Prognostic significance of mid-range ejection fraction following acute coronary syndrome (ANZACS-QI 23).

AIM: Recommendations regarding medication use after acute coronary syndrome (ACS) are dichotomised according to whether left ventricular ejection fraction (LVEF) is <40% or ≥40%. In the context of heart failure (HF), a mid-range EF (mrEF, 40-49%) confers an intermediate prognosis between reduced EF (rEF, <40%) and preserved EF (pEF, ≥50%). The aim of this study was to describe, in the context of ACS, the frequency of each EF subgroup and their associated outcomes. METHODS: Consecutive patients presenting with ACS who underwent coronary angiography during 2015 were enrolled in the ANZACS-QI (All New Zealand Acute Coronary Syndrome-Quality Improvement) registry. Outcomes were obtained using anonymised linkage to national datasets. Cox proportional hazards models were used to adjust for confounding variables. RESULTS: Of the cohort of 6,216 patients, 31% did not have an LVEF assessment. Of those with a recorded LVEF, 63% had pEF, 21% had mrEF and 16% had rEF. Mean follow-up was 1.5 years. After adjusting for age, sex, clinical risk factors and post-ACS management, those with mrEF and rEF had a higher adjusted risk of all-cause mortality compared to pEF (HR 1.55, 95% CI 1.12-2.15 and HR 2.57, 95% CI 1.89-3.48, respectively). After adjustment, rEF was associated with an increased risk of subsequent HF hospitalisation (HR 2.32, 95% CI 1.75-3.08). CONCLUSIONS: One in five patients post-ACS have mrEF, which is associated with an intermediate risk of morbidity and mortality compared to those with pEF and rEF. Further study is warranted to determine the optimal management for these patients.

Acute coronary syndrome registry enrolment status: differences in patient characteristics and outcomes and implications for registry data use (ANZACS-QI 36).

AIMS: Clinical registry-derived data are widely used to represent patient populations. In New Zealand (NZ), a national registry-the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry-aims to include all patients undergoing coronary angiography; other acute coronary syndrome (ACS) patients are also registered but without complete capture. This study compares national hospitalization data of all first-time ACS admissions in NZ with patients in the ANZACS-QI registry, to investigate the use of clinical registry-derived data in research and in assessing clinical care. METHODS AND RESULTS: Patients admitted with first-time ACS in the NZ National Hospitalisation Dataset between 1 January 2015 and 31 December 2016 were included. Clinical characteristics and time to 12-month clinical outcomes were compared between patients captured and not-captured in the registry. A total of 16 569 patients were admitted with first-time ACS, median age 69 years, 61% male; 60% (n = 9918) were enrolled in ANZACS-QI. Registry-captured patients were younger, more often male, and with a lower comorbidity burden than non-captured patients. Overall, 16% patients died within 12 months, 15% experienced a non-fatal cardiovascular (CV) readmission, and 28% either died or were readmitted. Patients not captured in the registry were more than twice as likely to have experienced death or a non-fatal CV readmission within 12 months as captured patients. CONCLUSIONS: First-time ACS patients captured in the ANZACS-QI registry had very different clinical characteristics and outcomes than those not captured. Cardiovascular registry-derived data are dependent on registry design and may not be representative of the wider patient population; this must be considered when using registry-derived data.

Outcomes for working age patients after first-time acute coronary syndrome - ANZACS-QI 35.

BACKGROUND: Acute coronary syndrome (ACS) events and the ongoing burden of disease can have a significant impact on the subsequent life-course of working age people. METHODS: We report 12-month clinical outcomes for 10,822 patients hospitalized with first-time ACS between 2015-2016 and enrolled in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry, with a focus on people of working age (defined as <65 years). RESULTS: Nearly half (48%) of first-time ACS occurred in people of working age. Compared to those >65 years, these patients had a high burden of cardiovascular risk factors, and were more likely to be male (75% vs 60%), to be of non-European ethnicity (36% vs 15%), and to be living in areas of high deprivation. Subsequent clinical events were common in the younger patients, with 15% dying or being readmitted for cardiovascular causes within 12 months despite high rates of angiography (96%), revascularization (74%) and evidence-based medical therapy at the time of the index ACS event. CONCLUSIONS: The high risk factor burden and subsequent high rate of clinical events in working age patients reinforces the need for a longer-term focus on strategies to improve clinical outcomes following first-time ACS.

