Short, Medium and Long-Term Cause-Specific Mortality Following First-Ever Heart Failure Hospitalisation in New Zealand.

BACKGROUND: Heart failure (HF) is associated with high mortality, but there are limited reports on the underlying cause of death. This study reports short-, medium- and long-term cause-specific mortality following first-ever HF hospitalisation in New Zealand. METHOD: First-ever HF hospitalisations were identified from hospital discharge coding between 2010 and 2013. Mortality outcomes were obtained via anonymised linkage to national datasets. Short (0-30 days), medium (31-364 days), and long-term (1-5 years) mortality rates were identified. Cause of death was identified from death certification coding and classified as cardiovascular and non-cardiovascular. Cox regression analysis was performed to adjust for confounding variables. RESULTS: A cohort of 34,264 individuals with first-ever HF hospitalisation were identified. Mean age was 75.8±13 years and 50.5% were male. A total of 21,637 (63.1%) died within 5 years of hospitalisation; 4,122 (12.0%) within the first 30 days, 6,358 (18.6%) between 31-364 days, and 11,157 (32.6%) between 1 and 5 years. Older age, male gender, Maori ethnicity, higher socioeconomic deprivation and increased comorbidity were independent factors associated with higher all-cause mortality. Cardiovascular causes accounted for 51% of total deaths. Cardiovascular mortality was 6.0%, 9.5%, and 16.7% at 30 days, 31-364 days, and 1-5 years, respectively. The most common causes of non-cardiovascular mortality were neoplasms, chronic respiratory diseases and infections, accounting for 14.6%, 11.0%, and 5.5% of total deaths respectively. Comorbidity was associated with higher non-cardiovascular mortality (hazard ratio [HR] 3.35; 95% confidence interval [CI] 3.16-3.55) but not cardiovascular mortality (HR 0.79; 95% CI 0.72-0.86). CONCLUSIONS: In New Zealand, mortality following first-ever HF hospitalisation is high. Non-cardiovascular death is common and there are ethnic inequities.

Comparison of electrographic changes, clinical features and outcomes in different variants of Takotsubo syndrome.

BACKGROUND: Dysfunction of the left ventricular (LV) apex (apical variant) is the most common form in Takotsubo syndrome (TS). Several less common non-apical variants have been described - mid-ventricular, basal and focal. We hypothesised that the clinical presentation, and electrocardiographic (ECG) findings may vary between apical and non-apical TS. METHODS: We prospectively identified 194 consecutive patients with TS presenting to Middlemore Hospital, Auckland and obtained clinical, echocardiography, coronary angiography, and long-term follow-up data. ECGs at admission and Day 1 were compared. RESULTS: Of 194 patients with TS, 168 (86.6%) had apical TS, and 26 (13.4%) non-apical TS (11 mid-ventricular TS, 5 basal TS, 10 focal TS). Apical TS patients had more significant LV systolic impairment (p = 0.001) and longer length of stay (p = 0.001). The extent of T-wave inversion (TWI) was similar for both groups on admission (p = 0.88). By Day 1 the extent of TWI was greater in apical TS group (median number of leads 5 vs. 1, p = 0.02). The change in QTc interval between admission and Day 1 was greater in apical TS group (29.7 ms vs. 2.77 ms, p < 0.001). Composite in-hospital complication rate was similar for both groups (13.7% vs. 15.4%, p = 0.77). CONCLUSIONS: Compared with non-apical variants, apical TS patients develop more extensive TWI and greater QT prolongation on ECG, and more significant LV systolic impairment, but in-hospital complications were similar. Clinicians should be aware that there is a sub-group of TS patients who have non-apical regional wall motion abnormalities and who don't develop ECG changes typical of the more common apical variant.

Recurrent Takotsubo Syndrome: How Frequent, and How Does It Present?

