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Kemp BJ, Thompson DR, Coates V, Bond S, Ski CF, Monaghan M, McGuigan K. International guideline comparison of lifestyle management for acute coronary syndrome and type 2 diabetes mellitus: A rapid review. Health Policy 2024; 146:105116. [PMID: 38943831 DOI: 10.1016/j.healthpol.2024.105116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 05/07/2024] [Accepted: 06/16/2024] [Indexed: 07/01/2024]
Abstract
Acute coronary syndrome (ACS) is a life-threatening condition, with ACS-associated morbidity and mortality causing substantial human and economic challenges to the individual and health services. Due to shared disease determinants, those with ACS have a high risk of comorbid Type 2 diabetes mellitus (T2DM). Despite this, the two conditions are managed separately, duplicating workload for staff and increasing the number of appointments and complexity of patient management plans. This rapid review compared current ACS and T2DM guidelines across Australia, Canada, Europe, Ireland, New Zealand, the UK, and the USA. Results highlighted service overlap, repetition, and opportunities for integrated practice for ACS-T2DM lifestyle management across diet and nutrition, physical activity, weight management, clinical and psychological health. Recommendations are made for potential integration of ACS-T2DM service provision to streamline care and reduce siloed care in the context of the health services for ACS-T2DM and similar comorbid conditions.
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Affiliation(s)
- Bridie J Kemp
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - David R Thompson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Vivien Coates
- School of Nursing and Paramedic Science, Ulster University, Magee Campus, Londonderry, UK
| | - Sarah Bond
- School of Nursing and Paramedic Science, Ulster University, Magee Campus, Londonderry, UK
| | - Chantal F Ski
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK; Australian Centre for Heart Health, Deakin University, Melbourne, Australia
| | | | - Karen McGuigan
- Queen's Communities and Place, Queen's University Belfast, Belfast, UK.
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McDermott M, Kimenai DM, Anand A, Huang Z, Houston A, Williams S, Evison F, Gallier S, Carenzo C, Glampson B, Hasan M, Robertson A, Phillips T, Davis C, Sapey E, Mayer E, Mason S, Stammers M, Mills NL. Adoption of high-sensitivity cardiac troponin for risk stratification of patients with suspected myocardial infarction: a multicentre cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2024; 43:100960. [PMID: 38975590 PMCID: PMC11227019 DOI: 10.1016/j.lanepe.2024.100960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 07/09/2024]
Abstract
Background Guidelines recommend high-sensitivity cardiac troponin to risk stratify patients with possible myocardial infarction and identify those eligible for discharge. Our aim was to evaluate adoption of this approach in practice and to determine whether effectiveness and safety varies by age, sex, ethnicity, or socioeconomic deprivation status. Methods A multi-centre cohort study was conducted in 13 hospitals across the United Kingdom from November 1st, 2021, to October 31st, 2022. Routinely collected data including high-sensitivity cardiac troponin I or T measurements were linked to outcomes. The primary effectiveness and safety outcomes were the proportion discharged from the Emergency Department, and the proportion dead or with a subsequent myocardial infarction at 30 days, respectively. Patients were stratified using peak troponin concentration as low (<5 ng/L), intermediate (5 ng/L to sex-specific 99th percentile), or high-risk (>sex-specific 99th percentile). Findings In total 137,881 patients (49% [67,709/137,881] female) were included of whom 60,707 (44%), 42,727 (31%), and 34,447 (25%) were stratified as low-, intermediate- and high-risk, respectively. Overall, 65.8% (39,918/60,707) of low-risk patients were discharged from the Emergency Department, but this varied from 26.8% [2200/8216] to 93.5% [918/982] by site. The safety outcome occurred in 0.5% (277/60,707) and 11.4% (3917/34,447) of patients classified as low- or high-risk, of whom 0.03% (18/60,707) and 1% (304/34,447) had a subsequent myocardial infarction at 30 days, respectively. A similar proportion of male and female patients were discharged (52% [36,838/70,759] versus 54% [36,113/67,109]), but discharge was more likely if patients were <70 years old (61% [58,533/95,227] versus 34% [14,428/42,654]), from areas of low socioeconomic deprivation (48% [6697/14,087] versus 43% [12,090/28,116]) or were black or asian compared to caucasian (62% [5458/8877] and 55% [10,026/18,231] versus 46% [35,138/75,820]). Interpretation Despite high-sensitivity cardiac troponin correctly identifying half of all patients with possible myocardial infarction as being at low risk, only two-thirds of these patients were discharged. Substantial variation in the discharge of patients by age, ethnicity, socioeconomic deprivation, and site was observed identifying important opportunities to improve care. Funding UK Research and Innovation.
