Investigation and treatment after non-ST segment elevation acute coronary syndrome for patients presenting to rural or urban hospitals in Aotearoa New Zealand: ANZACS-QI 75.

AIMS: Compare the care patients with non-ST segment elevation acute coronary syndrome (NSTEACS) received in Aotearoa New Zealand depending on the rural-urban category of the hospital they are first admitted to. METHODS: Patients with NSTEACS investigated with invasive coronary angiogram between 1 January 2014 and 31 December 2019 were included. There were three hospital categories (routine access to percutaneous coronary intervention [urban interventional], other urban [urban non-interventional] and rural) and three ethnicity categories (Maori, Pacific and non-Maori/non-Pacific). Clinical performance measures included: angiography ≤3 days, assessment of left ventricular ejection fraction (LVEF) and prescription of secondary prevention medication. RESULTS: Of 26,779 patients, 66.2% presented to urban-interventional, 25.6% to urban non-interventional and 8.2% to rural hospitals. A smaller percentage of patients presenting to urban interventional than urban non-interventional and rural hospitals were Maori (8.1%, 17.0% and 13.0%). Patients presenting to urban interventional hospitals were more likely to receive timely angiography than urban non-interventional or rural hospitals (78.5%, 60.8% and 63.1%). They were also more likely to have a LVEF assessment (78.5%, 65.4% and 66.3%). In contrast, the use of secondary prevention medications at discharge was similar between hospital categories. Maori and Pacific patients presenting to urban interventional hospitals were less likely than non-Maori/non-Pacific to receive timely angiography but more likely to have LVEF assessed. However, LVEF assessment and timely angiography in urban non-interventional and rural hospitals were lower than in urban interventional hospitals for both Maori and non-Maori/non-Pacific. CONCLUSIONS: Patients presenting to urban hospitals without routine interventional access and rural hospitals were less likely to receive LVEF assessment or timely angiography. This disproportionately impacts Maori, who are more likely to live in these hospital catchments.

Outcomes and access to angiography following non-ST-segment elevation acute coronary syndromes in patients who present to rural or urban hospitals: ANZACS-QI 72.

AIM: This study's aim was to identify differences in invasive angiography performed and health outcomes for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) presenting to either i) a rural hospital, or an urban hospital ii) with or iii) without routine access to percutaneous intervention (PCI) in New Zealand. METHODS: Patients with NSTEACS between 1 January 2014 and 31 December 2017 were included. Logistic regression was used to model each of the outcome measures: angiography performed within 1 year; 30-day, 1-year and 2-year all-cause mortality; and readmission within 1 year of presentation with either heart failure, a major adverse cardiac event or major bleeding. RESULTS: There were 42,923 patients included. Compared to urban hospitals with access to PCI, the odds of a patient receiving an angiogram were reduced for rural and urban hospitals without routine access to PCI (odds ratio [OR] 0.82 and 0.75) respectively. There was a small increase in the odds of dying at 2 years (OR 1.16), but not 30 days or 1 year for patients presenting to a rural hospital. CONCLUSION: Patients who present to hospitals without PCI are less likely to receive angiography. Reassuringly there is no difference in mortality, except at 2 years, for patients that present to rural hospitals.

Both incidence and prevalence of ischaemic heart disease are declining in parallel: a national data-linkage study in New Zealand (ANZACS-QI 52).

AIMS: To examine trends in ischaemic heart disease (IHD) incidence and prevalence in New Zealand from 2005 to 2016, using comprehensive linked national hospitalization and mortality data as proxy measures of all significant events. METHODS AND RESULTS: Incident and prevalent cases of IHD in people aged ≥25 years were identified using individual patient-linkage of routinely collected ICD-10-coded hospitalization and mortality data. Incidence rates and prevalence proportions were calculated by sex and age group and then age-standardized to the 2016 New Zealand population. Ischaemic heart disease incidence and prevalence declined in men and women in all age groups. The average annual rate of decline in age-standardized IHD incidence was 3.3% for women and 2.7% for men, and the rate of decline in age-standardized IHD prevalence was 3.2% for women and 2.2% for men. Despite a 17% increase in the New Zealand population aged 25 years and over during the study period, the total number of people living with IHD also decreased, particularly in those aged 65 years and older. CONCLUSION: In contrast to observations from other countries, where IHD incidence but not IHD prevalence has been falling, declining IHD incidence in New Zealand in recent decades is now mirrored by declining IHD prevalence.