BACKGROUND: Recurrent Takotsubo syndrome (TS) is not uncommon but experience with TS recurrence is inherently limited by the infrequency of the condition itself and incomplete long-term follow-up. There is limited published data on the clinical features and outcomes of patients with recurrent TS. We aimed to describe the clinical characteristics and outcomes of patients with recurrent TS in a large Auckland cohort. METHOD: The clinical profile, in-hospital, and long-term outcomes were prospectively assessed in consecutive patients with recurrent TS presenting to Auckland's three major hospitals between January 2006 and January 2023. RESULTS: During the study period, 472 TS patients were identified. Of the 467 patients discharged alive after the index event, 45 (9.6%) patients (mean age 62.3±11.0 years), all women, experienced recurrent TS. Median time interval from index event to the first recurrence was 3.14 years (range 27 days to 13.8 years). In 27 (60%) of the 45 patients, the subsequent events involved a stressor (physical triggers, n=8; emotional triggers, n=19). The stressor type differed between the index and recurrent event in 18 (40%) of the 45 patients. Thirteen (28.9%) had a different echocardiographic variant of TS at first recurrence. All patients with recurrent TS were discharged alive. Four patients died late after discharge from the first recurrence, all but one from a non-cardiac cause. CONCLUSIONS: One in 10 patients with TS experience recurrent events. These may occur many years later, and both the stressor type and the echocardiographic variant may be different at the recurrent event.

Cardiogenic Shock Prior to Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction: Outcomes and Predictors of Mortality (ANZACS-QI 73).

BACKGROUND & AIMS: Cardiogenic shock (CS) is a serious complication of acute myocardial infarction (MI) and is associated with significant mortality. We describe a contemporary, real-world cohort of patients with ST-elevation MI (STEMI) and CS, including 30-day mortality and clinically relevant predictors of mortality. METHODS: All patients presenting with STEMI who were treated with percutaneous coronary intervention (PCI) in New Zealand (2016 to 2020) were identified from the Aotearoa New Zealand All Cardiology Services Quality Improvement (ANZACS-QI) registry and stratified based on their Killip class on arrival to the cardiac catheterisation laboratory. Primary outcome was 30-day all-cause mortality. Multivariable analysis was used to identify predictors of mortality prior to PCI and to develop a mortality scoring system. RESULTS: In total, 6,649 patients were identified, including 192 (2.9%) Killip IV (CS) patients. Thirty-day mortality was 47.5% in patients with CS, 14.6% in those with heart failure without shock, and 3% in those without heart failure. Independent predictors of 30-day mortality for patients with CS were: estimated glomerular filtration rate <60 mL/min/1.73m2 (relative risk [RR] 1.89, 95% confidence interval [CI] 1.39-2.58), cardiac arrest (RR 1.54, 95% CI 1.15-2.06), diabetes (RR 1.31, 95% CI 1.01-1.70), female sex (RR 1.32, 95% CI 1.01-1.72), femoral arterial access (RR 1.42, 95% CI 1.06-1.90) and left main stem culprit (RR 2.16, 95% CI 1.65-2.84). A multivariable Shock score was developed which predicts 30-day mortality with good global discrimination (area under the curve 0.79, 95% CI 0.73-0.85). CONCLUSION: In this national cohort, the 30-day mortality for STEMI patients presenting with CS treated with PCI remains high, at nearly 50%. The ANZACS-QI Shock score is a promising tool for mortality risk stratification prior to PCI but requires further validation.

Widening ethnic inequities in heart failure incidence in New Zealand.

OBJECTIVE: Ethnic inequities in heart failure (HF) have been documented in several countries. This study describes New Zealand (NZ) trends in incident HF hospitalisation by ethnicity between 2006 and 2018. METHODS: Incident HF hospitalisations in ≥20-year-old subjects were identified through International Classification of Diseases, 10th Revision-coded national hospitalisation records. Incidence was calculated for different ethnic, sex and age groups and were age standardised. Trends were estimated with joinpoint regression. RESULTS: Of 116 113 incident HF hospitalisations, 12.8% were Maori, 5.7% Pacific people, 3.0% Asians and 78.6% Europeans/others. 64% of Maori and Pacific patients were aged <70 years, compared with 37% of Asian and 19% of European/others. In 2018, incidence rate ratios compared with European/others were 6.0 (95% CI 4.9 to 7.3), 7.5 (95% CI 6.0 to 9.4) and 0.5 (95% CI 0.3 to 0.8) for Maori, Pacific people and Asians aged 20-49 years; 3.7 (95% CI 3.4 to 4.0), 3.6 (95% CI 3.2 to 4.1) and 0.5 (95% CI 0.4 to 0.6) for Maori, Pacific people and Asians aged 50-69 years; and 1.5 (95% CI 1.4 to 1.6), 1.5 (95% CI 1.3 to 1.7) and 0.5 (95% CI 0.5 to 0.6) for Maori, Pacific people and Asians aged ≥70 years. Between 2006 and 2018, ethnicity-specific rates diverged in ≥70-year-old subjects due to a decline in European/others (annual percentage change (APC) -2.0%, 95% CI -2.5% to -1.6%) and Asians (APC -3.3%, 95% CI -4.4% to -2.1%), but rates remained unchanged for Maori and Pacific people. In contrast, regardless of ethnicity, rates either increased or remained unchanged in <70-year-old subjects. CONCLUSION: Ethnic inequities in incident HF hospitalisation have widened in NZ over the past 13 years. Urgent action is required to address the predisposing factors that lead to development of HF in Maori and Pacific people.

