds of receiving optimal care was significantly lower in chronic heart failure (0.53, 0.46–0.61) and chronic renal failure (0.52, 0.44–0.62) compared to patients without these conditions. There were 2 04 667 deaths over a mean follow-up time of 2.25 years. The hazard of death in optimally treated patients with ≥one LTC was double that of those without LTCs (HR 2.18, 95% CI 2.09–2.27) and 2.5-fold in sub-optimally treated patients with ≥one LTC compared with no LTCs (2.60, 2.52–2.69). Conclusion Patients with LTCs received fewer treatments and were less likely to receive optimal care than those without. Treatment receipt was lowest in chronic heart failure and chronic renal failure. The worst survival was observed in patients with ≥one LTC receiving sub-optimal care.