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.

Pharmacological therapy following acute coronary syndromes in patients with atrial fibrillation: how do we balance ischaemic risk with bleeding risk?

BACKGROUND: Dual anti-platelet therapy (DAPT) with aspirin and a P2Y12receptor antagonist is standard of care following an acute coronary syndrome (ACS), as it has been shown to reduce recurrent myocardial infarction (MI) and death. In atrial fibrillation (AF) patients, the use of oral anticoagulants (OACs) is the standard of care as these agents have been shown to reduce the risk of stroke and death. Current guidelines suggest that decisions around antithrombotic therapy should be made by assessing ischaemic and bleeding risks. The aim of this study was to examine current pharmacotherapy of AF inpatients with ACS. METHODS: We prospectively enrolled ACS patients being managed invasively with a medical history of AF, or those in AF during admission ECG, from the pre-existing Wellington ACS registry. Enrolment criteria included pre-treatment on DAPT. Demographics, clinical characteristics, management, in-hospital outcomes and discharge medications were recorded. RESULTS: At discharge, only 11.8% of AF patients were prescribed an OAC and this was not related to risk of stroke (CHA2DS2-VASc score), bleeding (CRUSADE score) or any other clinical characteristics. However, discharge OAC use was associated with whether the patient was treated with an OAC at admission (OR 14, CI 3.4-58, p=0.001). DAPT was the default discharge treatment and occurred in 72% of AF patients. A moderate correlation between stroke risk and bleeding risk was identified (rs=0.68, p=0.01). A group of 44 (47%) patients were identified who were at high risk of stroke (CHA2DS2-VASc ≥2) and low risk of bleeding (CRUSADE score ≤30). CONCLUSION: At discharge we observed a very low rate of OAC prescription. Despite most AF patients being high risk for stroke, DAPT was the preferred treatment option. Our data suggests there is a group of patients with high stroke risk and relatively low bleeding risk, in who OAC use may be appropriate. Developing a guideline to assist clinicians in targeting this group of patients may help improve outcomes in AF patients following MI.

Management of non ST-elevation acute coronary syndrome patients in New Zealand: a longitudinal analysis. Results from the New Zealand Acute Coronary Syndrome national audits of 2002, 2007 and 2012.

AIMS: The first New Zealand Acute Coronary Syndrome (ACS) national audit of 2002 was a collaborative effort between clinicians and nurses, and demonstrated important limitations to Non ST-elevation ACS patient (NSTEACS) care. A momentum for change was created. Subsequent audits in 2007 and 2012 allow assessment over time. METHODS: Over 14 days in May 2002, 2007 and 2012, patients with suspected ACS admitted to a hospital in New Zealand were audited. 'Definite' ACS was determined at discharge, after in-hospital investigations; we reviewed NSTEACS patients. RESULTS: From 2002, more patients underwent assessment of left ventricular function (echocardiogram) and coronary angiography. Evidence-based in-hospital medical treatments and revascularisation have also increased over the decade. CONCLUSIONS: Over a ten-year period, evidence-based care for patients presenting with a NSTEACS event in New Zealand has improved. However, considerable room remains to optimise management, particularly with development of systems of care to facilitate prompt referral and delivery of angiography in these high-risk individuals.

The management of acute coronary syndrome patients across New Zealand in 2012: results of a third comprehensive nationwide audit and observations of current interventional care.

