Assessing the quality of cardiac rehabilitation programs by measuring adherence to the Australian quality indicators.

BACKGROUND: Every year, over 65,000 Australians experience an acute coronary syndrome (ACS) and around one-third occur in people with prior coronary heart disease. Cardiac rehabilitation (CR) aims to prevent a repeat ACS by supporting patients' return to an active and fulfilling lifestyle. CR programs are efficacious, but audits of clinical practice show variability of program delivery, which may compromise patient outcomes. Core components, quality indicators and accreditation of programs have been introduced internationally to increase program standardisation. With Australian quality indicators (QIs) for cardiac rehabilitation recently introduced, we aimed to conduct a survey in one state of Australia to assess the extent to which programs adhere to the measurement of QIs comparing country, metropolitan, telephone and face to face programs. METHODS: A cross- sectional survey design with face validity testing was used to formulate questions to evaluate cardiac rehabilitation program and personnel characteristics and QI adherence. Between October 2020- December 2021, 23 cardiac rehabilitation programs across country and metropolitan areas were invited to participate. Quality improvement was defined as adherence to the Australian Quality Indicators, and we developed an objective score to calculate program performance categorised by quartiles. Significance of CR completion and time to enrolment between program type (telephone versus face to face) and location (country versus metropolitan were compared using Pearson's Chi-square and Mann-Whitney U tests. RESULTS: Among the 23 CR programs, 15 were country and 8 metropolitan-based and 22 were face to face and 1 telephone-based. Median wait time from discharge was 27.0 days, (interquartile range 19.3-46.0) across all programs and country completions of enrolled were 76.9% versus metropolitan 56.5%, p < 0.001 and telephone versus face to face 92.9% versus 59.6% p < 0.001. Pre-program QI adherence was higher than post program for depression, medication adherence, health-related quality of life and comprehensive re-assessment. Seventy four percent of programs were ranked at a medium level of performance (mean score: 11.4/16, SD ± 0.79). CONCLUSIONS: A survey of 23 cardiac rehabilitation programs, showed variability in adherence to measurement of the Australian Cardiovascular and Rehabilitation Association and Australian Heart Foundation Cardiac Rehabilitation Quality Indicators. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ANZCTR), ACTRN12621000222842 , registered 03/03/2021.

Comparison of the management and in-hospital outcomes of acute coronary syndrome patients in Australia and New Zealand: results from the binational SNAPSHOT acute coronary syndrome 2012 audit.

BACKGROUND/AIMS: We aimed to assess differences in patient management, and outcomes, of Australian and New Zealand patients admitted with a suspected or confirmed acute coronary syndrome (ACS). METHODS: We used comprehensive data from the binational Australia and New Zealand ACS 'SNAPSHOT' audit, acquired on individual patients admitted between 00.00 h on 14 May 2012 to 24.00 h on 27 May 2012. RESULTS: There were 4387 patient admissions, 3381 (77%) in Australia and 1006 (23%) in New Zealand; Australian patients were slightly younger (67 vs 69 years, P = 0.0044). Of the 2356 patients with confirmed ACS, Australian patients were at a lower cardiovascular risk with a lower median Global Registry Acute Coronary Events score (147 vs 154 P = 0.0008), but as likely to receive an invasive coronary angiogram (58% vs 54%, P = 0.082), or revascularisation with percutaneous coronary intervention (32% vs 31%, P = 0.92) or coronary artery bypass graft surgery (7.0% vs 5.6%, P = 0.32). Of the 1937 non-segment elevation myocardial infarction/unstable angina pectoris (NSTEMI/UAP) patients, Australian patients had a shorter time to angiography (46 h vs 67 h, P < 0.0001). However, at discharge, Australian NSTEMI/UAP survivors were less likely to receive aspirin (84% vs 89%, P = 0.0079, a second anti-platelet agent (57% vs 63%, P = 0.050) or a beta blocker (67% vs 77%, P = 0.0002). In-hospital death rates were not different (2.7% vs 3.2%, P = 0.55) between Australia and New Zealand. CONCLUSIONS: Overall more similarities were seen, than differences, in the management of suspected or confirmed ACS patients between Australia and New Zealand. However, in several management areas, both countries could improve the service delivery to this high-risk patient group.