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

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

Nationwide dispensing of cardioprotective medications during the first year following acute coronary syndrome (ANZACS-QI 56).

AIM: A number of evidence-based medications are recommended following an acute coronary syndrome (ACS), including statins, antithrombotics (antiplatelet and/or anticoagulants), a beta-blocker and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACE-I/ARB). This study aimed to describe the dispensing of the cardioprotective medications in the first year following an ACS hospitalisation in New Zealand and how this varies according to age, sex and type of coronary intervention. METHOD: National hospitalisation data was used to identify all New Zealand residents aged 35-79 years who were discharged from hospital in the years 2013/14 with a primary discharge diagnosis of ACS. Using anonymous linkage to national pharmaceutical dispensing and mortality datasets, the dispensing of each group of medications was examined in survivors of quarters one, two and four of the first year post discharge. RESULTS: There were 14,496 patients; mean age was 63.4 years and 68.8% were male. Dispensing of medications in survivors steadily fell across quarters one, two and four: 90.8%, 82.1% and 78.8% of patients were dispensed statins; 90.6%, 79.8% and 78.1% were dispensed aspirin; 82.7%, 72.6% and 70.0% were dispensed beta-blockers; 69.6%, 62.7% and 61.3% were dispensed ACE-I/ARB; 67.7%, 53.6% and 40.4% were dispensed a P2Y12 inhibitor; and 68.6%, 53.0% and 40.7% were dispensed a combination of two or more antithrombotics. CONCLUSION: Cardioprotective medication dispensing was lower than would have been the case if the current ACS guidelines were followed. The greatest decrease in dispensing occurred between quarter one and quarter two, which highlights a potentially important period for targeted interventions to improve adherence.

Ethnic variation in the trends of new implantable cardioverter defibrillator implants in New Zealand 2005-2019 (ANZACS-QI 63).

AIMS: Ethnic variation in implantable cardioverter defibrillator (ICD) implant rates have been reported internationally but have not previously been examined in New Zealand. This study examined trends in new ICD implants by ethnicity over an extended period. METHODS: All patients who received a new ICD implant between 2005 and 2019 were identified using the National Minimum Dataset, which collects information on all public hospital admissions in New Zealand. Ethnicity was classified using the following standard prioritisation: Maori, Pacific, Asian and European/Other. New ICD implant rates were analysed by ethnicity and age groups. RESULTS: A total of 5,514 new ICDs were implanted. New ICD implant rates increased from 41.4/million in 2005 to 98.2/million in 2019, an average increase of 5.4%/year (p<0.01). The highest age-standardised implant rates were among Maori, followed by Pacific, European/Other and Asian ethnicities. The largest increase was seen in Pacific people at 8.9%/year (p<0.01), followed by Maori and Asian people at 4.7%/year and 4.3%/year respectively (both p<0.01). In European/Other patients, ICD implant rates increased by 10.3%/year (p<0.01) between 2005 to 2012, then plateaued at -0.4%/year (p=0.71) between 2012 to 2019. By 2019, the age-standardised implant rates in Maori and Pacific people were two-fold higher than European/Others. CONCLUSION: There is marked ethnic variation in ICD implant rates in New Zealand. The higher implant rates in Maori and Pacific parallel known ethnic differences in rates of underlying cardiac disease. The more rapid increase in implant rates in these ethnic groups may represent more equitable treatment over time.

The importance of considering both primary and secondary diagnostic codes when using administrative health data to study acute coronary syndrome epidemiology (ANZACS-QI 47).

AIMS: Routinely collected health administrative data have become an important data source for investigators assessing disease epidemiology. Our aim was to investigate the implications of identifying acute coronary syndrome (ACS) events in New Zealand (NZ) national hospitalization data using either the first (primary) or subsequent (secondary) codes. METHODS AND RESULTS: Using national health datasets, we identified all NZ hospitalizations (2014-16) for patients ≥20 years with a primary or secondary International Classification of Diseases 10th Revision, Australian Modification (ICD10-AM) ACS code. Outcomes included 1-year all-cause and cause-specific mortality, hospitalized non-fatal myocardial infarction, heart failure, stroke, or major bleeding, and a composite comprising these outcomes. Of 35 646 ACS hospitalizations, 78.5% were primary and 21.5% secondary diagnoses. Compared to primary coding, patients with a secondary diagnosis were older (mean 77 vs. 69 years), more likely to be females (48% vs. 36%), had more comorbidity, and were less likely to receive coronary angiography or revascularization. Higher adverse event rates were observed for the secondary diagnosis group including a three-fold higher 1-year mortality (40% vs. 13%) and two-fold higher composite adverse outcome (54% vs. 26%). The use of primary codes alone, rather than combined primary and secondary codes, resulted in overestimation of coronary angiography and revascularization rates, and underestimation of the 1-year case fatality (13.1% vs. 19.0%) and composite adverse event rate (26% vs. 32%). CONCLUSION: Patient characteristics and outcomes of ACS events recorded as primary vs. secondary codes are very different. These findings have important implications for designing studies utilizing ICD10-AM codes.