Paired risk scores to predict ischaemic and bleeding risk twenty-eight days to one year after an acute coronary syndrome.

OBJECTIVE: The recommended duration of dual anti-platelet therapy (DAPT) following acute coronary syndrome (ACS) varies from 1 month to 1 year depending on the balance of risks of ischaemia and major bleeding. We designed paired ischaemic and major bleeding risk scores to inform this decision. METHODS: New Zealand (NZ) patients with ACS investigated with coronary angiography are recorded in the All NZ ACS Quality Improvement registry and linked to national health datasets. Patients were aged 18-84 years (2012-2020), event free at 28 days postdischarge and without atrial fibrillation. Two 28-day to 1-year postdischarge multivariable risk prediction scores were developed: (1) cardiovascular mortality/rehospitalisation with myocardial infarction or ischaemic stroke (ischaemic score) and (2) bleeding mortality/rehospitalisation with bleeding (bleeding score). FINDINGS: In 27 755 patients, there were 1200 (4.3%) ischaemic and 548 (2.0%) major bleeding events. Both scores were well calibrated with moderate discrimination performance (Harrell's c-statistic 0.75 (95% CI, 0.74 to 0.77) and 0.69 (95% CI, 0.67 to 0 .71), respectively). Applying these scores to the 2020 European Society of Cardiology ACS antithrombotic treatment algorithm, the 31% of the cohort at elevated (>2%) bleeding and ischaemic risk would be considered for an abbreviated DAPT duration. For those at low bleeding risk, but elevated ischaemic risk (37% of the cohort), prolonged DAPT may be appropriate, and for those with low bleeding and ischaemic risk (29% of the cohort) short duration DAPT may be justified. CONCLUSION: We present a pair of ischaemic and bleeding risk scores specifically to assist clinicians and their patients in deciding on DAPT duration beyond the first month post-ACS.

External Validation of a Clinical Score to Differentiate Takotsubo Syndrome From Non-ST-Elevation Myocardial Infarction in Women.

BACKGROUND AND AIMS: Clinical presentation of Takotsubo Syndrome (TS) mimics acute coronary syndrome (ACS). A score to differentiate TS from ACS would be helpful to facilitate appropriate investigation and management. We have previously developed a clinical score (NSTE-Takotsubo Score) to distinguish women with non-ST-segment elevation myocardial infarction (NSTEMI) from TS with non-ST-segment elevation (NSTE-TS). This study sought to assess the diagnostic validity of this score in an external validation cohort. METHODS: The external cohort consisted of women with NSTE-TS (n=110) and NSTEMI (n=113) from two major tertiary hospitals in New Zealand. The five variables in the arithmetic score (range -6 to +5) and their relative weights are: T-wave inversion (TWI) in ≥6 leads (3 points), recent stress (2 points), diabetes mellitus (DM) (-1 point), prior cardiovascular disease (CVD) (-2 points) and presence of ST depression (-3 points). Two clinicians blinded to the diagnoses calculated the score using clinical and electrocardiogram (ECG) data on day 1 post-admission. RESULTS: The NSTE-Takotsubo Score discriminated well between NSTE-TS and NSTEMI. The sensitivity and specificity of a score ≥1 to distinguish NSTE-TS from NSTEMI were 78% and 85%, respectively. The area under the receiver operator curve was 0.78 (95% CI 0.72 to 0.84). CONCLUSION: In an external validation cohort, the NSTE-Takotsubo Score was easy to apply and useful to identify women likely to have NSTE-TS on day 1 post-admission.

A Risk Model to Predict Statin Non-Adherence Following an Acute Coronary Syndrome.