Patterns of inflammatory activation associated with precipitants of acute coronary syndromes: a case-crossover study.

AIMS: We sought to assess a broad array of possible precipitants of acute coronary syndromes (ACS) and evaluate their association with detectable inflammatory activation. METHODS AND RESULTS: Within a case-crossover design, using a standardised questionnaire, interviews among 348 ST-elevation myocardial infarction (44%) or high-risk non-ST-elevation ACS patients (56%), explored potential precipitants, including: infection (INF)-temperature >38°C and/or respiratory tract, urinary or skin infection; inflammation (INFL)-exacerbation of inflammatory conditions; exercise (EX)-moderate to heavy exercise; fast food (FF)-consumption of a meal purchased from a fast food company. Risk and control periods were: weekly over 8 weeks for INF and INFL; 24 hourly over 4 days for FF and 4 hourly over 48 h for EX. C-reactive protein (CRP) levels were assessed at admission. These precipitants were identified in 203/348 (58.3%) patients. An increased temporal risk was observed for: INF (0-7 days vs 7-8 weeks odds ratio (OR): 7.5, confidence interval (CI): 1.7-67.6, P = 0.002); INFL (0-7 days vs 7-8 weeks OR: 14.0, CI: 2.13-591.9, P = 0.001); EX (0-4 h vs 24-28 h OR: 2.2, CI: 1.3-3.5, P = 0.001) and FF (0-24 h vs 72-96 h OR: 5.67, CI: 1.6-30.2, P = 0.003). CRP levels were significantly elevated among patients reporting infective and inflammatory potential precipitants, but not among those reporting fast food consumption and unaccustomed moderate-heavy exercise. CONCLUSION: Infection, inflammatory conditions, moderate-heavy exercise and potentially fast food consumption appear to precipitate high-risk ACS. Increased inflammation as measured by CRP was not consistently detected despite the identification of an ACS precipitant. Strategies that target improved overall health may also lead to fewer ACS events through a reduction in triggers.

An invasive management strategy is associated with improved outcomes in high-risk acute coronary syndromes in patients with chronic kidney disease.

INTRODUCTION: Chronic kidney disease (CKD) is associated with poor outcomes after acute coronary syndromes, yet selection for invasive investigation and management is low. METHODS: Patients presenting with ST segment elevation myocardial infarction (STEMI) or intermediate- to high-risk non-ST segment elevation acute coronary syndrome (NSTEACS) (n=2597) were stratified into groups based on kidney function, defined as normal (glomerular filtration rate (GFR)≥60mL/min/1.73m(2) ), moderate CKD (GFR 30-59mL/min/1.73m(2) ) and severe CKD (GFR <30mL/min/1.73m(2)). Based on these stratums of kidney function, incidence and outcome measures were obtained for: rates of angiography and revascularization; 6-month mortality; and the incidence and outcome of in-hospital acute kidney impairment (AKI). RESULTS: Patients with CKD were less likely to be offered coronary angiography after STEMI/NSTEACS (P<0.001); however, after selection, revascularization rates were similar (percutaneous coronary intervention (P=0.8); surgery (P=0.4)). Six-month mortality rates increased with CKD (GFR≥60, 2.8%; GFR 30-59, 9.9%; GFR<30, 16.5%, P≤0.001), as well as the combined efficacy/safety end-point (GFR≥60, 9.4%; GFR 30-59, 20.2%; GFR<30, 27.1%, P≤0.001). Six-month mortality was lower in patients who had received prior angiography (GFR≥60, 1.5% vs 3.6%, P=0.001; GFR 30-59, 5.1% vs 12.7%, P<0.001; GFR<30, 7.3% vs 18.5%, P=0.094). Risk of AKI increased with CKD (GFR≥60, 0.7%; GFR 30-59, 3.4%; GFR<30, 6.8%, P≤0.001), and was associated with high 6-month mortality (35.6% vs 4.1%, P<0.001). CONCLUSIONS: In patients with CKD after STEMI/NSTEACS, 6-month mortality and morbidity is high, selection for angiography is lower, yet angiography is associated with a reduced long-term mortality, and with comparable revascularization rates to those without CKD. In-hospital AKI is more common in CKD and predicts a high 6-month mortality.