Increases in early discharge following acute coronary syndrome hospitalisations and associated clinical outcomes in New Zealand between 2006 and 2015: ANZACS-QI-43 study.

BACKGROUND: International guidelines recommend early discharge for uncomplicated acute coronary syndrome (ACS) patients within 3 days; however, there is a paucity of contemporary literature regarding the safety of this strategy. AIMS: To report the trends in the proportion of ACS hospitalisations discharged within 3 days and their outcomes in New Zealand. METHODS: ACS hospitalisations 2006-2015 using national routinely collected data were categorised by length of stay (LOS) into ≤3, 4-5 and >5 days, excluding deaths during the index admission. Trend analysis of death, cardiovascular and bleeding events and their composites (net adverse clinical events) at 30-day and 1-year post-discharge were performed using generalised linear mixed regression models adjusting for covariates by LOS subgroups. RESULTS: Among 130 037 ACS hospitalisations, LOS ≤ 3 days increased from 32% in 2006 to 44% in 2016. This trend was observed for all demographics, ACS subtypes and management strategies. Event rates at 30 days and 1 year were the lowest for the LOS ≤3 days subgroup (all-cause mortality 1.6% and 9.1% respectively). Thirty-day and 1-year all-cause mortality rates were unchanged over time for this subgroup (adjusted odds ratio (95% confidence interval) of 1.011 (0.985-1.038) and 0.991 (0.979-1.003)), while net adverse clinical event rates significantly decreased (0.962 (0.950-0.973) and 0.972 (0.964-0.980) respectively). CONCLUSION: There was a substantial increase in early discharge post-ACS over 10 years. These patients were associated with reduction in adverse clinical events up to 1 year and no increase in all-cause mortality. These findings from a comprehensive national register suggest that guideline recommendations on early discharge after uncomplicated ACS are safe and appropriate.

Maori, Pacific, Aboriginal and Torres Strait Islander Women's Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?

Maori and Pacific women in New Zealand and Aboriginal and Torres Strait Islander women in Australia are recognised as nurturers and leaders within their families and communities. However, women's wellbeing, and that of their communities, are affected by a high burden of cardiovascular disease experienced at a younger age than women from other ethnic groups. There has been little focus on the cardiovascular outcomes and strategies to address heart health inequities among Maori, Pacific, Aboriginal and Torres Strait Islander women. The factors contributing to these inequities are complex and interrelated but include differences in exposure to risk and protective factors, rates of multi-morbidity, and substantial gaps within the health system, which include barriers to culturally responsive, timely and appropriate cardiovascular care. Evidence demonstrates critical treatment gaps across the continuum of risk and disease, including assessment and management of cardiovascular risk in young women and time-critical access to and receipt of acute services. Cardiovascular disease in women impacts not only the individual, but their family and community, and the burden of living with disease limits women's capacity to fulfil their roles and responsibilities which support and sustain families and communities. Our response must draw on the strengths of Maori, Pacific, Aboriginal and Torres Strait Islander women, acknowledge health and wellbeing holistically, address the health and social needs of individuals, families and communities, and recognise that Indigenous women in New Zealand, Australia and across the Pacific must be involved in the design, development and implementation of solutions affecting their own health.

Inequity in one-year mortality after first myocardial infarction in Maori and Pacific patients: how much is associated with differences in modifiable clinical risk factors? (ANZACS-QI 49).