BACKGROUND: Patients at risk of statin non-adherence are often not identified during hospital admission with an acute coronary syndrome (ACS). METHODS: In 19,942 patients hospitalised for ACS, statin dispensing was determined from the national pharmaceutical dispensing database. A risk score for non-adherence was developed from a multivariable Poisson regression model of associations between risk factors and the statin Medication Possession Ratio (MPR) <0.8 6-18 months after hospital discharge. RESULTS: Statin MPR was <0.8 in 4,736 (24%) patients. MPR <0.8 was more likely in patients with a history of cardiovascular disease (CVD) (RR 3.79, CI 95% 3.42-4.20) and those without known CVD (RR 2.25, 95% CI 2.04-2.48) who were not taking a statin on ACS admission, compared to patients with low density lipoprotein (LDL) cholesterol <2 mmol/L who were on a statin. For patients taking a statin on admission, higher LDL was associated with MPR <0.8 (≥3 versus <2 mmol/L, RR 1.96, 95%CI 1.72-2.24). Other independent risk factors for MPR <0.8 were age <45 years, female, disadvantaged ethnic groups, and no coronary revascularisation during the ACS admission. The risk score, which included nine variables, had a C-statistic of 0.67. MPR was <0.8 in 12% of 5,348 patients with a score ≤5 (lowest quartile) and 45% of 5,858 patients with a score ≥11 (highest quartile). CONCLUSION: A risk score generated from routinely collected data predicts statin non-adherence in patients hospitalised with ACS. This may be used to target inpatient and outpatient interventions to improve medication adherence.

What is the Statin Possession Ratio Cut-Off Which Identifies Those at Increased Risk Following Acute Coronary Syndrome (ANZACS-QI 68)?

AIMS: More optimal dispensing of statins is associated with greater cholesterol lowering; however, it is not known whether this translates to improved outcomes following acute coronary syndrome (ACS). The aim of this study was to assess the association between various levels of statin adherence and outcomes following ACS. METHODS: Patients hospitalised with ACS who underwent coronary angiography between 2014-2018 were identified from the All New Zealand ACS Quality Improvement (ANZACS-QI) registry. Medication possession ratio (MPR) was used to assess statin adherence and calculated over 1 year post-discharge using linked pharmaceutical dispensing datasets. Optimal, adequate and suboptimal adherence was defined as an MPR of ≥1.0, 0.8-0.99 and 0-0.79, respectively. A combined outcome of all-cause mortality and rehospitalisation for atherosclerotic disease was identified from 1 year post-discharge through September 2021. Cox proportional hazard models were used to adjust for confounding variables. RESULTS: Of the 30,452 patients, 68% had optimal adherence, 15% adequate adherence and 16% had suboptimal adherence to statins. Mean follow-up was 3.6 years. Those with suboptimal adherence had a higher adjusted risk of the combined outcome compared with those with optimal adherence (HR 1.18, 95% CI 1.11-1.26). There was no significant difference in adjusted outcome between those with optimal and adequate adherence (HR 0.99, 95% CI 0.92-1.06). CONCLUSIONS: Suboptimal statin adherence following ACS is associated with an increased risk of mortality and rehospitalisation. An MPR cut-off of 0.8 seems reasonable to identify those at higher risk of cardiovascular events that could benefit the most from interventions to improve statin adherence and is appropriate as a target for quality improvement programs.

A nurse-led and medically supported outpatient follow-up model following an acute coronary syndrome is as safe and effective as medical follow-up alone (ANZACS-QI 69.

BACKGROUND: At Middlemore Hospital, acute coronary syndrome (ACS) patients are admitted under the care of one of seven cardiologists working on a weekly rotation. Between 2010 and 2018 patients under the care of three of the cardiologists were followed up in a "medical only" post-ACS follow-up clinic model where the cardiologist or registrar saw all patients. Those admitted under the other four cardiologists were seen in a "nurse-led, cardiologist-supported" follow-up model where the majority of patients were seen by a nurse specialist. The study aim was to compare quality of care and outcomes between patients managed under these two follow-up clinic models. METHOD: The ANZACS-QI registry was used to identify all ACS admissions, 2010 to 2018. The ANZACS-QI records for 5296 patients, discharged alive, were anonymously linked with hospital clinic follow-up and national administrative datasets. Time to follow-up, medication dispensation and titration and one-year clinical outcomes were compared for the two follow-up models. RESULTS: Characteristics of patients managed under each model were similar. 4395 patients attended follow up, 74% in the nurse-led model. At one year there were no differences between the medical- and nurse-led cohorts in all-cause mortality (4.6% vs 3.9, p=0.29), rehospitalisations for myocardial infarction (MI) (9.2% vs 8.3%, p=0.31), stroke (1.2% vs 1.4% p=0.71), heart failure (5.7% vs 6.9%, p=0.15) or a combined endpoint of all-cause mortality and/or rehospitalisation for MI/stroke/HF (15.2% vs 14.8%, p=0.71). Patients were seen earlier post-discharge in the nurse-led model, (mean 83 vs 101 days). Medication dispensation one year post-discharge was similar for both models of care. CONCLUSION: The nurse-led model is associated with earlier access to follow-up, was equally as effective at maintaining secondary prevention pharmacotherapy and associated with similar survival and readmission with non-fatal ACS/stroke/heart failure.