Clinical effectiveness in everyday practice: improving outcomes for all patients through a national acute coronary syndrome data collaborative.

The management of acute coronary syndromes (ACS) has an extensive and impressive evidence-base with which to guide clinical practice. Despite this, translation to the clinical environment has proved to be challenging and incomplete and can be attributed to patient, provider and system factors. Causes of suboptimal guideline adherence relate to diverse issues, including patient complexity, barriers in knowledge translation of guideline recommendations and a limited capacity within health services. Addressing these factors may enable more effective guideline implementation. In Australia, the infrastructure for clinical data management is fragmented, uncoordinated and often administratively driven, compromising access to important information, which might improve clinical effectiveness. An integrated approach is required to improve clinical effectiveness in ACS care in Australia. Greater access to information both to assist in clinical decision-making and monitoring outcomes may help direct the focus towards understudied populations and improve performance and clinically relevant outcomes. A peer-led initiative based on common datasets, providing rapid feedback, while developing and disseminating a 'toolbox' of proven and sustainable interventions, could improve clinical effectiveness in the Australian management of ACS and provides a rationale for a national ACS registry.

Fatal venous air embolism in a cat undergoing dental extractions.

A five-year-old domestic shorthair cat underwent general anaesthesia and tooth extractions. Immediately after use of a high-speed, air-driven, water-cooled dental drill, the cat suffered cardiac arrest and attempted resuscitation was unsuccessful. Post-mortem radiographs showed air in the vena cava, right atrium, right auricle and right ventricle, hepatic and renal veins. These findings were confirmed at post-mortem examination. The cause of death was massive air embolism. There are reports of fatal venous air embolism in the human literature from the use of high-speed, air-driven, water-cooled dental drills. In this case, we believe that the air jet from the cooling system provided an enormous pressure gradient allowing air entry through an alveolar bone fracture or the inflamed gingival tissues. This is the first report of fatal venous air embolism associated with the use of a high-speed dental drill in the veterinary literature.

Current management of acute coronary syndromes in Australia: observations from the acute coronary syndromes prospective audit.

BACKGROUND: Acute coronary syndromes (ACS) management is now well informed by guidelines extrapolated from clinical trials. However, most of these data have been acquired outside the local context. We sought to describe the current patterns of ACS care in Australia. METHODS: The Acute Coronary Syndrome Prospective Audit study is a prospective multi-centre registry of ST-segment elevation myocardial infarction (STEMI), high-risk non-ST-segment elevation ACS (NSTEACS-HR) and intermediate-risk non-ST-segment elevation ACS (NSTEACS-IR) patients, involving 39 metropolitan, regional and rural sites. Data included hospital characteristics, geographic and demographic factors, risk stratification, in-hospital management including invasive services, and clinical outcomes. RESULTS: A cohort of 3402 patients was enrolled; the median age was 65.5 years. Female and non-metropolitan patients comprised 35.5% and 23.9% of the population, respectively. At enrolment, 756 (22.2%) were STEMI patients, 1948 (57.3%) were high-risk NSTEACS patients and 698 (20.5%) were intermediate-risk NSTEACS patients. Evidence-based therapies and invasive management use were highest among suspected STEMI patients compared with other strata (angiography: STEMI 89%, NSTEACS-HR 54%, NSTEACS-IR 34%, P < 0.001) (percutaneous coronary intervention: STEMI 68.1%, NSTEACS-HR 22.2%, NSTEACS-IR 8.1%, P < 0.001). In hospital mortality was low (STEMI 4.0%, NSTEACS-HR 1.8%, NSTEACS-IR 0.1%, P < 0.001), as was recurrent MI (STEMI 2.4%, NSTEACS-HR: 2.8%, NSTEACS-IR 1.2%, P = 0.052). CONCLUSION: There appears to be an 'evidence-practice gap' in the management of ACS, but this is not matched by an increased risk of in-hospital clinical events. Objective evaluation of local clinical care is a key initial step in developing quality improvement initiatives and this study provides a basis for the improvement in ACS management in Australia.