AIMS: Ischaemic heart disease (IHD) mortality rates after myocardial infarction (MI) are higher in Maori and Pacific compared to European people. The reasons for these differences are complex and incompletely understood. Our aim was to use a contemporary real-world national cohort of patients presenting with their first MI to better understand the extent to which differences in the clinical presentation, cardiovascular (CVD) risk factors, comorbidity and in-hospital treatment explain the mortality outcomes for Maori and Pacific peoples. METHODS: New Zealand residents (≥20 years old) hospitalised with their first MI (2014-2017), and who underwent coronary angiography, were identified from the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. All-cause mortality up to one year after the index admission date was obtained by linkage to the national mortality database. RESULTS: There were 17,404 patients with a first ever MI. European/other comprised 76% of the population, Maori 11.5%, Pacific 5.1%, Indian 4.3% and Other Asian 2.9%. Over half (55%) of Maori, Pacific and Indian patients were admitted with their first MI before age 60 years, compared with 29% of European/other patients. Maori and Pacific patients had a higher burden of traditional and non-traditional cardiovascular risk factors, and despite being younger, were more likely to present with heart failure and, together with Indian peoples, advanced coronary disease at presentation with first MI. After adjustment for age and sex, Maori and Pacific, but not Indian or Other Asian patients had significantly higher all-cause mortality at one year compared with the European/other reference group (HR 2.55 (95% CI 2.12-3.07), HR 2.98 (95% CI 2.34-3.81) for Maori and Pacific respectively). When further adjusted for differences in clinical presentation, clinical history and cardiovascular risk factors, the excess mortality risk for Maori and Pacific patients was reduced substantially, but a differential persisted (HR 1.77 (95% CI 1.44-2.19), HR 1.42 (95% CI 1.07-1.83)) which was not further reduced by adjustment for differences in in-hospital management and discharge medications. CONCLUSION: In New Zealand patients after their first MI there is a three-fold variation in one-year mortality based on ethnicity. At least half of the inequity in outcomes for Maori, and three-quarters for Pacific people, is associated with differences in preventable or modifiable clinical factors present at, or prior to, presentation.

Trends in length of stay following acute coronary syndrome hospitalisation in New Zealand 2006-2016: ANZACS-QI 32 study.

AIMS: Length of hospital stay (LOS) for acute coronary syndrome (ACS) has important clinical and cost implications. We report recent trends and predictors of ACS hospitalisation LOS in New Zealand. METHODS: Using routine national hospitalisation datasets, we calculated mean LOS for ACS admissions annually from 2006 to 2016, by demographics, ACS subtype and ACS procedures (coronary angiography, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)). We also identified predictors of longer LOS. RESULTS: Among 185,962 ACS hospitalisations, mean LOS decreased from 7.8 to 6.7 days between 2006 and 2016 (adjusted decrease = -0.18 days/year). Decline in LOS was observed for all demographic subgroups by age, sex, ethnicity and deprivation quintile. While coronary angiography and PCI rates increased during this time, LOS declined for all management strategies. However, the adjusted rate of decline was greater for patients receiving coronary angiography without revascularisation (-0.24 days/year), PCI (-0.22 days/year) and CABG (0.33 days/year)-than those not receiving angiography (-0.14 days/year), P<0.001. A greater decline occurred for NSTEMI and STEMI (9.4 to 7.5 days and 7.8 to 6.2 days, respectively) than UA (5.4 to 4.9 days). Predictors of longer LOS in 2016 were older age, female, Maori or Pacific ethnicity, not receiving coronary angiography, initial presentation to a non-interventional hospital and CABG. CONCLUSIONS: Mean LOS for ACS hospitalisations declined between 2006 and 2016. The decline was greatest in the increasing proportion of patients who received a coronary angiogram. Further reductions in LOS may be achieved by implementation of nationally agreed pathways for adequate and timely access to coronary angiography.

Contrasting Trends in Acute Coronary Syndrome Hospitalisation and Coronary Revascularisation in New Zealand 2006-2016: A National Data Linkage Study (ANZACS-QI 27).