Heart failure clinics improve use of evidence-based heart failure therapies in patients with reduced ejection fraction following acute coronary syndrome (ANZACS-QI 48).

AIMS: To describe the use of evidence-based heart failure therapies in patients with reduced left ventricular ejection fraction (LVEF) following acute coronary syndrome (ACS). METHODS: Patients with ACS and LVEF ≤40% were identified from the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry between June 2017 and May 2018. Data was obtained from retrospective review of clinical records. Dispensed medications were identified from pharmacy dispensing records and compared with target doses recommended in guidelines. RESULTS: Of 292 patients, 28% were seen in cardiology heart failure (HF) clinic, 54% seen in general cardiology clinic and 17% were not seen in cardiology clinic. At one year post-discharge, 52% and 39% were dispensed ≥50% target dose of angiotensin converting enzyme inhibitor (ACEi)/ angiotensin receptor blocker (ARB), and beta-blockers respectively. Seventy-one percent and 68% of patients were on maximally tolerated doses of ACEi/ARB and beta-blockers respectively. The highest rates of medication up-titration occurred in those seen in cardiology HF clinics. Seventy-four percent and 59% were dispensed ≥50% target dose of ACEi/ARB and beta-blocker respectively. Ninety-five percent and 89% were on maximally tolerated doses of ACEi/ARB and beta-blockers respectively. Thirteen percent were potentially eligible for primary prevention implantable cardiac defibrillator; however, only 24% of these eligible patients had one implanted by one year post-discharge. CONCLUSIONS: Evidence-based HF therapies were underutilised in this regional cohort of patients with reduced LVEF post-ACS. Strategies to improve use of these therapies should focus on increasing the number of patients seen by HF clinics and reducing clinic waiting times.

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.

Clinical Characteristics and Burden of Risk Factors Among Patients With Early Onset Acute Coronary Syndromes: The ANZACS-QI New Zealand National Cohort (ANZACS-QI 17).

BACKGROUND: Cardiovascular (CV) risk factor profiles of people experiencing acute coronary syndromes (ACS) vary with age, and in New Zealand (NZ), Maori and people of Pacific Island descent typically present with ACS at a younger age. We aimed to explore age- and ethnicity-related differences in CV risk factors in a large NZ cohort with first-time ACS. METHODS: The All NZ Acute Coronary Syndrome Quality Improvement program (ANZACS-QI) registry collects comprehensive data for patients admitted with ACS at NZ hospitals. This analysis includes patients with no prior atherosclerotic CV disease enrolled from 1 July, 2012 to 30 June, 2015. RESULTS: 14,190 patients had confirmed ACS, 8493 (60%) patients with no prior CVD comprised the study cohort. The mean age was 64 years, 25% were aged <55years, and 66% were male. Those aged <55years were more likely than older patients to be current smokers (48% vs 19%), have higher body mass index (BMI) (48% vs 34% with BMI≥30kg/m2), and higher total cholesterol:HDL ratios (≥4.0, 70% vs 50%), all p<0.001. Sixteen per cent of those <55years had diabetes; these patients often had a BMI≥30kg/m2 (67%) and higher median HbA1c than older patients with diabetes (69mmol/mol vs 55mmol/mol). Maori and people of Pacific Island descent were overrepresented in the younger age group; these patients had a very high risk factor burden. CONCLUSIONS: A quarter of NZ patients admitted to hospital with a first-time CV disease event are aged <55years. Younger patients have a very high risk factor burden: half are current smokers, half have a BMI≥30kg/m2, and 16% have diabetes.

Differences between self-reported and verified adverse cardiovascular events in a randomised clinical trial.

