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.

Correlation between epicardial adipose tissue and body mass index in New Zealand ethnic populations.

AIM: We aimed to investigate the correlation between epicardial adipose tissue (EAT) and body mass index (BMI) in different ethnic groups in New Zealand. METHODS: The study included 205 individuals undergoing open heart surgery. Maori and Pacific groups were combined to increase statistical power. EAT was measured using 2D echocardiography. RESULTS: There were 164 New Zealand Europeans (NZE) and 41 Maori/Pacific participants. The mean (SD) age of the study group was 67.9 (10.1) years, 69.1 (9.5) for NZE and 63.5 (11.4) for Maori/Pacific. BMI was 29.6 (5.5) kg/m2 for NZE and 31.8 (6.2) for Maori/Pacific. EAT thickness was 6.2 (2.2) mm and 6.0 (1.8) mm for NZE and Maori/Pacific, respectively. Using univariate linear regression, BMI showed moderate correlation with EAT in NZE (R2=0.26, p<0.001); however, there was no significant correlation between BMI and EAT in Maori/Pacific patients (R2=0.05, p=0.17). Using multivariate analysis, BMI remained a significant predictor of EAT thickness in NZE (R2 =0.27, p<0.001). CONCLUSIONS: BMI was associated with EAT thickness in NZE patients, but not in Maori/Pacific patients. The same level of BMI can carry different connotations of risk in different ethnic groups, with BMI likely being an inconsistent measure of obesity in in Maori/Pacific patients.

Changes to management of a non-pandemic illness during the COVID-19 pandemic: case study of invasive management of acute coronary syndrome.

The coronavirus 2019 (COVID-19) pandemic requires significant changes to standard operating procedures for non-COVID-19 related illnesses. Balancing the benefit from standard evidence-based treatments with the risks posed by COVID-19 to patients, healthcare workers and to the population at large is difficult due to incomplete and rapidly changing information. In this article, we use management of acute coronary syndromes as a case study to show how these competing risks and benefits can be resolved, albeit incompletely. While the risks due to COVID-19 in patients with acute coronary syndromes is unclear, the benefits of standard management are well established in this condition. As an aid to decision making, we recommend systematic estimation of the risks and benefits for management of any condition where there is likely to be an increase in non-COVID-19 related mortality and morbidity due to changes in routine care.

The impact of a national COVID-19 lockdown on acute coronary syndrome hospitalisations in New Zealand (ANZACS-QI 55).

BACKGROUND: Countries with a high incidence of coronavirus 2019 (COVID-19) reported reduced hospitalisations for acute coronary syndromes (ACS) during the pandemic. This study describes the impact of a nationwide lockdown on ACS hospitalisations in New Zealand (NZ), a country with a low incidence of COVID-19. METHODS: All patients admitted to a NZ Hospital with ACS who underwent coronary angiography in the All NZ ACS Quality Improvement registry during the lockdown (23 March - 26 April 2020) were compared with equivalent weeks in 2015-2019. Ambulance attendances and regional community troponin-I testing were compared for lockdown and non-lockdown (1 July 2019 to 16 February 2020) periods. FINDINGS: Hospitalisation for ACS was lower during the 5-week lockdown (105 vs. 146 per-week, rate ratio 0•72 [95% CI 0•61-0•83], p = 0.003). This was explained by fewer admissions for non-ST-segment elevation ACS (NSTE-ACS; p = 0•002) but not ST-segment elevation myocardial infarction (STEMI; p = 0•31). Patient characteristics and in-hospital mortality were similar. For STEMI, door-to-balloon times were similar (70 vs. 72 min, p = 0•52). For NSTE-ACS, there was an increase in percutaneous revascularisation (59% vs. 49%, p<0•001) and reduction in surgical revascularisation (9% vs. 15%, p = 0•005). There were fewer ambulance attendances for cardiac arrests (98 vs. 110 per-week, p = 0•04) but no difference for suspected ACS (408 vs. 420 per-week, p = 0•44). Community troponin testing was lower throughout the lockdown (182 vs. 394 per-week, p<0•001). INTERPRETATION: Despite the low incidence of COVID-19, there was a nationwide decrease in ACS hospitalisations during the lockdown. These findings have important implications for future pandemic planning. FUNDING: The ANZACS-QI registry receives funding from the New Zealand Ministry of Health.

Beat-to-beat blood pressure measurement using a cuffless device does not accurately reflect invasive blood pressure.

BACKGROUND: The availability of an accurate continuous cuffless blood pressure (BP) monitor would provide an alternative to both invasive continuous BP and 24-h intermittent cuff-based BP monitors. We investigated the accuracy of a cuffless beat to beat (BtB) device compared to both invasive BP (iBP) and brachial cuff BP (cBP) measurements. METHODS: Patients undergoing clinically indicated coronary angiography (CA) and/or percutaneous coronary intervention (PCI) were recruited. After calibration to an initial cBP reading, BP was measured simultaneously using a BtB device (SOMNOtouch NIBP), brachial artery iBP, and cBP at two time points. RESULTS: The study was terminated early due to a significant bias. Recordings from 14 participants (11 males, mean age 68.4 years) were analysed. Readings from BtB BP were higher than iBP. The bias between BtB BP and iBP was 34.3 mmHg (95%CI: 27.0, 41.5) and 23.6 mmHg (95%CI: 16.8, 30.4) for SBP and DBP respectively. A similar bias was seen between BtB BP and cBP, but cBP and iBP were largely in agreement. CONCLUSIONS: In patients undergoing CA/PCI, significant differences were detected between BtB BP and both invasively measured and cuff BP. The non-invasive BtB BP measurement device tested is not suitable for clinical or research use.