BACKGROUND: Evaluating trends in acute coronary syndrome (ACS) and invasive coronary procedures, including coronary angiography, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) can identify areas for improvement in clinical care and inform future health planning. This national data-linkage study reports trends in ACS hospitalisations and procedure rates in New Zealand between 2006 and 2016. METHODS: All adult ACS hospitalisations and associated angiography and revascularisation procedures were identified from hospital discharge codes. Crude and age-standardised ACS incidence and procedure rates were calculated for each calendar year. RESULTS: Between 2006 and 2016 there were 188,264 ACS admissions. During this time, there was a steady decline in hospitalisation rates, from 685 to 424 per 100,000 per year. This decline was observed in both sexes and in all age groups. There were also significant increases in coronary angiography and revascularisation rates, from 29.8% to 54.3% and 20.6% to 37.3%, respectively, between 2006 and 2016. The rate of revascularisation by PCI increased from 16.0% to 31.0%, a greater increase than revascularisation by CABG, which increased from 4.6% to 6.5%. Increases in procedures were observed in all age groups and both sexes. The proportions of coronary angiograms that resulted in revascularisation each year consistently ranged from 67 to 70% throughout the period. CONCLUSIONS: Acute coronary syndrome hospitalisation rates in New Zealand decreased by nearly 40% between 2006 and 2016, while the use of coronary angiography and revascularisation after ACS nearly doubled. The similar proportions of angiograms that resulted in revascularisation each year suggests that, despite the doubling of angiograms over the 10-year study period, they are not over-utilised.

Acute reperfusion for ST-elevation myocardial infarction in New Zealand (2015-2017): patient and system delay (ANZACS-QI 29).

AIM: Prompt access to cardiac defibrillation and reperfusion therapy improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The study aim was to describe the 'patient' and 'system' delay in patients who receive acute reperfusion therapy for ST-elevation myocardial infarction (STEMI) in New Zealand. METHODS: In 2015-17, 3,857 patients who received acute reperfusion therapy were captured in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. 'Patient delay' is the time from symptom onset to first medical contact (FMC), and 'system delay' the time from FMC until reperfusion therapy (primary percutaneous coronary intervention (PCI) or fibrinolysis). RESULTS: Seventy percent of patients received primary PCI and 30% fibrinolysis. Of those receiving fibrinolysis, 122 (10.5%) received pre-hospital fibrinolysis. Seventy-seven percent were transported to hospital by ambulance. After adjustment, people who were older, male and presented to a hospital without a routine primary PCI service were less likely to travel by ambulance. Patient delay: The median delay was 45 minutes for ambulance-transported patients and 97 minutes for those self-transported to hospital, with a quarter delayed by >2 hours and >3 hours, respectively. Delay >1 hour was more common in older patients, Maori and Indian patients and those self-transported to hospital. System delay: For ambulance-transported patients who received primary PCI, the median time was 119 minutes. For ambulance-transported patients who received fibrinolysis, the median system delay was 86 minutes, with Maori patients more often delayed than European/Other patients. For patients who received pre-hospital fibrinolysis the median delay was 46 minutes shorter. For the quarter of patients treated with rescue PCI after fibrinolysis, the median needle-to-rescue time was prolonged-four hours. CONCLUSIONS: Nationwide implementation of the NZ STEMI pathway is needed to reduce system delays in delivery of primary PCI, fibrinolysis and rescue PCI. Ongoing initiatives are required to reduce barriers to calling the ambulance early after symptom onset.

High level of capture of coronary intervention and associated acute coronary syndromes in the all New Zealand acute coronary syndrome quality improvement cardiac registry and excellent agreement with national administrative datasets (ANZACS-QI 25).

BACKGROUND: The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry was designed to collect data on all coronary angiograms and percutaneous coronary interventions (PCI) in New Zealand, and all acute coronary syndromes (ACS) associated with these procedures. This study compares the completeness of capture in ANZACS-QI of coronary procedures and ACS admissions with those recorded in the National Hospitalisation Dataset and evaluates data quality by assessing agreement in ACS diagnoses and coronary procedures between datasets. METHODS: The national dataset, which included all New Zealand public hospital admissions in 2015 (n=962,700 episodes), was anonymously linked with the ANZACS-QI CathPCI (n=14,649 coronary angiogram episodes) and ACS cohorts (n=8,141 episodes) for 2015. Total numbers of coronary angiogram, PCI and ACS admissions were used as denominators and calculated by combining unique episodes from both data sources. RESULTS: Of all coronary angiogram episodes (n=15,377) and all PCI episodes (n=5,711), 92% were captured in both datasets, 5% in the national dataset only and 3% in ANZACS-QI only. Overall, 95% of coronary angiogram and PCI episodes were captured in ANZACS-QI. Of ACS episodes with associated coronary angiography (n=8,237), 85% were captured. Overall, 54% of all ACS episodes (n=15,167) were captured, including 71% in <70-year-olds. Seventy-five percent of all ST-elevation myocardial infarctions (STEMI) were captured. Ninety percent of ACS diagnoses in ANZACS-QI had a matching diagnosis in the national dataset. There was excellent agreement in recorded gender, date of birth and ethnicity (>99%). Sub-type of ACS was also highly concordant for STEMI and non-STEMI diagnoses (92% and 89% agreement, respectively). CONCLUSIONS: Consistent with its aim, the ANZACS-QI registry captured almost all New Zealand public hospital coronary angiography and PCI procedures including those associated with an ACS diagnosis. The high level of agreement between the registry and national dataset supports the use of both datasets for ongoing quality improvement reporting and research.