OBJECTIVES: In clinical trials, adverse events are usually self-reported but may be adjudicated if serious or of particular interest. After adjudicating cardiovascular events for a 5-year calcium supplement trial, we observed discrepancies between self-reported and verified events. We systematically analysed those differences to assess their importance. DESIGN: Secondary analysis of adverse cardiovascular events in a 5-year, randomised, placebo-controlled trial of calcium supplementation (1 g calcium daily) in 1471 postmenopausal women (mean age 74 years). SETTING: Clinical research centre. METHODS: The participant's medical records were reviewed for all self-reported myocardial infarctions (MIs) or strokes, and the event independently adjudicated. Cause of death was obtained from hospital records or death certificates. To identify unreported events, the national hospital discharge database was searched and related hospital records were reviewed. RESULTS: 45 women reported 64 MIs, of which 33 (52%) were verified after adjudication. An additional 25 MIs were identified: 1 during adjudication of other events, 21 from the hospital discharge database, 3 from death certificates. 68 women reported 86 strokes of which 50 (58%) were verified. An additional 13 strokes were identified: 7 during adjudication of reported transient ischaemic attacks, 5 from the hospital discharge database, 1 from death certificates. Therefore, 43% of verified MIs and 21% of verified strokes were not reported to investigators. For non-adjudicated discharge codes, 10% of MIs and 22% of strokes were not verified after adjudication. Nineteen per cent of verified MIs and 27% of verified strokes were not identified in discharge coding or death certificates. Neither the event source nor the level of adjudication altered the relationship between treatment allocation and cardiovascular events. CONCLUSIONS: When adverse event accuracy is critical, researchers should consider adjudicating self-reported events and hospital discharge codes, and attempt to identify unreported events. TRIAL REGISTRATION: Australia New Zealand Clinical Trials registry: ACTRN 012605000242628.

Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial.

OBJECTIVE: To determine the effect of calcium supplementation on myocardial infarction, stroke, and sudden death in healthy postmenopausal women. DESIGN: Randomised, placebo controlled trial. SETTING: Academic medical centre in an urban setting in New Zealand. PARTICIPANTS: 1471 postmenopausal women (mean age 74): 732 were randomised to calcium supplementation and 739 to placebo. MAIN OUTCOME MEASURES: Adverse cardiovascular events over five years: death, sudden death, myocardial infarction, angina, other chest pain, stroke, transient ischaemic attack, and a composite end point of myocardial infarction, stroke, or sudden death. RESULTS: Myocardial infarction was more commonly reported in the calcium group than in the placebo group (45 events in 31 women v 19 events in 14 women, P=0.01). The composite end point of myocardial infarction, stroke, or sudden death was also more common in the calcium group (101 events in 69 women v 54 events in 42 women, P=0.008). After adjudication myocardial infarction remained more common in the calcium group (24 events in 21 women v 10 events in 10 women, relative risk 2.12, 95% confidence interval 1.01 to 4.47). For the composite end point 61 events were verified in 51 women in the calcium group and 36 events in 35 women in the placebo group (relative risk 1.47, 0.97 to 2.23). When unreported events were added from the national database of hospital admissions in New Zealand the relative risk of myocardial infarction was 1.49 (0.86 to 2.57) and that of the composite end point was 1.21 (0.84 to 1.74). The respective rate ratios were 1.67 (95% confidence intervals 0.98 to 2.87) and 1.43 (1.01 to 2.04); event rates: placebo 16.3/1000 person years, calcium 23.3/1000 person years. For stroke (including unreported events) the relative risk was 1.37 (0.83 to 2.28) and the rate ratio was 1.45 (0.88 to 2.49). CONCLUSION: Calcium supplementation in healthy postmenopausal women is associated with upward trends in cardiovascular event rates. This potentially detrimental effect should be balanced against the likely benefits of calcium on bone. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN 012605000242628.

The effect of an integrated care approach for heart failure on general practice.

BACKGROUND: Recent studies have investigated specific strategies for heart failure management. None has involved collaboration between primary and secondary care. Potential gains for patients may result from collaborative strategies. OBJECTIVE: To assess the effect of an integrated management approach for patients with heart failure on general practice. METHODS: The study design was a cluster randomized controlled trial of integrated primary/ secondary care compared with usual care for heart failure patients. The study took place at Auckland Hospital, New Zealand and involved 197 patients admitted with an episode of heart failure. Patients were randomized to management group or control group (who received "usual" care). Management group patients received early clinical review, education sessions, a personal diary for medications and weight, and regular clinical follow-up alternating between GP and hospital clinic. Follow-up was for 12 months. RESULTS: Patients visited GPs frequently (median 14 visits, range 0-40), with no statistical difference between the two groups. Heart failure was the most common reason for consulting the GP. There was no relationship between GP consultations and patients' attendance at the study clinic, or hospital admissions. Management group GPs and patients expressed a high level of satisfaction. CONCLUSION: GP consultation rates were not affected by the programme. Further research will determine if general practice based programmes result in further gains.