Cardiovascular responses in anticipation of changes in posture and locomotion.

Measurements were made in 29 adult baboons that were housed in social groups, allowing the occurrence of the full range of species-specific behavioral interactions. The cardiovascular variables measured included blood pressure, heart rate, renal blood flow, lower limb blood flow, and occasionally mesenteric blood flow. The data were telemetered from backpacks worn by the animals and were recorded in analogue form on a polygraph, digitally on a computer and were also recorded on the audio channels of videotape being made of the behavior and social interactions of the baboons. The video and the computer recordings were synchronized by a timing system that made it possible to relate the cardiovascular responses to the behavioral responses. A numerically based behavioral code was developed that allowed the categorization of the totality of the behavior, including postural and locomotor changes. Comparisons between baseline cardiovascular values and those occurring 1 s before the initiation of a movement or posture change gave no evidence of anticipatory cardiovascular responses unless the movement was associated with behavior that included emotional content. Hypothalamic perifornical lesions reduced or eliminated these anticipatory changes.

A system to acquire and record physiological and behavioral data remotely from nonhuman primates.

We describe an integrated system to record physiological and behavioral variables from nonhuman primates in social groups. The system records data simultaneously from two animals in family groups of five. It synchronizes behavioral and physiological data within 16 ms, either on-line or from recordings. Behavioral data are entered by trained observers on-line or from videotape. Recordings of physiological data are produced on-line as stripchart records, tape recordings on the audio channels of video cassettes, and magnetic disk files. The physiological data include two arterial blood flows, arterial blood pressure and heart rate. The data are transmitted from freely behaving animals to a central site via radio telemetry. The infrared link controls the radio transmitter and physiological signal processing electronics, as well as two sources of drugs for each animal. All of the electronics are contained in a small, light backpack that can be worn by either male or female baboons.

Potential survival gains in the treatment of myocardial infarction.

OBJECTIVES: To evaluate the potential impact of complete implementation of guideline recommendations in myocardial infarction (MI) care, and contrast this with new innovations. DESIGN: Modelling of potential events prevented from literature-based treatment effects and observed guideline recommendation utilisation rates. SETTING: Hospital-based care. PARTICIPANTS: Nationwide registry of 1630 patients with MI adjusted for age, gender and GRACE score extrapolated to a population of 10 000 patients. INTERVENTIONS: Literature-based efficacy estimates associated with guideline-recommended treatments and a putative treatment providing a 10-30% 12-month event reduction. MAIN OUTCOME MEASURES: Mortality and recurrent MI or stroke by 30 days and 30 days to 12 months. RESULTS: Adjusted-mortality rates for optimally managed patients with ST-segment MI (STEMI) and non-ST-segment MI (NSTEMI) to 30 days were 0.6% and 2.5%, respectively. Adjusted mortality from 30 days to 12 months was 1.8% among optimally managed patients. No reperfusion occurred in 31% of patients with STEMI. Fewer than four guideline treatments were prescribed in 26% of patients at discharge. Compared with in-hospital care, better application of secondary prevention treatments provided the greater absolute gains (STEMI 23 lives/10 000 patients by 30 days, NSTEMI 43 lives/10 000 by 30 days and secondary prevention 104 lives/10 000 by 12 months). A putative novel treatment reducing mortality by 30% among optimally managed patients would save a further 4 lives/10 000 by 12 months. CONCLUSIONS: Potential gains from improved clinical effectiveness in MI care are likely to compare favourably with benefits achieved though innovations, and should inform priorities in research and implementation strategies for improving MI outcomes.