AIMS: To audit all patients admitted to a New Zealand (NZ) Hospital with a suspected or definite acute coronary syndrome (ACS) over a 14-day period, to assess their presentation type and management in hospital and at discharge, with emphasis on time delays for invasive management and revascularisation treatments. METHODS: We updated the established NZ ACS Audit group of 39 hospitals admitting ACS patients across NZ, and enrolled NZ patients in conjunction with the bi-National Australia and NZ ACS 'SNAPSHOT' audit. Comprehensive data was recorded on all patients admitted between 00.00 hours on 14 May 2012 to 24.00 hours on 27 May 2012. Patient management at intervention centres (7 public, 3 private) was compared with non-intervention centres (29 public). RESULTS: There were 1007 patient admissions: STEMI (10%), NSTEMI (26%), UAP (17%), other diagnoses including secondary myonecrosis (18%), chest pain thought unlikely to be ischaemic (29%). Cardiac investigations were used in a minority of patients: chest X-ray (91%), echocardiogram (29%), exercise test (23%), computed tomographic (CT) angiogram (4%) and conventional coronary angiogram (33%). Patients admitted to a non-intervention centre (n=439) were less likely to receive an echocardiogram (25 vs 31%, p<0.05). Non-intervention centre patients with NSTEMI/UAP waiting longer for angiography (3.8 vs 2.1 days p<0.0001), and had a longer length of hospital stay (4.0 vs 3.1 days, p=0.043). For patients with a final diagnosis of a definite ACS (n=531), non-intervention centre patients were significantly less likely to be revascularised with PCI (25% vs 37%, p=0.0019) although CABG surgery numbers were not statistically different (4.1% vs 7.3%, p=0.13). CONCLUSIONS: A collaborative group of clinicians and nurses has performed a third nationwide audit of suspected and definite ACS patients, and shown some gaps in the current service, including limited access to echocardiography and cardiac angiography. In particular we noted significant delays for non-intervention centre patients accessing planned invasive assessment. This study reveals areas of clinical need and emphasises the benefit of ongoing clinical audit, with subsequent feedback and a focus on integrated clinical service delivery, which can improve the care of ACS patients in New Zealand.

ACS patients in New Zealand experience significant delays to access cardiac investigations and revascularisation treatment especially when admitted to non-interventional centres: results of the second comprehensive national audit of ACS patients.

AIM: To compare the management of acute coronary syndrome (ACS) patients presenting to interventional versus non-interventional New Zealand hospitals, with emphasis, on access delays for invasive assessment and revascularisation treatments. METHODS: Using data collected by the New Zealand Cardiac Society ACS Audit Group over 14 days from each hospital in New Zealand (n=39) that admits ACS patients, patient management at intervention centres (6 public, 3 private) was compared with non-intervention centres (30 public). Investigations and revascularisation procedures performed on transferred patients were attributed to the referring centre. RESULTS: From 00.00 hours on 14 May 2007 to 24.00 hours on 27 May 2007, 1003 patients were admitted to a New Zealand hospital with a suspected or definite ACS: ST-segment-elevation myocardial infarction [STEMI] (8%), non-STEMI [NSTEMI] (41%), unstable angina pectoris [UAP] 33%, or another cardiac or medical diagnosis (17%). Patients admitted to a non-intervention centre (n=556) were older (median age 70 vs 66 years, p=0.0097), with similar risk factors, and were more likely to be of Maori (12% vs 5.8%, p<0.0001), and less likely to be of Indian (1.3% vs 4.5%, p=0.0026) or Pacific Island (2.0% vs 4.9%, p=0.012) ethnicity. Patients admitted to a non-intervention centre were less likely to have a chest X-ray performed (84% vs 93 %, p<0.0001), but, as likely to have an echocardiogram, exercise test, or cardiac angiogram for cardiac risk assessment as patients admitted to an intervention centre (n=447). However, only 1 in 2 patients overall underwent either treadmill testing or angiography, and only 1 in 3 underwent angiography. Time delays to access cardiac angiography were evident with only 23% of all patients receiving this test within 48 hours of hospital admission. Patients at non-intervention centres had a significantly longer median wait for cardiac angiography than those admitted to an intervention centre (5.1 vs 2.5 days, p<0.0001). CONCLUSIONS: Patients admitted to a New Zealand hospital with an acute coronary syndrome experience delays in accessing investigations and subsequent revascularisation. Furthermore, inequity exists with delays being significantly longer for patients admitted to a non-intervention centre. A comprehensive national strategy is needed to improve access to optimal cardiac care.

