Suspected ACS Patients Presenting With Myocardial Damage or a Type 2 Myocardial Infarction Have a Similar Late Mortality to Patients With a Type 1 Myocardial Infarction: A Report From the Australian and New Zealand 2012 SNAPSHOT ACS Study

BACKGROUND

Cardiac troponin (T and I) are considered the standard markers for detection of myocardial damage and the diagnosis of acute coronary syndrome (ACS) among patients who present to an emergency department with chest pain. However, these markers can be released in other situations and may be associated with short- and long-term clinical outcomes. In this study, we examine late mortality rates among patients presenting with a suspected ACS due to an unstable coronary plaque and those patients having a non-ACS.

METHODS

4388 patients were hospitalised with suspected ACS, between 14 and 27 May 2012 in the Australia and New Zealand SNAPSHOT ACS study. Those patients were categorised in five diagnostic groups: 1) ST elevation MI (n=419); 2) non-ST elevation MI (n=1012); 3) unstable angina (n=925); 4) non-ACS diagnoses (n=837); and 5) chest pain considered unlikely ischaemic (not otherwise specified, n=1195).

RESULT

The respective mortality rates at 18 months in these groups were 16.2%, 16.3%, 6.8%, 12.8%, and 4.8%; Pearson χ²=110 p<0.001. Among non-ACS diagnoses patients (group 4) those with the highest mortality rates (cardiac (14.4%), respiratory (18.2%), sepsis (15.4%) and neoplastic (67%) diagnoses) had the highest rates of elevated troponin levels (48%, 31%, 38% and 67% respectively). By contrast, those with the lowest mortality rates (musculoskeletal (2.9%), gastrointestinal disorders (3.9%) and non-specific chest pain (7.4%)) had the lowest rate of elevated troponin levels (9%, 18% and 15.8% respectively). However, after adjusting for baseline clinical and demographic characteristics, the mortality rate at 18 months for patients with elevated troponin was similar for ACS or non-ACS diagnoses (Hazard Ratio, 95% C.I.0.98-1.07, p=0.333).

CONCLUSIONS

Among patients in the 2012 SNAPSHOT ACS study, non-ACS diagnoses characterised by high rates of elevated troponin levels had high mortality rates similar to those diagnosed with ACS. Therapies known to be effective in ACS patients, including early invasive management, should be examined in these non-ACS patients with troponin elevations within adequately powered randomised trials.

House Calls

I have always enjoyed doing house calls and in some cases consider it part of the general practice care of patients. I get to see the context that the patient lives in as well as often meet significant others whom I would not normally meet. It also gets me out of the rooms for a change of scenery.

A Study of Coronary Bifurcation Shape in a Normal Population

During percutaneous coronary intervention, stents are placed in narrowings of the arteries to restore normal blood flow. Despite improvements in stent design, deployment techniques and drug-eluting coatings, restenosis and stent thrombosis remain a significant problem. Population stent design based on statistical shape analysis may improve clinical outcomes. Computed tomographic (CT) coronary angiography scans from 211 patients with a zero calcium score, no stenoses and no intermediate artery, were used to create statistical shape models of 446 major coronary artery bifurcations (left main, first diagonal and obtuse marginal and right coronary crux). Coherent point drift was used for registration. Principal component analysis shape scores were tested against clinical risk factors, quantifying the importance of recognised shape features in intervention including size, angles and curvature. Significant differences were found in (1) vessel size and bifurcation angle between the left main and other bifurcations; (2) inlet and curvature angle between the right coronary crux and other bifurcations; and (3) size and bifurcation angle by sex. Hypertension, smoking history and diabetes did not appear to have an association with shape. Physiological diameter laws were compared, with the Huo-Kassab model having the best fit. Bifurcation coronary anatomy can be partitioned into clinically meaningful modes of variation showing significant shape differences. A computational atlas of normal coronary bifurcation shape, where disease is common, may aid in the design of new stents and deployment techniques, by providing data for bench-top testing and computational modelling of blood flow and vessel wall mechanics.

An Acronymic Wilderness

No abstract available.

The value of CT cardiac angiography and CT calcium score testing in a modern cardiology service in New Zealand: a report of a single centre eight-year experience from 5,237 outpatient procedures

BACKGROUND

Computed tomographic (CT) cardiac angiography is of increasing value in several areas of patient management in cardiology. We assessed the ability of CT cardiac angiography to effectively 'rule out' severe coronary stenoses in patients presenting with 'atypical' symptoms and/or an equivocal stress test, which offers a new approach to the management of coronary artery disease. We also examined the use of the CT calcium score test in cardiovascular (CVS) risk assessment.