Morbidity, mortality and economic burden of renal impairment in cardiac intensive care.

BACKGROUND: Moderate to severe impairment of renal function has emerged as a potent risk factor for adverse short- and long-term outcomes among patients presenting with cardiac disease. AIMS: We sought to define the clinical, late mortality and economic burden of this risk factor among patients presenting to cardiac intensive care. METHODS: A clinical audit of patients presenting to cardiac intensive care was undertaken between July 2002 and June 2003. All patients presenting with cardiac diagnoses were included in the study. Baseline creatinine levels were assessed in all patients. Late mortality was assessed by the interrogation of the National Death Register. Renal impairment was defined as estimated glomerular filtration rate <60 mL/min per 1.73 m2, as calculated by the Modified Diet in Renal Disease formula. In-hospital and late outcomes were compared by Cox proportional hazards modelling, adjusting for known confounders. A matched analysis and attributable risk calculation were undertaken to assess the proportion of late mortality accounted for by impairment of renal function and other known negative prognostic factors. The in-hospital total cost associated with renal impairment was assessed by linear regression. RESULTS: Glomerular filtration rate <60 mL/min per 1.73 m2 was evident in 33.0% of this population. Among these patients, in-hospital and late mortality were substantially increased: risk ratio 13.2; 95% CI 3.0-58.1; P < 0.001 and hazard ratio 6.2; 95% CI 3.6-10.7; P < 0.001, respectively. In matched analysis, renal impairment to this level was associated with 42.1% of all the late deaths observed. Paradoxically, patients with renal impairment were more conservatively managed, but their hospitalizations were associated with an excess adjusted in-hospital cost of $A1676. CONCLUSION: Impaired renal function is associated with a striking clinical and economic burden among patients presenting to cardiac intensive care. As a marker for future risk, renal function accounts for a substantial proportion of the burden of late mortality. The burden of risk suggests a greater potential opportunity for improvement of outcomes through optimisation of therapeutic strategies.

Organization of central nervous system pathways influencing blood pressure responses during emotional behavior.

A series of studies has demonstrated that the perifornical area of the hypothalamus ("acro-named" HACER, for Hypothalamic Area Controlling Emotional Responses) is responsible for producing the elevated blood pressure and other cardiovascular responses that accompany emotional behavior. The central neural structures providing afferents to the HACER are detailed, and the efferent outflow is analyzed to demonstrate how the HACER produces cardiovascular responses.

Neurons controlling cardiovascular responses to emotion are located in lateral hypothalamus-perifornical region.

We did four experiments to determine whether the lateral hypothalamus-perifornical (LH/PF) region is the source of neuronal cell bodies responsible for producing the cardiovascular (CV) responses associated with emotion or the defense reaction. Of particular concern was whether the paraventricular nucleus (PVN) plays a role in the generation of these CV responses. Mapping the hypothalamus with electrical stimulation showed that the CV pattern of responses was never produced by stimulating the PVN and was invariably produced by stimulating the LH/PF region. Complete electrolytic destruction of the PVN and subsequent axonal degeneration did not change the CV pattern of responses elicited by LH/PF stimulation, whereas any encroachment of the lesion on the LH/PF region decreased the magnitude of the CV responses. Injection of the neuroexcitotoxin ibotenic acid (Ibo) into the PVN did not affect responses to LH/PF stimulation, whereas Ibo injection into the LH/PF region eliminated or severely attenuated the CV responses. Retrograde labeling of cells from the thoracic cord and the ventrolateral reticular formation revealed a scattered group of cells in the LH/PF region that may be the cells controlling the CV responses. These results point directly to the LH/PF region as the source of the cell bodies responsible for the autonomic responses associated with emotion or defense reactions.

Localized neural control of blood flow in the renal cortex of the anaesthetized baboon.

