Prognostic interactions between statins and in-hospital revascularisation on the outcome of acute coronary syndrome.

AIM: To examine if the prognostic benefit of in-hospital revascularisation on survival among patients with acute coronary syndrome (ACS) was influenced by the use of statins at the initial hospital discharge. METHODS: All ACS survivors discharged from Dunedin and Invercargill coronary care units between the years 2000 and 2002 were included. RESULTS: Of the 1057 hospital survivors with ACS (age 64.9+/-12.6 years, 63% male), 481 (45.5%) had in-hospital revascularisation (CABG in 123 patients and PCI in 377, including 19 with both procedures). Statins were prescribed at discharge in 47% of patients without and 73% of patients with revascularisation. Revascularisation was associated with lower mortality up to 5 years of follow-up (hazard ratio 0.29, 95% confidence interval 0.20-0.42). After adjusting for baseline differences and the use of statins, the hazard ratio was 0.39 (95% confidence interval 0.27-0.58). While the use of statins was a predictor for long-term survival (p<0.001), no significant interaction was found between the use of statins and in-hospital revascularisation in predicting survival. CONCLUSION: Both in-hospital revascularisation and the use of statins at hospital discharge independently improved outcome over a follow-up period of 2-5 years. There was no prognostic interaction detected between these two beneficial therapies.

The use of different evidence-based medications and 5-year survival after an acute coronary syndrome: an observational study.

BACKGROUND: The use of different evidence-based medications (EBM medications) in-hospital survivors of acute coronary syndrome (ACS) may be associated with different long-term survival. METHODS: In 1025 consecutive survivors receiving aspirin, we analysed the associations between statins (prescribed in 59.5%), beta-blockers (76.8%) and ACE-inhibitors/angiotensin receptor blockers (54.1%) and all-cause mortality up to 5 years as the endpoint, adjusting to the baseline risk using the GRACE hospital discharge risk score. RESULTS: The use of beta-blockers and statins was associated with reduced mortality. Significant reduction was observed from 6 months for statins, and from 2 years for beta-blockers. Results were similar after further adjustment for concomitant use of other EBM medications. When interaction terms between different EBM medications were tested, the only significant interaction was between statins and beta-blockers (P=0.010). This interaction persisted (P=0.018) when the 1025 patients were sub-grouped regardless of the use of ACE-inhibitors/angiotensin receptor blockers. The use of beta-blockers was associated with reduced mortality for patients not discharged on statins (hazard ratio of 0.46, 95% C.I. 0.30-0.69), but this was not true for patients discharged on statins (hazard ratio of 1.19, 95% C.I. 0.62-2.30). CONCLUSIONS: Different EBM medications after an ACS may be associated with different long-term survival and statins may be more important than others in patients already taking aspirin.

Relation between blood pressure at hospital discharge after an acute coronary syndrome and long-term survival.

There are limited data on the relation between blood pressure (BP) at hospital discharge and long-term outcomes after acute coronary syndromes. In this study, of 1,053 consecutive survivors of acute coronary syndromes (mean age 64.9 +/- 12.6 years, 63% men), patients with lower diastolic BP were older, had higher Global Registry of Acute Coronary Events (GRACE) discharge risk scores, and had higher 2-year mortality. When modeled with GRACE score in predicting survival, only diastolic BP but not pulse pressure or systolic BP was significant in predicting survival up to 5 years. When cardioprotective medications and in-hospital revascularization were incorporated in the model, the independent predictors for survival included lower GRACE score, higher diastolic BP, and the use of beta blockers and statins. The square term of diastolic BP was also significant, indicating a J-shaped relation. Adding diastolic BP to GRACE score tended to improve the C index for predicting 6-, 12-, and 24-month survival (p = 0.14, 0.07, and 0.09, respectively). In conclusion, this study established the independent prognostic relation between diastolic BP and survival after acute coronary syndromes.

Survival over 5 years in the initial hospital survivors with acute coronary syndrome: a comparison between a community hospital and a tertiary hospital in New Zealand.

AIMS: To compare the outcome of hospital survivors with acute coronary syndrome (ACS) discharged from a community hospital (Invercargill hospital) versus from a tertiary teaching (Dunedin) hospital followed for up to 5 years. METHODS: All ACS survivors discharged from Dunedin and Invercargill coronary care units between the years 2000-2002 were included. We previously found higher 1-year mortality for Invercargill patients but the explanation was unclear. RESULTS: Of the 844 patients admitted to Dunedin and 299 admitted to Invercargill hospital, 1057 survived the index ACS episode and formed the cohort for the current study. At 2 years, the mortality of these initial survivors was 8.5% higher for Invercargill patients (18.4% vs 9.9%, p<0.001). Over up to 5 years of follow-up, comparing Invercargill patients to Dunedin patients, the unadjusted hazard ratio for mortality was 1.26 (95%CI: 0.90-1.75). After adjusting to the hospital discharge GRACE score (119+/-40 for Dunedin patients and 130+/-40 for Invercargill patients, p=0.001), this dropped to 1.12 (95%CI: 0.80-1.57). After further adjusting to the discharge medications aspirin (97% vs 98%) and ACE-inhibitors (53% vs 49%), this was 1.14 (95%CI 0.81-1.59). After further adjusting to the use of beta-blockers (78% vs 71%), this was 1.07 (95%CI: 0.76-1.50). After final adjustment for the use of statins (65% vs 42%), this was 0.96 (95%CI: 0.68-1.36). CONCLUSION: Patients discharged from Invercargill hospital fare worse over the first 2-years and tended to fare worse over the first 5-years. This was due both to their higher baseline risk at discharge and the under-use of statins. Of note, PHARMAC rules for statins only changed around the end of the study period allowing more liberal use of statins.

