All-Cause Mortality Following an Acute Coronary Syndrome: 12-Year Follow-Up of the Comprehensive 2002 New Zealand Acute Coronary Syndrome Audit.

BACKGROUND: To describe the long-term mortality of a complete national cohort of acute coronary syndrome (ACS) patients enrolled in 2002, to compare this with a national age, sex and Maori ethnicity matched population, and to assess the influence of baseline factors on the 12-year mortality. METHODS: We reviewed 721 patients with a discharge diagnosis of an ACS who were enrolled in the first New Zealand ACS audit group cohort over 14days in May 2002. We matched the cohort to the national mortality database using each patient's unique national identity number. RESULTS: Over a median follow-up of 12.7 years of 721 patients discharged with an ACS, overall mortality was 52%: ST-elevation myocardial infarction (STEMI) (58%), non-ST-elevation myocardial infarction (NSTEMI) (61%) and unstable angina pectoris (UAP) (42%) patients, p<0.0001. In an age-adjusted survival model, males had a 29% increased mortality rate compared to females with a hazard ratio of 1.29 (95% CI 1.04, 1.61, p=0.019). Over 12 years there were 339 (47%) deaths, compared to 284 (39%) deaths observed in the matched population. The standardised mortality ratio for patients admitted with an ACS in New Zealand is 1.3 (95% CI 1.2, 1.5) with eight patients per 100 not surviving to 12 years compared to this matched population. CONCLUSIONS: The high mortality rate in this ACS cohort is a stark reminder of the prognostic implications of a presentation with an ACS. It emphasises the on-going need for optimal management of these patients throughout every stage of their initial treatment and subsequent on-going care.

Blood pressure and hypertension in people living at high altitude in Nepal.

This study aimed to describe blood pressure (BP) and hypertension (HT) in samples of high altitude populations of Nepal and to explore associations of systolic and diastolic BP with altitude. This was a cross-sectional survey of cardiovascular disease and associated risk factors among 521 people living at four different altitude levels, all above 2800 m, in the Mustang and Humla districts of Nepal. Data on BP was available for all 521 participants. Systolic and diastolic BP levels were highest at the altitude of 3620 m (the highest area surveyed) but did not consistently increase with altitude. Using the cut-point of ≥ 140/90 mmHg (systolic/diastolic), the prevalence of HT (or on anti-hypertensive medication) was 46.1%, 40.9% and 54.5%, respectively, at 2800, 3270 and 3620 m of Mustang district, and 29.1% at 2890 m of Humla district. In a multivariate model adjusting for potential confounders, there was strong evidence of a relationship between systolic BP and altitude; mean systolic BP increased by 15.6 mmHg (95% CI: 4.0-27.2), P = 0.009 for every 1000 m elevation. Although diastolic BP and the probability for HT or on anti-hypertensive medication also tended to increase with increasing altitude levels, there was no evidence of a relationship. In the present study three out of four communities living at higher altitude levels showed a greater prevalence of HT among those aged 30 years or older compared with the overall national data. These findings indicate a probable high risk of raised BP in high altitude populations in Nepal.

Lipid Profiles, Glycated Hemoglobin, and Diabetes in People Living at High Altitude in Nepal.

This study aimed to describe lipid profiles and the distribution of glycated hemoglobin (HbA1c) in a sample of a high altitude population of Nepal and to explore associations between these metabolic risk variables and altitude. A cross-sectional survey of cardiovascular disease and associated risk factors was conducted among 521 people living at four different altitude levels, all above 2800 m, in the Mustang and Humla districts of Nepal. Urban participants (residents at 2800 m and 3620 m) had higher total cholesterol (TC) and triglyceride (TG) than rural participants. A high ratio of TC to high-density lipoprotein-cholesterol (HDL) (TC/HDL ≥ 5.0) was found in 23.7% (95% CI 19.6, 28.2) and high TG (≥1.7 mmol/L) in 43.3% (95% CI 38.4, 48.3) of participants overall. Mean HbA1c levels were similar at all altitude levels although urban participants had a higher prevalence of diabetes. Overall, 6.9% (95% CI 4.7, 9.8) of participants had diabetes or were on hypoglycaemic treatment. There was no clear association between lipid profiles or HbA1c and altitude in a multivariate analysis adjusted for possible confounding variables. Residential settings and associated lifestyle practices are more strongly associated with lipid profiles and HbA1c than altitude amongst high altitude residents in Nepal.

A decade of improvement in the management of New Zealand ST-elevation myocardial infarction (STEMI) patients: results from the New Zealand Acute Coronary Syndrome (ACS) Audit Group national audits of 2002, 2007 and 2012.