Revascularisation and outcomes after acute coronary syndromes in patients with prior coronary artery bypass grafting-ANZACS-QI 67.

AIMS: Coronary angiography in patients with previous coronary artery bypass grafts (CABG) is technically more difficult with increased procedure time, radiation exposure and in-hospital complications. In a contemporary national registry of acute coronary syndrome (ACS) patients undergoing an invasive strategy, we compared the management and outcomes of patients with and without prior CABG. METHODS: The All New Zealand ACS Quality Improvement (ANZACS-QI) registry was used to identify patients admitted to New Zealand public hospitals with an ACS who underwent invasive coronary angiography (2014-2018). Outcomes were ascertained by anonymised linkage to national datasets. RESULTS: Of 26,869 patients, 1,791 (6.7%) had prior CABG and 25,078 (93.3%) had no prior CABG. Prior CABG patients were older (mean age 71 years vs 65 years), more comorbid and less likely to be revascularised than those without CABG (49.8% vs 73.0%). Compared to patients without CABG, at a mean follow-up of 2.1 years, patients with prior CABG had higher all-cause mortality (HR 2.03 (1.80-2.29)), and were more likely to have recurrent myocardial infarction (HR 2.70 (2.40-3.04)), rehospitalisation with congestive cardiac failure (HR 2.36 (2.10-2.66)) and stroke (HR 1.82 (1.41-2.34)). CONCLUSION: In contemporary real-world practice, despite half of the patients with ACS and prior CABG receiving PCI, the outcomes remain poor compared with those without prior CABG.

Guideline-Directed Medical Therapy Before and After Primary Prevention Implantable Cardioverter Defibrillator Implantation in New Zealand (ANZACS-QI 66).

INTRODUCTION: Guidelines recommend angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB)/angiotensin receptor neprilysin inhibitors (ARNI); beta blockers; and mineralocorticoid receptor antagonists (MRA) in patients with symptomatic heart failure and reduced left ventricular ejection fraction before consideration of primary prevention implantable cardioverter defibrillator (ICD). This study aims to investigate dispensing rates of guideline-directed medical therapy (GDMT) before and after primary prevention ICD implantation in New Zealand. METHODS: All patients receiving a primary prevention ICD between 2009 and 2018 were identified using nationally collected data on all public hospital admissions in New Zealand. This was anonymously linked to national pharmaceutical data to obtain medication dispensing. Medications were categorised as low dose (<50% of target dose), 50-99% of target dose or target dose based on international guidelines. RESULTS: Of the 1,698 patients identified, ACEi/ARB/ARNI, beta blockers and MRA were dispensed in 80.2%, 83.6% and 45.4%, respectively, prior to ICD implant. However, ≥50% target doses of each medication class were dispensed in only 51.8%, 51.8% and 34.5%, respectively. Only 15.8% of patients were receiving ≥50% target doses of all three classes of medications. In the 1,666 patients who survived 1 year after ICD implant, the proportions of patients dispensed each class of medications remained largely unchanged. CONCLUSION: Dispensing of GDMT was suboptimal in patients before and after primary prevention ICD implantation in New Zealand, and only a minority received ≥50% target doses of all classes of medication. Interventions are needed to optimise use of these standard evidence-based medications to improve clinical outcomes and avoid unnecessary device implantation.

Prehospital identification of ST-segment elevation myocardial infarction and mortality (ANZACS-QI 61).