Patients admitted with an acute coronary syndrome (ACS) in New Zealand in 2007: results of a second comprehensive nationwide audit and a comparison with the first audit from 2002.

AIMS: To audit all patients admitted to a New Zealand (NZ) Hospital with an acute coronary syndrome (ACS) over a 14-day period, to assess their number, presentation type and patient management during the hospital admission and at discharge. To compare patient management in 2007 with the 1st NZ Cardiac Society ACS Audit from 2002. METHODS: We updated the established NZ ACS Audit group of 36 hospitals to 39 hospitals now admitting ACS patients across New Zealand. A comprehensive data form was used to record individual patient information for all patients admitted between 00.00 hours on 14 May 2007 to 24.00 hours on 27 May 2007. RESULTS: 1003 patients, 9% more than in 2002 (n=930), were admitted with a suspected or definite ACS: 8% with a ST-segment-elevation myocardial infarction (STEMI), 41% with a non-STEMI (NSTEMI), 33% with unstable angina pectoris (UAP), and 17% with another cardiac or medical condition. In 2007 non-invasive risk stratification following presentation remained similar to 2002 and was suboptimal: exercise treadmill tests (21% vs 20%, p=0.62), echocardiograms (19% vs 20%, p=0.85). An increase in utilisation of coronary angiography was noted (32% vs 21%, p<0.0001). In hospital revascularisation rates remained low in patients with diagnosed ACS (n=828): STEMI (45%), NSTEMI (23%) and UAP (7.3%). In comparison to 2002, changes were noted in revascularisation techniques with percutaneous coronary intervention (PCI) performed in 19% vs 7% (p<0.0001). The use of coronary artery bypass grafting (CABG) remained extremely low: 2.8% vs 3.5% (p=0.20). The use of hospital and discharge medication of proven benefit was also limited. CONCLUSIONS: A collaborative group of clinicians and nurses has performed a second nationwide audit of ACS patients. Despite a small increase in access to cardiac angiography, guideline recommended risk stratification following the index suspected ACS admission with a treadmill test or cardiac angiogram occurred in only 1 in 2 (48%) patients. Furthermore, in patients with a definite ACS, levels of revascularisation are low. (PCI 19%, CABG 2.8%). These aspects of care remain of significant concern and have not substantially changed in 5 years. There remains an urgent need to develop a comprehensive national strategy to improve all aspects of ACS patient management.

Long-term clinical outcomes with the next-generation Resolute Stent System: a report of the two-year follow-up from the RESOLUTE clinical trial.

AIMS: The 12-month results of RESOLUTE were favourable for the new Resolute stent. Two-year safety and efficacy results from RESOLUTE have been evaluated and are now reported. METHODS AND RESULTS: RESOLUTE was a prospective, multicentre, non-randomised, single-arm, controlled trial of the Resolute stent in 139 participants with symptomatic ischaemic heart disease due to single de novo lesions in a native coronary artery. The 2-year rates of MACE (all-cause death, myocardial infarction, emergent cardiac bypass surgery, and target lesion revascularisation [TLR]), death, late stent thrombosis, target vessel revascularisation (TVR), and target vessel failure (TVF) were assessed. Clinical events included two MACE (one TLR; one non-cardiac death) occurring between year one and two resulting in cumulative 2-year TLR, TVR, and TVF rates of 1.4%, 1.4%, and 7.9%, respectively. One possible stent thrombosis event occurred in the first year after stent implantation however no late or very late ARC-defined definite and probable stent thromboses occurred through two years. CONCLUSIONS: The 2-year data from RESOLUTE demonstrated no safety concerns including no late stent thrombosis or loss of effectiveness with the Resolute stent. The finding that few events occurred in year two is encouraging, yet requires verification in a larger population.

Management of patients admitted with an Acute Coronary Syndrome in New Zealand: results of a comprehensive nationwide audit.