AIMS: To audit the management of ST-segment elevation myocardial infarction (STEMI) patients admitted to a New Zealand Hospital over three 14-day periods to review their number, characteristics, management and outcome changes over a decade. METHODS: The acute coronary syndrome (ACS) audits were conducted over 14 days in May of 2002, 2007 and 2012 at New Zealand Hospitals admitting patients with a suspected or definite ACS. Longitudinal analyses of the STEMI subgroup are reported. RESULTS: From 2002 to 2012, the largest change in management was the proportion of patients undergoing reperfusion by primary PCI from 3% to 15% and 41%; P<0.001, and the rates of second antiplatelet agent use in addition to aspirin from 14% to 62% and 98%; P<0.001. The use of proven secondary prevention medications at discharge also increased during the decade. There were also significant increases in cardiac investigations for patients, especially echocardiograms (35%, 62% and 70%, P<0.001) and invasive coronary angiograms (31%, 58% and 87%, P<0.001). Notably even in 2012, one in four patients presenting with STEMI did not receive any reperfusion therapy. CONCLUSIONS: Substantial improvements have been seen in the management of STEMI patients in New Zealand over the last decade, in accordance with evidenced-based guideline recommendations. However, there appears to be considerable room to optimise management, particularly with the use of timely reperfusion therapy for more patients.

Electrocardiography in people living at high altitude of Nepal.

OBJECTIVE: The main objective of this study was to estimate the prevalence of coronary heart disease (CHD) of high-altitude populations in Nepal determined by an ECG recordings and a medical history. METHODS: We carried out a cross-sectional survey of cardiovascular disease and risk factors among people living at four different altitude levels, all above 2800 m, in the Mustang and Humla districts of Nepal. 12-lead ECGs were recorded on 485 participants. ECG recordings were categorised as definitely abnormal, borderline or normal. RESULTS: No participant had Q waves to suggest past Q-wave infarction. Overall, 5.6% (95% CI 3.7 to 8.0) of participants gave a self-report of CHD. The prevalence of abnormal (or borderline abnormal) ECG was 19.6% (95% CI 16.1 to 23.4). The main abnormalities were: right axis deviation in 5.4% (95% CI 3.5 to 7.7) and left ventricular hypertrophy by voltage criteria in 3.5% (95% CI 2.0 to 5.5). ECG abnormalities were mainly on the left side of the heart for Mustang participants (Tibetan origin) and on the right side for Humla participants (Indo-Aryans). There was a moderate association between the probability of abnormal (or borderline abnormal) ECG and altitude when adjusted for potential confounding variables in a multivariate logistic model; with an OR for association per 1000 m elevation of altitude of 2.83 (95% CI 1.07 to 7.45), p=0.03. CONCLUSIONS: Electrocardiographic evidence suggests that although high-altitude populations do not have a high prevalence of CHD, abnormal ECG findings increase by altitude and risk pattern varies by ethnicity.

Injury and Mortality in Young Nepalese Migrant Workers: A Call for Public Health Action.

Approximately 3.5 million Nepalese are working as migrant workers in the Gulf countries, Malaysia, and India. Every year there are more than 1000 deaths and many hundreds cases of injuries among Nepalese workers in these countries excluding India. A postmortem examination of migrant workers is not carried out in most of these countries, and those with work-related injuries are often sent back to home. Uninsured migrant workers also do not have easy access to health care services in host countries due to the high medical and hospital fees. Greater efforts are needed to protect the health and well-being, labor rights, and human rights of migrant workers from Nepal and other South-Asian nations. There is a need to enforce universal labor laws in these countries and to develop accurate records of mortality and morbidity and their causes.

Blood Pressure and Hypertension in Adults Permanently Living at High Altitude: A Systematic Review and Meta-Analysis.