BACKGROUND: Early recognition of ST-segment elevation myocardial infarction (STEMI) is needed for timely cardiac monitoring and reperfusion therapy. METHODS: Three anonymously linked New Zealand national datasets (July 2016-November 2018) were used to assess the utilisation of ambulance transport in STEMI cases, the concordance between ambulance initial clinical impressions and hospital STEMI diagnoses, and the association between initial paramedic clinical impressions and 30-day mortality. The St John Ambulance electronic record captures community call-outs and paramedic initial clinical impressions. The national cardiac (ANZACS-QI) registry and national administrative datasets capture all New Zealand public hospital admission diagnoses and mortality data. RESULTS: Of 5465 patients with STEMI, 73% were transported to hospital by ambulance. For these patients, the initial paramedic impression was STEMI in 50.7%, another acute coronary syndrome (ACS) diagnosis in 19.9% and non-ACS diagnosis in 29.7%. Only 37% of the 5465 patients with STEMI were both transported by ambulance and clinically suspected of STEMI by paramedics. Compared with patients with paramedic-'suspected STEMI', 30-day mortality was over threefold higher for patients thought to have a non-ACS condition (10.9% and 34.9%, respectively), but after adjustment for available covariates, this was substantially ameliorated (HR 1.48, 95% CI 1.22 to 1.80). CONCLUSIONS: In this national data linkage study, only 4 out of every 10 patients with STEMI were both transported by ambulance and had STEMI suspected by paramedics. Although patients with STEMI not suspected of an ACS diagnosis by paramedics had the highest mortality rate, this is largely explained by the different risk profile of these patients.

Ten-year trends in cardiac implantable electronic devices in New Zealand: a national data linkage study (ANZACS-QI 51).

BACKGROUND: Implant rates for cardiac implantable electronic devices (CIED), including permanent pacemakers (PPM) and implantable cardioverter defibrillators (ICD), have increased globally in recent decades. AIMS: This is the first national study providing a contemporary analysis of national CIED implant trends by sex-specific age groups over an extended period. METHODS: Patient characteristics and device type were identified for 10 years (2009-2018) using procedure coding in the National Minimum Datasets, which collects all New Zealand (NZ) public hospital admissions. CIED implant rates represent implants/million population. RESULTS: New PPM implant rates increased by 4.6%/year (P < 0.001), increasing in all age groups except patients <40 years. Males received 60.1% of new PPM implants, with higher implant rates across all age groups compared with females. The annual increase in age-standardised implant rates was similar for males and females (3.4% vs 3.0%; P = 0.4). By 2018 the overall PPM implant rate was 538/million. New ICD implant rates increased by 4.2%/year (P < 0.001), increasing in all age groups except patients <40 and ≥ 80 years. Males received 78.1% of new ICD implants, with higher implant rates across all age groups compared to females. The annual increase in age-standardised implant rates was higher in males compared with females (3.5% vs 0.7%; P < 0.001). By 2018 the overall ICD implant rate was 144/million. CONCLUSION: CIED implant rates have increased steadily in NZ over the past decade but remain low compared with international benchmarks. Males had substantially higher CIED implant rates compared with females, with a growing gender disparity in ICD implant rates.

Regional variation in cardiac implantable electronic device implants trends in New Zealand over the past decade (ANZACS-QI 54).

BACKGROUND: Permanent pacemaker (PPM) and implantable cardioverter defibrillator (ICD) implant rates have increased in New Zealand over the past decade. AIMS: To provide a contemporary analysis of regional variation in implant rates. METHODS: New PPM and ICD implants in patients aged ≥15 years were identified for 10 years (2009-2018) using procedure coding in the National Minimum Datasets, which collects all New Zealand public hospital admissions. Age-standardised new implant rates per million adult population were calculated for each of the four regions (Northern, Midland, Central and Southern) and the 20 district health boards (DHB) across those regions. Trend analysis was performed using joinpoint regression. RESULTS: New PPM implant rates increased nationally by 3.4%/year (P < 0.001). The Northern region had the highest new PPM implant rate, increasing by 4.5%/year (P < 0.001). Excluding DHB with <50 000 people, the new PPM implant rate for 2017/2018 was highest in Counties Manukau DHB (854.3/million; 95% confidence interval (CI): 774.9-933.6/million) and lowest in Canterbury DHB (488.6/million; 95% CI: 438.1-539.0/million). New ICD implant rates increased nationally by 3.0%/year (P = 0.002). The Midland region had the highest new ICD implant rate, increasing by 3.8%/year (P = 0.013). Excluding DHB with <50 000 people, the new ICD implant rate for 2017-2018 was highest in the Bay of Plenty DHB (228.5/million; 95% CI: 180.4-276.6/million) and lowest in Canterbury DHB (90.2/million; 95% CI: 69.9-110.4/million). CONCLUSION: There was significant variation in PPM and ICD implant rates across regions and DHB, suggesting potential inequity in patient access across New Zealand.