AIMS: To audit all patients presenting to a New Zealand hospital with a myocardial infarction or unstable angina (an acute coronary syndrome [ACS]) over a 14-day period, to assess their number, presentation type and patient management during the hospital admission. METHODS: We formed a group of clinicians to lead the local audit process with one representative for each hospital (n=36) that admitted ACS patients. A comprehensive data form was used to record individual patient information for patients admitted between 0000 hours on 13 May 2002 to 2400 hours on 26 May 2002. RESULTS: 930 patients were admitted with a suspected or definite ACS: 11% with a ST-segment-elevation myocardial infarction (STEMI), 31% with a non-STEMI, 36% with unstable angina pectoris (UAP), and 22% with another cardiac or medical diagnosis. Cardiac investigations were limited: echocardiogram (20%), exercise treadmill test (20%), cardiac angiogram (21%). In-hospital revascularisation rates were low for those patients with a definite presentation with an ACS (STEMI, non-STEMI, UAP, n=721). Percutaneous coronary intervention (PCI) rates were 13%, 8%, and 4%--with coronary artery bypass grafting (CABG) rates being 4%, 3%, and 4% respectively. The use of discharge medications of proven benefit was also generally low (n=695): aspirin (82%), clopidogrel (8%), beta-adrenergic blockers (63%), angiotensin converting enzyme (ACE) inhibitors (43%), and statins (55%). CONCLUSIONS: A collaborative group of clinicians has performed a nationwide audit of acute coronary syndrome patients, which has demonstrated low levels of investigations, evidence-based treatments, and revascularisation. There is a need for a comprehensive national strategy--particularly for continuing audit of the treatment of patients presenting with a suspected or definite acute coronary syndrome to a New Zealand hospital.

Acute Coronary Syndrome patients in New Zealand receive less invasive management when admitted to hospitals without invasive facilities.

AIM: To compare differences in the presentation and management of acute coronary syndrome (ACS) patients presenting to interventional versus non-interventional New Zealand hospitals. METHODS: We assessed the data collected by the New Zealand Cardiac Society ACS Audit Group over 14 days from each hospital in New Zealand (n=36) that admits ACS patients. Patient management at intervention centres (5 public, 3 private) was compared with non-intervention centres (28 public). Investigations and revascularisation procedures performed on transferred patients were attributed to the referring centre. RESULTS: From 0000 hours on 13 May 2002 to 2400 hours on 26 May 2002, 930 patients were admitted to a New Zealand hospital with a suspected or definite ACS: ST-segment-elevation myocardial infarction [STEMI] (11%), non-STEMI (31%), unstable angina pectoris [UAP] (36%), or another cardiac or medical diagnosis (22%). Patients admitted to a non-intervention centre (n=612) were the same age (median 70 years) with similar risk factors, but were more likely to be Maori (8.2% vs 3.8%, p=0.0063) and were less likely to have a history of prior cardiac angiography (26% vs 28%, p=0.02) or percutaneous coronary intervention [PCI] (9.6% vs 14%, p=0.03) than patients admitted to an intervention centre (n=318). Patients admitted to a non-intervention centre were more likely to have a chest X-ray (88% vs 81%, p<0.0024), as likely to have an exercise treadmill test (20% vs 22%, p=0.39), but less likely to receive an echocardiogram (17% vs 26%, p<0.0005), a cardiac angiogram (17% vs 30%, p<0.0001), or neither a treadmill nor a cardiac angiogram (68% vs 53%, p<0.0001) for cardiac risk assessment. For patients with a definite ACS presentation (STEMI, Non-STEMI, UAP, n=721), PCI was performed less often for patients admitted to non-intervention centres: 3% vs 14% (p<0.0001), although the rate of coronary artery bypass grafting was similar: 3% vs 5% (p=0.16). CONCLUSION: Patients admitted to a hospital without cardiac interventional facilities receive fewer investigations and less revascularisation than patients admitted to Intervention Centres. Hence patients admitted with an acute coronary syndrome in New Zealand receive inequitable management. A comprehensive National strategy is needed to improve access to optimal cardiac care.