METHODS

From a large single centre (Mercy Hospital) in Auckland, using a prospectively acquired, comprehensive database, we audited the entire eight-year experience of 5,169 patients (7/8/06 to 31/1/14) who underwent 5,237 64-slice computed tomographic (CT) cardiac angiogram or CT calcium score tests (GE Lightspeed scanner).

RESULTS

From 5,169 patients there were 5,237 CT procedures. The mean patient age was 57 (SD 10) years; 42% patients were female. Of the 3,603 (69%) full CT cardiac angiogram scans, 3,509 (67%) included a calcium score test. One thousand four hundred and eighty-three (28%) of scans were a calcium score test only. Of the 3,603 (69%) full CT cardiac angiogram scans, it was possible to 'rule out' significant coronary atheroma (stenosis ≥50%) in 2,947 (82%) of these procedures. Of the 4,903 (94%) patients who had a CT calcium score test, in whom we could calculate the NZ Framingham-based CVS risk, it was possible to reassign 532 (22%) of these patients who were previously thought to be at 'low risk' to be at a higher CVS risk.

CONCLUSION

CT cardiac angiography has become established in the modern management of cardiology patients. It has particular value as a tool to 'rule out' severe coronary stenoses, and as a tool to give a more accurate assessment of CVS risk. It adds significant value to the care of many patients within an established cardiology practice.

Books as therapy

No abstract available.

Clinical conundrums in primary health care

No abstract available.

Factors that shape the patient's hospital experience and satisfaction with lower limb arthroplasty: an exploratory thematic analysis

OBJECTIVE

It is generally accepted that the patients' hospital experience can influence their overall satisfaction with the outcome of lower limb arthroplasty; however, little is known about the factors that shape the hospital experience. The aim of this study was to develop an understanding of what patients like and do not like about their hospital experience with a view to providing insight into where service improvements could have the potential to improve the patient experience and their satisfaction, and whether they would recommend the procedure.

DESIGN

A mixed methods (quan-QUAL) approach.

SETTING

Large regional teaching hospital.

PARTICIPANTS

216 patients who had completed a postoperative postal questionnaire at 12 months following total knee or total hip arthroplasty.

OUTCOME MEASURES

Overall satisfaction with the outcome of surgery, whether to recommend the procedure to another and the rating of patient hospital experience. Free text comments on the best and worst aspects of their hospital stay were evaluated using qualitative thematic analysis.

RESULTS

Overall, 77% of patients were satisfied with their surgery, 79% reported a good-excellent hospital experience and 85% would recommend the surgery to another. Qualitative analysis revealed clear themes relating to communication, pain relief and the process experience. Comments on positive aspects of the hospital experience were related to feeling well informed and consulted about their care. Comments on the worst aspects of care were related to being made to wait without explanation, moved to different wards and when they felt invisible to the healthcare staff caring for them.

CONCLUSIONS

Positive patient experiences were closely linked to effective patient-health professional interactions and logistics of the hospital processes. Within arthroplasty services, the patient experience of healthcare could be enhanced by further attention to concepts of patient-centred care. Practical examples of this include more focus on developing staff-patient communication and the avoidance of 'boarding' procedures.

The dissonance between teaching and practice

No abstract available.

<i>Izilwane, imikhovu</i> and <i>izimpaka</i> – mythical creatures as explanations of illness

No abstract available.

Abstract P3-07-08: Quantitative HER family proteins assessment as prognostic and predictive biomarkers in the EGF30008 clinical trial

Background

Combined targeted strategy with letrozole (Le) and lapatinib (La) improves progression-free survival (PFS) in patients with metastatic breast cancer (MBC) co-expressing hormone receptor-positive (HR+) and HER2+ but not in HR+/HER2-negative (HER-) disease (Johnston J Clin Oncol 2009). However, among HER2+ tumors, quantitative levels of HER2 are heterogeneous with a broad dynamic range corresponding to approximately 163.7 to 17446.7 amol/µg as previously reported (Nuciforo SABCS 2014). In addition, within HER2- tumors, quantitative measurement of HER family proteins may identify those patients most likely to benefit from the addition of La to Le. In this retrospective study, we tested the prognostic and predictive ability of HER proteins quantification in clinically HER2+ tumor samples from the EGF30008 study.