Localized neural control of renal cortical blood flow was observed in five chloralose-anaesthetized baboons. Renal artery blood flow was measured with an electromagnetic flowmeter, while superficial renal cortical blood flow was measured with a laser Doppler flowmeter. Stimulation of all renal nerve bundles isolated produced significant reductions in total renal blood flow, but reduced the superficial renal cortical blood flow only in localized areas. Systemic arterial blood pressure did not vary significantly, which suggests that the changes in renal cortical blood flow were neurally mediated and not the result of autoregulation. The renal cortical blood flow response was delayed 1-4 s with respect to the total renal blood flow response. The localization of flow control is consistent with the neuroanatomy of the kidney, and the delayed renal cortical blood flow response is consistent with the vascular anatomy of the kidney and with previous measurements of red cell transit times through the renal cortex.

Differential effect of behavior on cardiac and vasomotor baroreflex responses.

Bilateral carotid occlusion was performed in seven baboons during dynamic leg exercise, static arm exercise, feeding, rest, and sleep. The baroreceptor reflex effects on blood pressure, heart rate and interval, renal blood flow, and terminal aortic blood flow were determined during each behavior. The carotid sinus baroreflex increase in blood pressure and heart rate was greatest during sleep and least during exercise. The hindlimb and renal vasomotor responses followed different patterns. The baroreceptor reflex sensitivity for renal vasoconstriction was greatest during rest and least during sleep. The reflex sensitivity in the hindlimb was unaltered by behavior. Thus behavior modifies baroreceptor reflex responses in the heart and peripheral circulation in different patterns.

A remote-controlled device for long-term blood collection from freely moving, socially housed animals.

A remote-controlled device was developed for injection of fluids and collection of blood samples from freely moving, socially housed animals via an indwelling catheter. Samples are collected at times chosen by the investigator, and the animal is not aware that sampling is occurring. This technique allows measurement of plasma catecholamines and other substances that fluctuate rapidly, are affected by psychosocial stimuli, and are altered by capture and other stressful activities that often accompany sample collection. Rapid retrieval of samples is facilitated by remote-controlled injection of an anesthetic. The device has been used to collect blood from dominant and subordinate male baboons before and during events such as chases and presentation of food treats. Heart rate and blood pressure were measured via radio telemetry, and behavior was recorded on videotapes. This technique allowed construction of multifaceted physiological profiles of social roles and behaviors.

Renal and hindlimb vascular control during acute emotion in the baboon.

Blood pressure, heart rate, oxygen consumption, and blood flow to the renal and hind-limb vasculatures were measured in healthy, unanesthetized baboons (Papio cynocephalus) in a controlled environment. Appropriate behavioral techniques were applied to allow the reproducible elicitation of a conditional emotional response (CER). Section of renal nerves and autonomic pharmacologic interventions were used to determine the mechanisms for the cardiovascular responses accompanying the CER. The resistance changes in the renal and hind-limb vascular beds were generated by rapid, neurally mediated vasoconstriction of the renal vasculature and by a slower acting, circulating vasoactive agent, most probably epinephrine, which causes a delayed second constriction in the renal bed and a net dilation in the hind limbs.

Effect of implant duration on in vivo sensitivity of electromagnetic flow transducers.

Twenty-three electromagnetic flow transducers with lumen diameters of 3.5-6.0 mm were implanted in rhesus monkeys and baboonss for 12 h to 120 days. Each flow transducer was calibrated 1) in vitro on dialysis tubing with saline before implantation, 2) in vivo the last day of the implant period, and 3) again in vitro after the flow transducer was recovered. Three other flow transducers were implanted on femoral arteries of baboon just central to an arteriovenous Silastic shunt, and were calibrated in vivo daily for 23-47 days. In vitro sensitivity was not affected by implant durations of up to 120 days. In vivo sensitivity fluctuated unpredictably for the first 3-4 wk of implant, after which it followed a systematic course that depended on the lumen size. In vivo sensitivity at any time during implant (after the initial period) could be accurately predicted by knowing either the in vitro sensitivity or the terminal in vivo sensitivity.