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.

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.

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 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.

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.

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.

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.

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.

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.

Impact of chronic kidney disease on mortality and cardiovascular outcomes after acute coronary syndrome: A nationwide data linkage study (ANZACS-QI 44).

AIMS: Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular disease (CVD). We examined the characteristics, management and outcomes of patients with CKD in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) national registry. METHODS: The cohort comprised New Zealand (NZ) patients with an acute coronary syndrome undergoing coronary angiography between January 2013 and December 2016. Patients were categorized according to their stage of CKD. Outcomes included all-cause and cause-specific mortality and hospitalization with myocardial infarction (MI), stroke and major bleeding. RESULTS: Of the 20 604 patients, 20.3% had normal renal function, with 53.3%, 23.3%, 1.7% and 1.4% having CKD stages 2, 3, 4 and 5 CKD, respectively. Patients with severe CKD were more likely to be Maori or Pacific and live in an area with greater socioeconomic deprivation. Death, recurrent MI or stroke, and major bleeding all increased incrementally with each worsening stage of CKD severity. Compared with those with normal renal function, patients with stage 5 CKD had a much higher all-cause (hazard ratio [HR] 16.41, 95% CI 13.06-20.61), cardiovascular (HR 16.38, 95% CI 12.17-22.04) and non-cardiovascular mortality (HR 13.66 9, 95% CI.56-19.51). In addition, patients with stage 5 CKD were at a higher risk of recurrent MI or stroke (HR 4.73, 95% CI 3.86-5.80) and bleeding (HR 5.84, 95% CI 4.39-7.76). CONCLUSION: CKD was associated with increased mortality and a high incidence of morbidity in patients undergoing coronary angiography in New Zealand. Initiatives to understand and improve outcomes in this group of patients are urgently needed.

Target Doses of Secondary Prevention Medications Are Not Being Achieved in Patients With Reduced Left Ventricular Ejection Fraction After Acute Coronary Syndrome (ANZACS-QI 34).

BACKGROUND: Patients with reduced left ventricular ejection fraction (EF<40%) are at high risk for adverse outcomes and benefit from evidence based doses of angiotensin converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB) and beta blockers. Our aim was to investigate the dispensing and uptitration of these medications following acute coronary syndrome (ACS), according to left ventricular ejection fraction. METHODS: Patients presenting with ACS who underwent coronary angiography during 2015 were recorded in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. Medication dispensing data on discharge and at 1-year follow-up were obtained using anonymised linkage to the national pharmaceutical dataset. Doses of medications dispensed were compared to target doses recommended in clinical guidelines. RESULTS: 4,082 patients were included in the study, of whom 602 (15%) had reduced ejection fraction (rEF). More patients with rEF were prescribed ACEi/ARB on discharge compared to those with preserved ejection fraction (pEF) (89% vs. 68%). Beta blocker dispensing on discharge was also higher in the rEF group (94% vs. 83%). In the rEF subgroup, 76% were maintained on ACEi/ARB and 85% on beta blockers by 1 year of follow-up. However, at discharge only 31% and 29% were on ≥50% of target doses of ACEi/ARB and beta blocker doses respectively, and by 1 year this increased only slightly to 34% and 35% respectively. CONCLUSIONS: There is suboptimal dispensing of evidence-based medications in the year following ACS. Further intervention is required to improve medication uptitration and adherence, particularly of beta blockers and ACEI/ARBs in those with reduced ejection fraction.

Prescribing Performance Post-Acute Coronary Syndrome Using a Composite Medication Indicator: ANZACS-QI 24.

BACKGROUND: Guidelines previously recommended use of dual antiplatelet therapy, statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARB) and beta blockers (five classes of drugs) in patients without contraindications or intolerance after acute coronary syndrome (ACS). However, recent guidelines have taken a more nuanced view regarding the use of ACEI/ARB and beta blockers. Our aim was to develop a composite post-discharge medication indicator, based on available evidence, to support quality improvement. METHODS: 4,112 consecutive post-ACS patients who underwent coronary angiography and left ventricular ejection fraction (LVEF) assessment in 2015-16 were recorded in the All New Zealand ACS Quality Improvement (ANZACS-QI) registry. Patients receiving coronary artery bypass grafting were excluded. Three composite indicator algorithms that took into account known contraindications/intolerances were compared across NZ District Health Boards (DHBs): RESULTS: Overall and individual DHB performance was highest (74%, DHB range 52-84%) when reported using the NHFA/CSANZ indicator, and slightly lower (69%, DHB range 48-78%) on the ANZACS-QI indicator. Performance was lowest using the older five-drug-class indicator (65%, DHB range 48-77%). CONCLUSIONS: We have developed a composite post-discharge medication indicator appropriate for use in identifying gaps in evidence-based management across NZ, which is now being reported regularly to DHBs.

What is the Optimal Rate of Invasive Coronary Angiography After Acute Coronary Syndrome? (ANZACS-QI 22).