Aryal, Nirmal, Mark Weatherall, Yadav Kumar Deo Bhatta, and Stewart Mann. Blood pressure and hypertension in adults permanently living at high altitude: a systematic review and meta-analysis. High Alt Med Biol. 17:185-193, 2016.-The objective of this study was to estimate the associations between altitude and mean blood pressure (BP) (or prevalence of hypertension [HT]) in adults who live permanently at high altitude. A literature search was conducted in December 2014 using PubMed, Scopus, and OvidSP (MedLine and EMBASE) databases to identify relevant observational studies. Inclusion criteria were reports of studies in populations permanently living at an altitude of ≥2400 m and in those 18 years or older. Meta-regression was used to estimate the association between average BP and HT and altitude. We identified 3375 articles and inclusion criteria were met for 21 reports, which included a total of 40,854 participants. Random-effects meta-regression estimated that for every 1000 m elevation the average systolic BP (SBP) (95% confidence interval [CI]) increased by 17 mmHg (0.2 to 33.8), p = 0.05 and diastolic BP (DBP) by 9.5 mmHg (0.6 to 18.4), p = 0.04 in participants with Tibetan origin. By contrast, in participants with non-Tibetan origin, average SBP decreased by 5.9 mmHg (-19.1 to 7.3), p = 0.38 and DBP by 4 mmHg (-13 to 5), p = 0.38. The odds ratios (95% CI) for the proportion of participants with HT per 1000 m increment in the altitude were 2.01 (0.37 to 11.02), p = 0.446 and 4.05 (0.07 to 244.69), p = 0.489 for Tibetan and non-Tibetan participants, respectively. Sensitivity analysis excluding two studies with older participants (≥60 years) reversed the direction of this effect in non-Tibetans with odds ratio (95% CI) of 0.10 (0.004 to 2.22) per 1000 m, p = 0.143. Overall, this review suggests weak association between BP and altitude in Tibetan origin populations.

Effects of fenofibrate on cardiovascular events in patients with diabetes, with and without prior cardiovascular disease: The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study.

BACKGROUND: In the FIELD study, comparison of the effect of fenofibrate on cardiovascular disease (CVD) between those with prior CVD and without was a prespecified subgroup analysis. METHODS: The effects of fenofibrate on total CVD events and its components in patients who did (n = 2,131) and did not (n = 7,664) have a history of CVD were computed by Cox proportional hazards modeling and compared by testing for treatment-by-subgroup interaction. The analyses were adjusted for commencement of statins, use of other CVD medications, and baseline covariates. Effects on other CVD end points were explored. RESULTS: Patients with prior CVD were more likely than those without to be male, to be older (by 3.3 years), to have had a history of diabetes for 2 years longer at baseline, and to have diabetic complications, hypertension, and higher rates of use of insulin and CVD medications. Discontinuation of fenofibrate was similar between the subgroups, but more patients with prior CVD than without, and also more placebo than fenofibrate-assigned patients, commenced statin therapy. The borderline difference in the effects of fenofibrate between those who did (hazard ratio [HR] 1.02, 95% CI 0.86-1.20) and did not have prior CVD (HR 0.81, 95% CI 0.70-0.94; heterogeneity P = .045) became nonsignificant after adjustment for baseline covariates and other CVD medications (HR 0.96, 95% CI 0.81-1.14 vs HR 0.78, 95% CI 0.67-0.90) (heterogeneity P = .06). CONCLUSIONS: Our findings do not support treating patients with fenofibrate differently based on any history of CVD, in line with evidence from other trials.

Why are there gaps in our management of those with high cardiovascular risk?

INTRODUCTION: Multiple New Zealand and other international studies have identified gaps in the management of those identified at high risk of a future cardiovascular (CV) event. This study sought to explore the views of health professionals about the barriers and facilitators present within the current primary health care system to the optimal management of those at high CV risk. METHODS: This qualitative study utilised a focus group methodology to examine the barriers and facilitators within primary health care (PHC), and employed a general inductive approach to analyse the text data. FINDINGS: The analysis of text data resulted in the emergence of interrelated themes, underpinned by subthemes. The patient, their circumstances and their characteristics and perceptions provided the first key theme and subthemes. The next key theme was primary health care providers, with subthemes of communication and values and beliefs. The general practice was the third theme and included multiple subthemes: implementation planning and pathway development, time and workload and roles and responsibilities. The final main theme was the health system with the subthemes linking to funding and leadership. CONCLUSION: This study determined the factors that act as barriers and facilitators to the effective management of those at high CV risk within the New Zealand PHC sector. General practice has a pivotal role in preventive health care, but to succeed there needs to be a refocusing of the PHC sector, requiring support from policy makers, District Health Boards and Primary Health Organisations, as well as those working in the sector.

Incidence and predictors of silent myocardial infarction in type 2 diabetes and the effect of fenofibrate: an analysis from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study.