Trends in ischaemic heart disease: patterns of hospitalisation and mortality rates differ by ethnicity (ANZACS-QI 21).

AIM: To examine trends in ischaemic heart disease (IHD) events by ethnicity. METHODS: All IHD deaths and hospitalisations from 2006-2015 were identified using individual-linkage of national hospitalisation and mortality data. Age-standardised IHD rates and average annual age-adjusted percent changes were estimated by ethnic group. Ratios of non-fatal to fatal events were calculated by dividing age-standardised hospitalisation by death rates. RESULTS: IHD mortality rates declined by 3.1-5.4% per year for most groups, except Pacific women, who experienced a non-significant decline of 1.3% per year. IHD hospitalisation rates declined significantly by 3.6-8.8% per year in all groups. IHD mortality rates were highest in Maori and Pacific people, but hospitalisation rates highest in Indians. Indians also had the highest ratio of hospitalisations to deaths. For every person who died from IHD in 2014/15, 7-8 Indians, but only 3-4 Maori or Pacific people, were hospitalised with IHD. CONCLUSION: Fatal and non-fatal IHD rates are declining in all groups, but Maori and Pacific people have disproportionately high rates of IHD mortality. The much lower ratio of IHD hospitalisations to deaths among Maori and Pacific people compared to others suggests there are still important barriers to preventive interventions and acute care for Maori and Pacific men and women.

Seasonal variation in Takotsubo syndrome compared with myocardial infarction: ANZACS-QI 16.

BACKGROUND: The incidence of myocardial infarction (MI) is characterised by seasonal variation, with a winter peak and summer trough. Takotsubo syndrome (TS) mimics MI, but is thought to have a distinct aetiology and may exhibit a reversed pattern of seasonal variation. This study investigated the seasonal variation in the incidence of TS in comparison to MI. METHODS: Two hundred and sixty consecutive patients with TS (95% women, median age 66 years) admitted between March 2004 and December 2016 in the Auckland region of New Zealand were identified. The study population was grouped into three-month intervals (seasons) according to the date of admission to analyse for potential seasonal variations in the incidence. The TS cohort was compared with 36,376 patients who presented with acute MI in the Auckland region (40% women, median age 71 years) between March 2004 and December 2016. RESULTS: The onset of TS differed as a function of season (p=0.02), with the events most frequent in summer (n=77, 30%) and least so in winter (n=46, 18%). In contrast, incidence of MI also varied by season (p=0.0003), with highest events in winter and lowest in summer. CONCLUSION: The pattern of seasonal variation in TS is reversed compared with MI, with peaks during summer.

30-day mortality after percutaneous coronary intervention in New Zealand public hospitals (ANZACS-QI 18).

AIM: The aim of this report is to provide hospitals in New Zealand with data about their own outcomes for percutaneous coronary intervention (PCI) procedures and allow comparisons with other New Zealand units and with international data. METHODS: All PCI procedures (n=5,033) were identified in nine public hospital catheterisation laboratories between 1 October 2014 and 30 September 2015. Risk-adjusted mortality rates were derived for each hospital and compared with the national rate. RESULTS: The overall 30-day mortality rate after PCI was 1.23%. The national 30-day mortality rates were 3.28% for the subgroup of patients treated for a ST segment elevation myocardial infarct and 0.66% for those treated for other acute coronary syndrome (ACS) or non-ACS indications. There were no statistically significant differences in outcomes between the different New Zealand public hospital catheterisation laboratories, either overall or for each patient subgroup. CONCLUSIONS: Mortality rates in the first 30 days after PCI are low and comparable across New Zealand public hospitals. The outcomes are comparable with international experience.

One in four major ischaemic heart disease events are fatal and 60% are pre-hospital deaths: a national data-linkage study (ANZACS-QI 8).