Contrasting trends in heart failure incidence in younger and older New Zealanders, 2006-2018.

OBJECTIVE: Studies indicate that age-standardised heart failure (HF) incidence has been decreasing internationally; however, contrasting trends in different age groups have been reported, with rates increasing in younger people and decreasing in the elderly. We aimed to describe age-specific trends in HF incidence in New Zealand (NZ). METHODS: In this nationwide data linkage study, we used routinely collected hospitalisation data to identify incident HF hospitalisations in NZ residents aged ≥20 years between 2006 and 2018. Age-specific and age-standardised incidence rates were calculated for each calendar year. Joinpoint regression was used to compare incidence trends. RESULTS: 116 113 incident HF hospitalisations were identified over the 13-year study period. Between 2006 and 2013, age-standardised incidence decreased from 403 to 323 per 100 000 (annual percentage change (APC) -2.6%, 95% CI -3.6 to -1.6%). This reduction then plateaued between 2013 and 2018 (APC 0.8%, 95% CI -0.8 to 2.5%). Between 2006 and 2018, rates in individuals aged 20-49 years old increased by 1.5% per year (95% CI 0.3 to 2.7%) and decreased in those aged ≥80 years old by 1.2% per year (95% CI -1.7 to -0.7%). Rates in individuals aged 50-79 years old initially declined from 2006 to 2013, and then remained stable or increased from 2013 to 2018. The proportion of HF hospitalisations associated with ischaemic heart disease decreased from 35.1% in 2006 to 28.0% in 2018. CONCLUSION: HF remains an important problem in NZ. The decline in overall incidence has plateaued since 2013 due to increasing rates of HF in younger age groups despite an ongoing decline in the elderly.

Type of Stressor and Medium-Term Outcomes After Takotsubo Syndrome: What Becomes of the Broken Hearted? (ANZACS-QI 59).

BACKGROUND: Takotsubo syndrome (TS) is often triggered by an acute physical or emotional stressor. We hypothesised that medium-term prognosis may be better for TS patients with an associated emotional stressor than for those with an acute physical illness. METHODS: We identified consecutive TS patients presenting in New Zealand (2006-2018). The clinical presentation and outcomes of TS patients according to types of stressor (physical, emotional or no stressor) were assessed. Post-discharge survival after TS was compared with age- and gender-matched patients after myocardial infarction (MI) and people in the community without known cardiovascular disease (CVD). RESULTS: Of 632 TS patients (95.9% women, mean age 65.0±11.1 years), 27.4% had an associated acute physical stressor, 46.4% an emotional stressor and 26.2% no evident stressor. In-hospital mortality was similar for each group (1.7%, 1.2%, 0.3% respectively, p=0.29). In a median 4.4 years post-discharge there were 54 deaths (53 non-cardiac). Compared with patients without known CVD, TS patients with physical stress and those with MI were less likely to survive (HR 4.46, 95%CI 3.10-6.42; HR 4.23, 95%CI 3.81-4.70 respectively) but survival for TS patients associated with emotional stress or no stressor was similar (HR 1.11, 95%CI 0.66-1.85; HR 1.08, 95%CI 0.54-2.18, respectively). Recurrence was similar among the three groups (p=0.14). CONCLUSION: Takotsubo syndrome associated with physical stressor has a post-discharge mortality risk as high as after MI. In contrast, prognosis for TS triggered by an emotional stressor is excellent, and similar to that of those without known CVD.

How common are non-acute coronary syndrome (ACS) diagnoses in patients with suspected ACS investigated with coronary angiography in New Zealand? (ANZACS-QI 58).