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.

A decade of improvement in the management of New Zealand ST-elevation myocardial infarction (STEMI) patients: results from the New Zealand Acute Coronary Syndrome (ACS) Audit Group national audits of 2002, 2007 and 2012.

AIMS: To audit the management of ST-segment elevation myocardial infarction (STEMI) patients admitted to a New Zealand Hospital over three 14-day periods to review their number, characteristics, management and outcome changes over a decade. METHODS: The acute coronary syndrome (ACS) audits were conducted over 14 days in May of 2002, 2007 and 2012 at New Zealand Hospitals admitting patients with a suspected or definite ACS. Longitudinal analyses of the STEMI subgroup are reported. RESULTS: From 2002 to 2012, the largest change in management was the proportion of patients undergoing reperfusion by primary PCI from 3% to 15% and 41%; P<0.001, and the rates of second antiplatelet agent use in addition to aspirin from 14% to 62% and 98%; P<0.001. The use of proven secondary prevention medications at discharge also increased during the decade. There were also significant increases in cardiac investigations for patients, especially echocardiograms (35%, 62% and 70%, P<0.001) and invasive coronary angiograms (31%, 58% and 87%, P<0.001). Notably even in 2012, one in four patients presenting with STEMI did not receive any reperfusion therapy. CONCLUSIONS: Substantial improvements have been seen in the management of STEMI patients in New Zealand over the last decade, in accordance with evidenced-based guideline recommendations. However, there appears to be considerable room to optimise management, particularly with the use of timely reperfusion therapy for more patients.

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.

Plasma heat shock protein 27 is associated with coronary artery disease, abdominal aortic aneurysm and peripheral artery disease.

Low protein levels of Hsp27 have been reported in atherosclerotic plaques. In addition, human studies have indicated that circulating Hsp27 levels are lower in coronary artery disease patients compared with controls. It remains, however, unclear whether this applies to other forms of atherosclerotic disease. Plasma Hsp27 from 280 subjects was examined by ELISA. The cohort included 80 coronary artery disease (CAD), 40 peripheral artery disease (PAD) and 80 abdominal aortic aneurysm (AAA) patients. Eighty elderly subjects, without any clinical history of vascular diseases, were used as a control group. Receiver operating curve (ROC) and logistic regression model analysis were performed to evaluate the potential value of Hsp27 as a circulating biomarker. Patients with atherosclerotic vascular diseases had significantly lower levels of Hsp27 than control subjects (p < 0.001). Moreover, Hsp27 was significantly lower in CAD patients than other atherosclerotic vascular disease groups (p < 0.001). There was no difference in Hsp27 levels between the AAA and PAD groups. Using the ROC-generated optimal cut-off values for Hsp27, logistic regression modeling indicated that low plasma Hsp27 was independently associated with the presence of multiple forms of atherosclerotic disease. In conclusion, circulating Hsp27 is significantly lower in patients with multiple forms of atherosclerotic arterial disease.

Spontaneous coronary artery dissection: long stenting in a patient with polycythemia vera.

Spontaneous coronary artery dissection is a rare cause of myocardial ischemia or sudden cardiac death. We describe a patient with polycythemia vera and a chronic spontaneous coronary artery dissection who was treated with successful angioplasty and long stenting.

Tricuspid Regurgitation and Right Heart Dimensions at Early and Late Follow-Up After Orthotopic Cardiac Transplantation.

Tricuspid regurgitation is common immediately after cardiac transplantation, but its course over long-term follow-up is not known. This study was performed to determine the prevalence of valvular regurgitation and to evaluate if pulmonary hypertension or right ventricular enlargement were associated with the severity of tricuspid regurgitation at early and late follow-up after cardiac transplantation. Fifty-five patients had hemodynamic and echocardiographic studies performed at 1 week and 2.4 +/- 1.3 years after cardiac transplantation. Right ventricular dimensions were measured and related to the severity of tricuspid regurgitation as assessed by Doppler color flow. There was a fall in right heart filling pressures with decreases in the systolic pulmonary artery pressure (31 mmHg +/- 7 mmHg vs 27 mmHg +/- 7 mmHg, P = 0.0001) and right atrial pressure (8 +/- 5 mmHg vs 6 +/- 4 mmHg, P < 0.01). Sixty-three percent of patients had mild or higher grade tricuspid regurgitation initially and 71% at follow-up (P = NS). The major determinant of tricuspid regurgitation severity at late follow-up was the presence of flail tricuspid leaflets (P < 0.0001). There was an association between the change in grade of tricuspid regurgitation and the change in right ventricular diastolic area (P = 0.002) and the change in tricuspid annulus diameter (P < 0.0001). The prevalence of tricuspid regurgitation remains high at late follow-up after cardiac transplantation and neither pulmonary hypertension nor right ventricular dilatation are prerequisites for tricuspid regurgitation, which can persist in their absence. Flail tricuspid leaflets are the most important predictors of the severity of tricuspid regurgitation following cardiac transplantation.