AIMS: To determine the incidence and predictors of, and effects of fenofibrate on silent myocardial infarction (MI) in a large contemporary cohort of patients with type 2 diabetes in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study. METHODS AND RESULTS: Routine electrocardiograms taken throughout the study were assessed by Minnesota-code criteria for the presence of new Q-waves without clinical presentation and analysed with blinding to treatment allocation and clinical outcome. Of all MIs, 36.8% were silent. Being male, older age, longer diabetes duration, prior cardiovascular disease (CVD), neuropathy, higher HbA(1c), albuminuria, high serum creatinine, and insulin use all significantly predicted risk of clinical or silent MI. Fenofibrate reduced MI (clinical or silent) by 19% [hazard ratio (HR) 0.81, 95% confidence interval (CI) 0.69-0.94; P = 0.006], non-fatal clinical MI by 24% (P = 0.01), and silent MI by 16% (P = 0.16). Among those having silent MI, fenofibrate reduced subsequent clinical CVD events by 78% (HR 0.22, 95% CI 0.08-0.65; P = 0.003). CONCLUSION: Silent and clinical MI have similar risk factors and increase the risk of future CVD events. Fenofibrate reduces the risk of a first MI and substantially reduces the risk of further clinical CVD events after silent MI, supporting its use in type 2 diabetes.

The burden of coronary heart disease in Maori: population-based estimates for 2000-02.

OBJECTIVE: To estimate coronary heart disease (CHD) incidence, prevalence, survival, case fatality and mortality for Maori, in order to support service planning and resource allocation. METHODS: Incidence was defined as first occurrence of a major coronary event, i.e. the sum of first CHD hospital admissions and out-of-hospital CHD deaths in people without a hospital admission for CHD in the preceding five years. Data for the years 2000-02 were sourced from the New Zealand Health Information Service and record linkage was carried out using a unique national identifier, the national health index. RESULTS: Compared to the non-Maori population, Maori had both elevated CHD incidence and higher case fatality. Median age at onset of CHD was younger for Maori, reflecting both higher age specific risks and younger population age structure. The lifetable risk of CHD for Maori was estimated at 37% (males) and 34% (females), only moderately higher than the corresponding estimates for the non-Maori population, despite higher Maori CHD incidence. This reflects the offsetting effect of the higher 'other cause' mortality experienced by Maori. Median duration of survival with CHD was similar to that of the non-Maori population for Maori males but longer for Maori females, which is most likely related to the earlier age of onset. CONCLUSIONS: This study has generated consistent estimates of CHD incidence, prevalence, survival, case fatality and mortality for Maori in 2000-02. The inequality identified in CHD incidence calls for a renewed effort in primary prevention. The inequality in CHD case fatality calls for improvement in access for Maori to secondary care services.

Did it fall or was it pushed? The contribution of trends in established risk factors to the decline in premature coronary heart disease mortality in New Zealand.

OBJECTIVE: To estimate the contribution of trends in three risk factors--systolic blood pressure (SBP), total blood cholesterol (TBC) and cigarette smoking--to the decline in premature coronary heart disease (CHD) mortality in New Zealand from 1980-2004. METHOD: Risk factor prevalence data by 10-year age group (35-64 years) and sex was sourced from six national or Auckland regional health surveys and three population censuses (the latter only for smoking). The data were smoothed using two-point moving averages, then further smoothed by fitting quadratic regression equations (SBP and TBC) or splines (smoking). Risk factor/CHD mortality hazard ratios estimated by expert working groups for the World Health Organization Global Burden of Disease Study 2001 were used to translate average annual changes in risk factor prevalences to the corresponding percentage changes in premature CHD mortality. The expected trends in CHD mortality were then compared with the observed trend to estimate the contribution of each risk factor to the decline. FINDINGS: Approximately 80% (73% for males, 87% for females) of the decline in premature CHD mortality from 1980 to 2004 is estimated to have resulted from the joint trends in population SBP and TBC distributions and smoking prevalence. Overall, approximately 42%, 36% and 22% of the joint risk factor effect was contributed by trends in SBP, TBC and smoking respectively. CONCLUSION: Our estimate for the joint risk factor contribution to the CHD mortality decline of 80% exceeds those of two earlier New Zealand studies, but agrees closely with a similar Australian study. This provides an indicator of the scope that still remains for further reduction in CHD mortality through primary and secondary prevention.

Can the incidence and prevalence of coronary heart disease be determined from routinely collected national data? Population-based estimates for New Zealand in 2001--03.