Methods

Formalin-fixed paraffin-embedded primary tumor tissues sections from HER2+ MBC population were used. After laser microdissection, tissue lysates were prepared for selected reaction monitoring mass spectrometry (SRM-MS) analysis. Absolute quantitation was accomplished through simultaneous detection of endogenous target and synthetic labeled heavy peptide identical to analytical targets (EGFR, HER2, HER3). HER2 protein levels were correlated with PAM50 molecular subtypes, ERBB2 and ESR1 genes by nCounter. PFS and overall survival (OS) were analyzed by Kaplan–Meier and log-rank test. To determine whether HER2 protein levels were predictive of La benefit, we tested the interaction term of HER2 protein as a continuous variable by treatment arm in a Cox model.

Results

Within the HER2+ study cohort (n=219), 107 had an available tumor block; 84 cases had sufficient material for HER expression measurement by SRM-MS. Average HER2 levels were

2321.1 amol/ug (median, 817.6). HER2 levels were lower in Le+La (n=43; mean, 1761 amol/ug) compared to Le (n=41; mean, 2908 amol/ug) arms, although the difference was non-significant (p=0.108). No expression of EGFR and HER3 was observed. HER2 protein levels were significantly different among PAM50 subtypes with HER2-enriched (HER2E) tumors showing the highest expression followed by Basal-like, Luminal A, Luminal B, and Normal-like (p&lt;0.001). A correlation between HER2 protein, ERBB2 (r=0.5, p&lt;0.001) and ESR1 (r=-0.5, p=0.001) gene expression was found. In patients with disease that expresses HER2 protein levels above the median a trend towards worse PFS (2.9 vs 7.7 months, p=0.092) and OS (21 vs 39 months, p=0.071) were observed. A statistically significant interaction was observed between HER2 protein levels and La treatment for both PFS (p=0.049) and OS (p&lt;0.001). HER2+ tumors with lower expression of HER2 benefited more from La than those with higher expression.

Conclusions

Levels of HER2 protein in HER2+ MBC are extremely heterogeneous. An association between HER2 protein and gene expression by nCounter was observed. HER2E tumors by PAM50 showed the highest levels of HER2 protein. Within the group of HER2+ MBC by standard IHC/FISH, tumors with high HER2 protein had a statistically non-significant worse outcome and do not seem to benefit from La. Further validation of these findings is warranted.

Citation Format: Nuciforo P, Thyparambil S, Galván P, Vilaro M, Jimenez J, Liao W-L, Cecchi F, Blackler A, Press MF, Gagnon R, Ellis C, Hembrough T, Johnston S, Prat A. Quantitative HER family proteins assessment as prognostic and predictive biomarkers in the EGF30008 clinical trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-08.

Abstract P2-08-16: Prognostic and predictive abilities of intrinsic subtype in hormone receptor-positive metastatic breast cancer from the EGF30008 phase III clinical trial

Background

Combination of letrozole and lapatinib improved progression-free survival (PFS) compared with letrozole and placebo in patients with hormone receptor-positive (HR+)/HER2+ metastatic breast cancer (MBC), but not HR+/HER2-negative (HER2-) disease (JCO 2009). However, HR+ disease is clinically and biologically heterogeneous with all intrinsic molecular subtypes (Luminal A, Luminal B, HER2-enriched [HER2E] and Basal-like) identified. Here, we tested retrospectively the prognostic and predictive ability of intrinsic subtype in tumor samples of the EGF30008 trial.

Methods

Expression profiling from FFPE tumor tissues was performed on the nCounter platform. Tumors were classified into each intrinsic subtype using the research-based PAM50 classifier (JCO 2009). Cox proportional hazard models for PFS and overall survival (OS) were used to generate point estimates of hazard ratios (HR) and corresponding 95% confidence intervals (CIs). Changes in likelihood ratio χ2 values were used to measure and compare the relative amount of information of each variable. Variables evaluated were: age, prior endocrine therapy, presence of visceral disease, number of metastatic sites, performance status, clinical HER2 status, and treatment. To determine whether the intrinsic subtypes were predictive of lapatinib benefit, we tested the interaction term of subtype by treatment arm in a Cox model that also included the main effects. Kaplan-Meier plots were used to depict the proportion of patients free from progression as a function of time.

Results

Tumor samples from 821 patients (63.8%) were profiled (85.7% primary and 14.3% metastatic tumor samples). Clinical-pathological features of this patient subset were well balanced compared with the original set. Within the entire cohort, all subtypes were identified: Luminal A (46.5%); Luminal B (29.7%); HER2E (7.4%); Basal-like (3.4%) and normal-like (12.9%). Within HER2+ disease, 28.6% of samples were HER2E. Intrinsic subtype was found the strongest prognostic factor independently associated with PFS and OS in all patients, and in patientswith HER2-negative or HER2+ disease (P&lt;0.0001). Median PFS and OS for each subtype within clinically HER2-negative disease were: Luminal A (16.85 and 45.0 months), Luminal B (10.97 and 37.0 months), HER2E (4.67 and 16.0 months) and Basal-like (4.14 and 23.0 months). Within clinically HER2-negative disease (n=644), 16 patients (2.5%) had HER2E disease. Patients with HER2-/HER2E disease benefited from lapatinib (6.5 vs 2.6 months; PFS HR =0.24, 95% CI: 0.07-0.86; P=0.019; HER2E vs not treatment interaction P=0.016). Finally, intrinsic subtype was not predictive of benefit from lapatinib within HER2+ disease.