Global Registry of Acute Coronary Events (GRACE) hospital discharge risk score accurately predicts long-term mortality post acute coronary syndrome.

BACKGROUND: The Global Registry of Acute Coronary Events (GRACE) hospital discharge risk score (GRACE score) developed from a multinational registry involving all subsets of acute coronary syndrome (ACS) predicted 6-month survival. There is currently no validated risk model to predict mortality beyond 6 months. METHODS AND RESULTS: Of the 1143 consecutive patients with ACS admitted to coronary care unit in 2000 to 2002 (mean age, 64.9 +/- 12.6 years), 39% had ST-elevation myocardial infarction, 39% had non-ST-elevation infarction, and 22% had unstable angina. The mortality was 7.5% during index admission, 12.1% at 6 months, 14.8% at 1 year, 18.7% at 2 years, 25.0% at 3 years, and 39.2% at 4 years. The GRACE hospital discharge risk score calculated for 1057 hospital survivors discriminated survival from death at 6 months (C index, 0.81), 1 year (C index, 0.82), 2 years (C index, 0.81), 3 years (C index, 0.81), and 4 years (C index, 0.80). The risk score worked for all 3 subsets of ACS at all time points, with C index >0.75 in all analyses. A separate multivariable mortality model for these 1057 patients over the 4-years follow-up period identified 10 independent predictors of mortality. Seven were in the GRACE risk model (age, history of ischemic heart disease, heart failure, increased heart rate on admission, serum creatinine level, evidence of myonecrosis, not receiving in-hospital percutaneous coronary intervention). CONCLUSIONS: The GRACE postdischarge risk score contains relevant prognostic factors and accurately discriminate survivors from nonsurvivors over the longer term (up to 4 years) in all subsets of ACS patients.

Community hospital versus tertiary hospital comparison in the treatment and outcome of patients with acute coronary syndrome: a New Zealand experience.

AIMS: To compare the baseline characteristics, use of evidence-based medications, rate of revascularisation, and mortality of acute coronary syndrome (ACS) patients managed in a community hospital (Invercargill Hospital) without, and a tertiary teaching hospital (Dunedin Hospital) with, catheterisation and an interventional facility. METHODS: All patients with ACS admitted into Dunedin and Invercargill coronary care units (CCUs) between 2000-2002 inclusive were included in the study. RESULTS: Major baseline characteristics including age, history of diabetes, heart rate and systolic blood pressure at presentation were not different between the two centres. However, the proportions of patients with ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI) were higher in Invercargill CCU. More Invercargill patients experienced a cardiac arrest or clinical heart failure on hospital arrival. The use of evidence-based medications, coronary angiography (65.5% vs 20.2%, p<0.00001), and revascularisation (46.7% vs 16.4%, p<0.0005) were significantly higher in patients admitted into Dunedin CCU. The in-hospital, 6-months, and 1-year mortality was significantly lower (absolute mortality difference of 4.3%, 9.5%, and 10.0%, p<0.05, respectively) for ACS patients admitted into Dunedin CCU. Using multivariable logistic regression incorporating baseline characteristics, use of evidence-based medicine on arrival and transfer for angiography, the 1-year adjusted hazard ratio 3.02 (95%CI 1.60-5.71) remains significantly higher for patients in Invercargill Hospital. CONCLUSION: There was a disparity in ACS outcome between community and tertiary hospitals in New Zealand. The use of evidence-based medicine in all ACS patients should be encouraged even if revascularisation was not offered.

Clinical outcome of older patients with acute coronary syndrome over the last three decades.

OBJECTIVE: To Evaluate the clinical outcome of patients with acute coronary syndrome (ACS) in the Coronary Care Unit (CCU) over three decades in Dunedin, New Zealand. DESIGN: Registry study. SETTING AND PATIENTS: all consecutive patients (n = 3,013) with ACS admitted to the CCU from 1979 to 1981 (n = 966) and from 1989 to 1991 (n = 1470) were included prospectively. Data on ACS patients managed in the CCU in 2001-2002 (n = 577) were obtained via medical chart review. RESULTS: There was a rising proportion of older (> or = 75 years of age) patients with ACS (3.8% in 1979-1981, 15.2% in 1989-1991 and 25.6% in 2001-2002, P < 0.0005). However, we observed a progressive reduction of in-hospital mortality for ACS (10.7, 7.3 and 5.0%, P < 0.005) and for ST-elevation myocardial infarction (STEMI) (18.4, 16.1 and 6.6%, P < 0.005). The progressive fall in mortality rate was also observed amongst older patients, both for ACS (27, 19.2 and 11.5%, P = 0.011) and for STEMI (34.8, 30.9 and 15.4%, P < 0.005). Of concern, only 10% of patients presented within 1 h of symptom onset and 50% within 5 h, and this has not changed over three decades. The variables associated with < 5 h from symptom onset to presentation were men [odds ratio (OR) 1.25, 95% confidence interval (CI) 1.10-1.42, P = 0.001], a history of ischaemic heart disease (OR 1.25, 95% CI 1.09-1.43, P = 0.002) and STEMI (OR 1.41, 95% CI 1.18-1.67, P < 0.0001). Advanced age was not a predictor for late presentation. CONCLUSIONS: Over the past three decades, more old patients were treated in the CCU. However, there was a decline in hospital mortality, particularly for STEMI. Further efforts are required to decrease the time to presentation.