BACKGROUND AND AIMS: The last two decades in New Zealand have seen increased availability of primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) and early invasive coronary angiography (ICA) for other high-risk acute coronary syndrome (ACS) patients. One metric to assess the clinical appropriateness of these invasive strategies is to examine the false-positive rate for the investigation (ie, the rate of non-ACS diagnoses). METHODS: All patients presenting to New Zealand public hospitals with suspected ACS who underwent ICA between 2015 and 2019 were recorded prospectively in the All New Zealand Acute Coronary Syndrome Quality Improvement registry. The cohort was divided according to clinical impression at presentation: (1) suspected STEMI <24h and (2) other suspected ACS. The final discharge diagnosis for each patient were obtained from the registry. RESULTS: There were 6,059 (20%) patients with suspected STEMI <24h and 24,258 (80%) with other suspected ACS. Of the suspected STEMIs <24h, 90.6% had a final diagnosis of STEMI, 3.5% non-ST segment elevation ACS (NSTEACS) and only 5.9% had a non-ACS diagnosis. Of those with other suspected ACS, 80.7% had a final ACS diagnosis. Across all New Zealand district health boards (DHBs), the proportion of non-ACS diagnoses was similar for suspected STEMI presentations. However, for other suspected ACS, the proportions were higher in DHBs with rapid access to coronary interventional facilities than in those without (17.6% vs 7.0%, p<0.001). CONCLUSIONS: False-positive catheter laboratory activations for suspected STEMI patients are low across New Zealand. The differences in the proportion of non-ACS diagnoses according to DHB interventional capability for other suspected ACS requires further investigation.

Obesity and All Cause Mortality Following Acute Coronary Syndrome (ANZACS-QI 53).

BACKGROUND: Some studies have suggested a lower mortality in obese subjects with cardiovascular disease. The aim of this study was to evaluate the relationship between body mass index (BMI) and outcomes in patients with acute coronary syndrome (ACS). METHODS: The study included 13,742 patients undergoing coronary angiography for ACS between 2012 and 2016 from the All New Zealand Acute Coronary Syndrome-Quality Improvement (ANZACS-QI) registry. Patients were categorised by BMI (kg/m2) as: underweight <18.5, normal 18.5 to <25, overweight 25 to <30, mildly obese 30 to <35, moderately obese 35 to <40, and severely obese ≥40. The primary endpoint of the study was all cause mortality with secondary endpoints of cardiovascular disease (CVD) and non-CVD mortality within 4 years of discharge. RESULTS: Unadjusted all cause mortality was lowest in the mildly obese but no different to normal or overweight after adjustment for multiple confounders. Adjusted all cause mortality was higher in the moderately (hazard ratio [HR] 1.39, 95% CI: 1.10-1.75) and severely obese (2.06, 95% CI: 1.57-2.70) compared to the mildly obese. Non-CVD mortality (HR 1.58, 95% CI: 1.12-2.23) was the major contributor to higher all cause mortality in moderately obese patients. Both CVD mortality (HR 2.36, 95% CI: 1.67-3.32) and non-CVD mortality (HR 1.67, 95% CI: 1.07-2.61) contributed to higher all cause mortality in the severely obese. CONCLUSIONS: Moderate and severe obesity is associated with worse survival post ACS influenced by higher non-CVD mortality in moderate/severe obesity and higher CVD mortality in severe obesity.

Demographic differences in the initiation and maintenance of statins in the first year post ACS in New Zealand: a data linkage study (ANZACS-QI 57).

INTRODUCTION: Prior New Zealand studies suggest that only approximately two-thirds of patients who present with an acute coronary syndrome (ACS) are adequately maintained on a statin post-discharge. This could be due to low initiation and/or poor longer-term adherence. AIM: To identify the pattern and adequacy of statin maintenance following ACS from initial prescription to one-year post-discharge. METHODS: All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry data for consecutive New Zealand residents (2015-2017) who were hospitalised with ACS and managed with coronary angiography were anonymously linked to national datasets to derive a medication possession ratio (MPR) to assess medication maintenance. An MPR ≥0.8 is considered adequate maintenance and ≥1 is considered optimal. RESULTS: Of the 16,557 patients who survived their ACS, 15,431 (93.2%) were prescribed a statin at discharge and 89.8% were dispensed a statin within three months. 79.8% (13,219/16,557) of patients had an MPR ≥0.8 during the first year, but only 61.0% (10,096/16,557) had optimal dispensing over this period. Regression analysis identified the independent predictors of sub-optimal maintenance over the first year as age <45 years, no prior statin and Maori and Pacific ethnicity. CONCLUSION: After ACS discharge, the gap between prescribing and dispensing rates was small with only minor demographic variation. One in ten patients were not initially dispensed a statin. Although eight in ten patients were adequately maintained, only six in ten had optimal maintenance with clear ethnic and age differences, which may reflect more general disparities in healthcare.