OBJECTIVE: To produce internally consistent estimates of coronary heart disease (CHD) incidence, prevalence, survival and mortality as a decision aid for service planning and resource allocation. METHODS: Incidence was defined as first occurrence of a major coronary event, i.e. the sum of first CHD hospital admissions and out-of-hospital CHD deaths without a hospital admission for CHD in the preceding five years. Mortality was defined as the sum of deaths coded to CHD and deaths coded to related causes but with prior hospitalisation for CHD (in the preceding five years). Data were sourced from the New Zealand Health Information Service and record linkage was carried out using a unique national identifier, the National Health Index (NHI). Given estimates for incidence and mortality, multi-state lifetables were built and estimates for prevalence, survival, lifetable risk, and median age at onset extracted. RESULTS: Estimated prevalence of CHD increased exponentially from around 2% for males and 0.5% for females at age 40-44 to peak at around 18% and 12% respectively at age 85-89. Median age at onset of CHD was 67.5 years for males and 77.5 years for females. Median survival duration was 9.5 years for males and 6.2 years for females. The lifetable risk of CHD was estimated at 35% for males and 28% for females. CONCLUSIONS: This study provides a complete and internally consistent picture of the descriptive epidemiology of CHD for the whole New Zealand population in 2001--03. This information will be useful for planning and funding of coronary prevention, treatment and rehabilitation services.

Survey of clinical echocardiography in New Zealand (SCANZ).

AIMS: In New Zealand, we have neither guidelines nor data regarding the provision of echocardiography and disparities between regional echocardiography are believed to exist. The purpose of this study was to provide a cross-sectional snapshot of clinical use of echocardiography within New Zealand (NZ). METHODS: Over a 1-week period (5/12/2005-11/12/2005) echocardiography laboratories around NZ (tertiary, secondary hospitals, and private practices) sent copies of their echo reports and referral forms (with patient identifiers removed) to a central site. Demographic information, clinical indication, measurements performed, and interpretation were collated, recorded, reviewed, tabulated, and entered into a Microsoft Access database. RESULTS: 1498 echoes were performed, 92% were transthoracic examinations. Adult examinations comprised 83% of the echocardiograms performed: median age was 61.7 years (interquartile range 47.3 to 74.1) and 56% were male. The three most common primary clinical indications were: left ventricular (LV) function (43%), valve disease (14%), and murmur (7.5%). Seventy-five percent reported abnormal findings. There was wide disparity in the population adjusted rates of echoes performed across NZ's district health boards. CONCLUSION: This prospective survey provides a contemporary overview of echocardiography in NZ and highlights the inherent geographical disparity in echocardiography utilisation throughout the country.

Troponin testing for chest pain in primary healthcare: a survey of its use by general practitioners in New Zealand.

AIM: Serum troponin is now the preferred biochemical marker for myocardial infarction. The aim of this study was to investigate general practitioner (GP) knowledge and use of serum troponin testing in primary healthcare. METHODS: We sent a postal survey about troponin testing to all GPs in the Wellington region (n=299) of New Zealand. RESULTS: Of the 299 surveys sent, 216 replies were received (72%). 54% (n=115) of participants were male and 58% (n=113) in full time practice. 92% were using troponin tests (58% monthly). ECG (79%) and serum troponin (78%) were the tests most commonly used to triage patients with chest pain. GPs had excellent knowledge of false negative scenarios (84% correctly identified false negative if test undertaken within 6 hours) and less knowledge of false positive scenarios (39% answered 'Don't know'). CONCLUSIONS: The majority of GPs use serum troponin tests, and have sufficient knowledge of the test for use in a primary care setting. Most GPs use the tests appropriately, although a small proportion of doctors may defer rapid admission to hospital while waiting for the test result (7%) or manage the patient within general practice (5%) in those patients who have chest pain considered 'possibly' due to myocardial infarction.

Troponin testing for chest pain in primary healthcare: a New Zealand audit.

AIM: Serum troponin is a widely used biomarker for the diagnosis of myocardial infarction (MI). The aim of this audit was to document the actual clinical circumstances when serum troponin tests are used to assess chest pain in primary healthcare. METHODS: We undertook an audit of general practitioner (GP) serum troponin requests made to community laboratories in the Wellington region over a 5-week period in 2004. RESULTS: 433 tests were ordered by 201 GPs and 10 tests were positive. We faxed 396 questionnaires to identifiable GPs requesting the tests and received 292 replies (74%). The time between initial onset of symptoms and troponin testing was biphasically distributed with peaks at 7-12 hours and 3.5 days. An ECG was performed in less than 50% of the cases. The GP's estimate of the likelihood of their patient's symptoms being due to MI was strongly influenced by both positive and negative test results. Patients were referred acutely to hospital on less than 5% of occasions. CONCLUSIONS: GPs used troponin testing mostly for late presentations some days after chest pain, to 'rule-out' MI. When used acutely, referral for admission occasionally awaited the troponin test result.