Conclusions

HR-positive disease is biologically heterogeneous and intrinsic subtypes are strongly prognostic in a first-line MBC setting. HR+/HER2- disease with a HER2E profile may benefit from lapatinib. The clinical value of intrinsic subtyping in HR+ MBC warrants further investigation, but patients with Luminal A/HER2-negative MBC disease might be good candidates for letrozole monotherapy in the first-line setting regardless of visceral disease and number of metastases.

Citation Format: Prat A, Cheang MCU, Galván P, Nuciforo P, Paré L, Adamo B, Viladot M, Press MF, Gagnon R, Ellis C, Johnston S. Prognostic and predictive abilities of intrinsic subtype in hormone receptor-positive metastatic breast cancer from the EGF30008 phase III clinical trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-08-16.

Survival after an acute coronary syndrome: 18-month outcomes from the Australian and New Zealand SNAPSHOT ACS study

OBJECTIVES

To assess the impact of the availability of a catheterisation laboratory and evidence-based care on the 18-month mortality rate in patients with suspected acute coronary syndromes (ACS).

DESIGN, SETTING AND PARTICIPANTS

Management and outcomes are described for patients enrolled in the 2012 Australian and New Zealand SNAPSHOT ACS audit. Patients were stratified according to their presentation to hospitals with or without cardiac catheterisation facilities. Data linkage ascertained patient vital status 18 months after admission. Descriptive and Cox proportional hazards analyses determined predictors of outcomes, and were used to estimate the numbers of deaths that could be averted by improved application of evidence-based care.

MAIN OUTCOME MEASURES

Mortality for ACS patients from admission to 18 months after admission.

RESULTS

Definite ACS patients presenting to catheterisation-capable (CC) hospitals (n = 1326) were more likely to undergo coronary angiography than those presenting to non-CC hospitals (n = 1031) (61.5% v 50.8%; P = 0.0001), receive timely reperfusion (for ST elevation myocardial infarction (STEMI) patients: 45.2% v 19.2%; P < 0.001), and be referred for cardiac rehabilitation (57% v 53%; P = 0.05). All-cause mortality over 18 months was highest for STEMI (16.2%) and non-STEMI (16.3%) patients, and lowest for those presenting with unstable angina (6.8%) and non-cardiac chest pain (4.8%; P < 0.0001 for trend). After adjustment for patient propensity to present to a CC hospital and patient risk, presentation to a CC hospital was associated with 21% (95% CI, 2%-37%) lower mortality than presentation to a non-CC hospital. This mortality difference was attenuated after adjusting for delivery of evidence-based care.

CONCLUSION

In Australia and New Zealand, the availability of a catheterisation laboratory appears to have a significant impact on long-term mortality in ACS patients, which is still substantial. This mortality may be reduced by improvements in evidence-based care in both CC and non-CC hospitals.

Management of non ST-elevation acute coronary syndrome patients in New Zealand: a longitudinal analysis. Results from the New Zealand Acute Coronary Syndrome national audits of 2002, 2007 and 2012

AIMS

The first New Zealand Acute Coronary Syndrome (ACS) national audit of 2002 was a collaborative effort between clinicians and nurses, and demonstrated important limitations to Non ST-elevation ACS patient (NSTEACS) care. A momentum for change was created. Subsequent audits in 2007 and 2012 allow assessment over time.

METHODS

Over 14 days in May 2002, 2007 and 2012, patients with suspected ACS admitted to a hospital in New Zealand were audited. 'Definite' ACS was determined at discharge, after in-hospital investigations; we reviewed NSTEACS patients.

RESULTS

From 2002, more patients underwent assessment of left ventricular function (echocardiogram) and coronary angiography. Evidence-based in-hospital medical treatments and revascularisation have also increased over the decade.

CONCLUSIONS

Over a ten-year period, evidence-based care for patients presenting with a NSTEACS event in New Zealand has improved. However, considerable room remains to optimise management, particularly with development of systems of care to facilitate prompt referral and delivery of angiography in these high-risk individuals.

The design meeting

“Design is everything. Everything” – Paul Rand