Aims: The aim of this study is to determine proportions of major ischaemic heart disease (IHD) events that are fatal and where they occur, in an era of rapidly falling IHD mortality. Methods and Results: Individual person linkage of national data sets identified all IHD hospitalizations and deaths in New Zealand from December 2008 to November 2010. Outcome measures were proportions of people: (i) hospitalized with IHD and alive at 28 days; (ii) hospitalized with IHD and died within 28 days; (iii) hospitalized for a non-IHD cause and died from IHD within 28 days; and (iv) not hospitalized and died from IHD. Three event definitions were used [broad-balanced: IHD deaths and IHD hospitalizations, unbalanced: IHD deaths and myocardial infarction (MI) hospitalizations, and narrow-balanced: MI deaths and MI hospitalizations]. About 37 867 IHD hospitalizations and 9409 IHD deaths were identified using the broad IHD definition. Approximately one-quarter of IHD events were fatal: 4% were deaths within 28 days of an IHD hospitalization, 6% were IHD deaths within 28 days of a non-IHD hospitalization, and 14% were non-hospitalized IHD deaths. Using different event definitions, overall case fatality varied from 24­25% (broad and narrow balanced) to 37­39% (unbalanced), whereas the proportion of all deaths that were non-hospitalized was approximately 60%. Forty per cent of deaths were first-ever events that manifested as non-hospitalized IHD deaths. Conclusion: About one-quarter of IHD are fatal, although the proportion is dependent on disease definitions and age. About 60% of all IHD deaths occur out of hospital, and of these 60% are in people not previously hospitalized for IHD.

The All New Zealand Acute Coronary Syndrome Quality Improvement Programme: Implementation, Methodology and Cohorts (ANZACS-QI 9).

The All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI) uses a web-based system to create a clinical registry of patients with acute coronary syndrome (ACS) and other cardiac problems admitted to hospitals across New Zealand. This detailed clinical registry is complemented by parallel analyses of, and individual linkage to, New Zealand's multiple routine health information datasets. The programme is primarily designed to support secondary care clinicians to implement evidence based guidelines and to meet national performance targets for New Zealand cardiac patients. ANZACS-QI simultaneously generates a large-scale research database and provides an electronic data infrastructure for clinical registry studies. ANZACS-QI has been successfully implemented in all the 41 public hospitals across New Zealand where acute cardiac patients are admitted. By June 2015 25,273 patients with suspected ACS and 30,696 referred for coronary angiography were registered in ANZACS-QI. In this report we describe the development and national implementation of ANZACS-QI, its governance, the data collection processes and the current ANZACS-QI cohorts and available outputs.

Ethnic differences in case fatality following an acute ischaemic heart disease event in New Zealand: ANZACS-QI 13.

BACKGROUND: The aim of this study was to investigate ischaemic heart disease (IHD) case fatality in high-risk ethnic populations in New Zealand. DESIGN: This is a national data-linkage study using anonymised hospitalisation and mortality data. METHODS: Linked individual patient data were used to identify 35-84-year-olds who experienced IHD events (acute IHD hospitalisations and/or deaths) in 2009-2010. Subjects were classified as: (i) hospitalised with IHD and alive at 28 days post-event; (ii) hospitalised with IHD and died within 28 days; (iii) hospitalised with a non-IHD diagnosis and died from IHD within 28 days; or (iv) died from IHD but not hospitalised. Multinomial logistic regression was used to estimate the proportion of people in each group, as well as overall 28-day case fatality, adjusted for ethnic differences in demographic and comorbidity profiles. RESULTS: A total of 26,885 people experienced IHD events (11.3% Maori, 4.0% Pacific and 2.5% Indian); 3.3% of people died within 28 days of IHD hospitalisations, 5.1% died of IHD within 28 days of non-IHD hospitalisations and 13.0% died of IHD without any recent hospitalisation. Overall adjusted case fatality was 12.6% in Indian, 20.5% in European, 26.0% in Pacific and 27.6% in Maori people. Compared to Europeans, the adjusted odds of death were approximately 50% higher in Maori and Pacific people and 50% lower in Indians, regardless of whether they were hospitalised. CONCLUSIONS: Major ethnic inequalities in IHD case fatality occur with and without associated hospitalisations. Improvements in both primary prevention and hospital care will be required to reduce inequalities.