English as a second language and outcomes of patients presenting with acute coronary syndromes: results from the CONCORDANCE registry.

OBJECTIVES: To investigate whether patients with English as their second language have similar acute coronary syndrome (ACS) outcomes to people whose first language is English. DESIGN: Retrospective, observational study, using admissions, treatment and follow-up data. PARTICIPANTS AND SETTING: A total of 6304 subjects from 41 sites enrolled in the investigator-initiated CONCORDANCE ACS registry. MAIN OUTCOME MEASURES: Baseline characteristics, treatments, and in-hospital and 6-month mortality. RESULTS: English as a second language (ESL) was reported by 1005 subjects (15.9%). Patients with English as their first language (EFL) were older, and were less likely to have diabetes mellitus or to smoke than the ESL patients. Prior myocardial infarction, heart failure and chronic renal failure were more common in the ESL group. In-hospital mortality was also higher in these patients (7.1% v 3.8% for EFL patients; P < 0.001). Predictors of in-hospital mortality included presentation in cardiogenic shock, cardiac arrest in hospital, a history of renal failure, prior cardiac failure, and ESL. Rates of cardiac catheterisation, percutaneous coronary intervention rates, and referral to cardiac rehabilitation were lower in the ESL group; at 6 months, all-cause mortality was also higher (13.8% v 8.3% for EFL group; P < 0.001). Logistic regression identified language, age, in-hospital renal failure, and recurrent ischaemia as predictors of 6-month mortality. CONCLUSION: Patients presenting with an ACS who report English as their second language have poorer outcomes than patients who use English as their first language. This difference may not be entirely explained by baseline demographic disparities or management differences.

Evidence-based care in a population with chronic kidney disease and acute coronary syndrome. Findings from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE).

BACKGROUND: Acute coronary syndrome (ACS) guidelines recommend that patients with chronic kidney disease (CKD) be offered the same therapies as other high-risk ACS patients with normal renal function. Our objective was to describe the gaps in evidence-based care offered to patients with ACS and concomitant CKD. METHODS: Patients presenting to 41 Australian hospitals with suspected ACS were stratified by presence of CKD (glomerular filtration rate <60 mL/min). Receipt of evidence-based care including, coronary angiography (CA), evidence-based discharge medications (EBMs), and cardiac rehabilitation (CR) referral, were compared between patients with and without CKD. Hospital and clinical factors that predicted receipt of care were determined using multilevel multivariable stepwise logistic regression models. RESULTS: Of the 4,778 patients admitted with suspected ACS, 1,227 had CKD. On univariate analyses, patients with CKD were less likely to undergo CA (59.1% vs 85.0%, P < .0001) or receive EBM (69.4% vs 78.7%, P < .0001), or were offered CR (49.5% vs 68.0%, P < .0001). After adjusting for patient characteristics and clustering by hospital, CKD remained an independent predictor of not undergoing CA only (odds ratio 0.48, 95% CI 0.37-0.61). Within the CKD cohort, presenting to a hospital with a catheterization laboratory was the strongest predictor of undergoing CA (odds ratio 3.07, 95% CI 1.91-4.93). CONCLUSION: The presence of CKD independently predicts failure to undergo CA but not failure to receive EBM or CR, which is predicted by comorbidities. Among the CKD population, performance of CA is largely determined by admission to a catheterization capable hospital. Targeting these patients through standardization of care across institutions offers opportunities to improve outcomes in this high-risk population.

Falling cholesterol trend at acute coronary syndrome presentation is strongly related to statin use for secondary prevention.

BACKGROUND: Lifestyle changes are believed responsible for temporal trends of reduced population total cholesterol (TC), but it is uncertain whether this applies to patients with known coronary heart disease (CHD) often prescribed lipid lowering therapy (LLT). We studied temporal TC trends at presentation with acute coronary syndrome (ACS) to determine the contribution of LLT given for secondary prevention. METHODS: TC and LLT were obtained in 5592 patients in annual surveys of ACS admissions in Australia between 1999 and 2013, and annual mean trends analysed by linear and segmented regression. RESULTS: TC declined from 5.13±1.1 to 4.53±1.2mmol/L (p<0.001) and LLT (96% statin) use at presentation increased from 37.4% to 47.5% (p=0.005). TC decline was greater in those on LLT vs. those not on therapy, with LLT contributing to 57% of the TC decline. The decline in TC and increase in LLT use was non-linear and much steeper in those with, than without CHD history, and LLT contributed substantially more to the TC decline (79%, p<0.001 vs. 27%, p=0.06 respectively). The rapid decline in TC and increase in LLT, plateauing after 2005 in those with CHD history differed markedly from trends in recent population studies, while TC trend for those without CHD history was slower, linear and consistent with population trends. CONCLUSIONS: Declining TC level at presentation for ACS was strongly associated with increasing LLT use in those with a history of CHD, indicating that increasing uptake of LLT for secondary prevention has impacted TC changes in the new millennium.

The relationship between the proportion of admitted high risk ACS patients and hospital delivery of evidence based care.

AIMS: Variations in the delivery of evidence based care to high risk patients with Acute Coronary Syndromes (ACS) exist between hospitals. We hypothesised that the relative proportion of admitted high risk patients contributes to variation in care and outcomes. METHODS: Receipt of evidence based therapies (EBT) according to patient risk was documented in the Australian Co-operative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE). Hospitals were stratified into quartiles (Q) by fraction of high risk patients according to: GRACE Risk Score (GRS), chronic kidney disease (CKD), age, Killip class, and myocardial infarction (MI). For each category, EBT and mortality were compared between hospital groups. RESULTS: This study included 8390 ACS patients from 39 hospitals. Patients with GRS>130, CKD, and >80years, were less likely to receive EBT at high proportion hospitals (p<0.0001 for all). After adjustment, proportion of patients with CKD negatively predicted coronary angiography (CA) (Q4 vs Q1: OR 0.21, 95%CI 0.10-0.45). Adjusted 6month mortality was greater in CKD and trended greater in >80years in hospitals treating the highest proportions of these patients (Q4 vs Q1 OR 3.80, 95%CI 1.85-7.83, and OR 3.10, 95%CI 0.99-9.70 respectively). CONCLUSION: Elderly ACS patients and those with CKD are less likely to receive EBT at hospitals seeing high proportions of these patients. Failure to provide EBT to these high risk populations may contribute to avoidable mortality in these institutions.