BACKGROUND: Invasive coronary angiography plays a pivotal role in the management of acute coronary syndromes (ACS). Wide variability in its use has been previously documented. Our aim was to investigate whether coronary angiography is being used appropriately prior to discharge after ACS, taking into account relative contraindications of the procedure. METHODS: Patients presenting with ACS in 2015 to two large, demographically distinct New Zealand (NZ) District Health Boards (DHBs)-Counties Manukau (CMDHB) and Waitemata (WDHB)-were identified from the NZ Ministry of Health National Dataset using ICD-10-AM codes. Patients' clinical data were obtained from the electronic and paper clinical records. Pre-defined relative contraindications to coronary angiography were identified. RESULTS: Of the 3,809 patient admissions coded with ACS, 600 patient admissions (300 from each DHB) were reviewed. Sixty-one (61) (10%) did not meet diagnostic criteria for ACS on review of clinical data and were excluded. Of the patients reviewed, 55% received coronary angiography, with a higher rate in WDHB than CMDHB (61% and 49%, respectively) and 37.5% had relative contraindications documented. The overall rate of angiography was appropriately high in those without a relative contraindication (90.3%) and low in those with one (7.4%). There were fewer patients with relative contraindications in WDHB than CMDHB (36.7% and 48.5%) but the rate of angiography in those with (6.9% and 7.8%) and without (92.5% and 87.5%) contraindications in the two DHBs was similar. CONCLUSIONS: The decision to offer coronary angiography after ACS appears to be appropriately influenced by the presence or absence of relative contraindications. Approximately 60% of patients had no documented relative contraindication suggesting that this may be an appropriate angiography rate in New Zealand practice. However, differences between the two DHBs of around 10% appear to be clinically appropriate due to variation in contraindication rates.

Myocardial Infarction Without Obstructive Coronary Artery Disease is Not a Benign Condition (ANZACS-QI 10).

BACKGROUND: Non-obstructive coronary artery disease (CAD) on coronary angiography after myocardial infarction (MI) is associated with a lower risk of adverse outcomes, but the prognosis may not be benign. Our aim was to assess outcomes in MI with and without obstructive CAD, and in an age and sex matched comparison cohort without known cardiovascular disease. METHODS: We performed a single centre analysis of consecutive patients undergoing coronary angiography for MI between 2007 and 2012. Patients were classified into those with obstructive CAD (≥50% epicardial coronary artery stenosis) and those without obstructive CAD (<50%). Myocardial infarction patient data was collected in an electronic registry and linked anonymously to national hospitalisation and mortality records. Age and sex matched patients without known CVD were identified from the community PREDICT cohort. RESULTS: Of the 2070 patients with MI, 302 (15%) had non-obstructive CAD. Compared to patients with obstructive disease they were younger (mean 57 v 61 years, p<0.001), more likely to be women (50% vs 23%, p<0.001), to be of Maori or Pacific vs. European ethnicity (p<0.001), more likely to be lifelong non-smokers (46% v 38%, p=0.02), non-diabetic (80v 73%, p <0.01), have no ST-segment deviation (78% v 46%, p<0.001), and have a low risk Global Registry of Acute Coronary Events acute coronary syndrome (GRACE ACS) score (54 v 35%, p<0.001). They were also less likely to receive 'triple therapy' secondary prevention medications (81% v 94%, p<0.0001). The cumulative two-year Kaplan-Maier composite outcome of mortality or non-fatal MI was 14.3% for MI with obstructive CAD, 4.6% for MI without obstructive disease, and 2.2% for patients without prior CVD (p<0.001). CONCLUSION: Myocardial infarction without obstructive coronary disease is common (∼1 in 7 patients) and is not clinically benign, with an adverse outcome rate double that of age and sex matched patients without CVD.

Management and Long-Term Outcome of Acute Coronary Syndrome Patients Presenting with Heart Failure in a Contemporary New Zealand Cohort (ANZACS-QI 4).

BACKGROUND: Acute heart failure (HF) associated with an acute coronary syndrome (ACS) predicts adverse outcome. There have been important recent improvements in ACS management. Our aim was to describe the management and outcomes in those with and without HF in a contemporary ACS cohort. METHODS: Consecutive patients presenting with ACS between 2007 and 2011 were enrolled in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. Outcomes and medication dispensing were obtained using anonymised linkage to national data sets. A summary pharmacotherapy measure of "quadruple therapy" was defined as dispensing of at least one agent from each of the four evidence-based classes - anti-platelet, statin, angiotensin converting enzyme inhibitor/angiotensin receptor blocker and beta blocker. RESULTS: Of 3743 ACS patients 14% had acute HF. Acute heart failure patients were older (69.2±12.6 vs 62.3±12.8 years, p<0.001), less likely to have coronary angiography (66% vs 86%, p<0.001) and revascularisation (46% vs 62%, p<0.001). Immediate post-discharge quadruple therapy was higher for those with than without HF (61% vs 55%, p=0.02) but fell to similar levels by one-year (45% vs 53%, p=0.55). At four years follow-up nearly half of those presenting with ACS and HF had died. After adjustment, HF remained a strong predictor of death within 28 days (OR 2.9, 95%CI 1.5 - 5.5) and beyond 28 days (HR 1.8, 95%CI 1.5 - 2.3). CONCLUSION: Acute heart failure complicating ACS is associated with heightened risk of short-term and long-term mortality. One in three ACS patients with HF did not have coronary angiography and less than half received quadruple therapy a year after presentation.

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.

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.