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Affiliation(s)
- Michael McDermott
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Dorien M. Kimenai
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Atul Anand
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Zen Huang
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Andrew Houston
- Bart's Health Life Science, Bart's Health NHS Trust, London, UK
| | - Sophie Williams
- Bart's Health Life Science, Bart's Health NHS Trust, London, UK
| | - Felicity Evison
- PIONEER Health Data Hub and NIHR Birmingham Biomedical Research Centre, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Suzy Gallier
- PIONEER Health Data Hub and NIHR Birmingham Biomedical Research Centre, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Catalina Carenzo
- Imperial Clinical Analytics, Research & Evaluation (iCARE) Secure Data Environment, NIHR Imperial Biomedical Research Centre, St Mary's Hospital, London, UK
| | - Ben Glampson
- Imperial Clinical Analytics, Research & Evaluation (iCARE) Secure Data Environment, NIHR Imperial Biomedical Research Centre, St Mary's Hospital, London, UK
| | - Madina Hasan
- CURE Group, Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Alexander Robertson
- CURE Group, Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Thomas Phillips
- Research Data Sciences Team, SETT Centre, University Hospital Southampton, Southampton, UK
| | - Cai Davis
- Research Data Sciences Team, SETT Centre, University Hospital Southampton, Southampton, UK
| | - Elizabeth Sapey
- PIONEER Health Data Hub and NIHR Birmingham Biomedical Research Centre, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Erik Mayer
- Imperial Clinical Analytics, Research & Evaluation (iCARE) Secure Data Environment, NIHR Imperial Biomedical Research Centre, St Mary's Hospital, London, UK
| | - Suzanne Mason
- CURE Group, Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Matthew Stammers
- Research Data Sciences Team, SETT Centre, University Hospital Southampton, Southampton, UK
| | - Nicholas L. Mills
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - HDRUK Regional Linked Data Driven Evidence Network
- British Heart Foundation (BHF) Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Bart's Health Life Science, Bart's Health NHS Trust, London, UK
- PIONEER Health Data Hub and NIHR Birmingham Biomedical Research Centre, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Imperial Clinical Analytics, Research & Evaluation (iCARE) Secure Data Environment, NIHR Imperial Biomedical Research Centre, St Mary's Hospital, London, UK
- CURE Group, Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
- Research Data Sciences Team, SETT Centre, University Hospital Southampton, Southampton, UK
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Cullen L, Greenslade J, Parsonage W, Stephensen L, Smith SW, Sandoval Y, Ranasinghe I, Gaikwad N, Khorramshahi Bayat M, Mahmoodi E, Schulz K, Than M, Apple FS. Point-of-care high-sensitivity cardiac troponin in suspected acute myocardial infarction assessed at baseline and 2 h. Eur Heart J 2024; 45:2508-2515. [PMID: 38842324 DOI: 10.1093/eurheartj/ehae343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 04/15/2024] [Accepted: 05/16/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND AND AIMS Strategies to assess patients with suspected acute myocardial infarction (AMI) using a point-of-care (POC) high-sensitivity cardiac troponin I (hs-cTnI) assay may expedite emergency care. A 2-h POC hs-cTnI strategy for emergency patients with suspected AMI was derived and validated. METHODS In two international, multi-centre, prospective, observational studies of adult emergency patients (1486 derivation cohort and 1796 validation cohort) with suspected AMI, hs-cTnI (Siemens Atellica® VTLi) was measured at admission and 2 h later. Adjudicated final diagnoses utilized the hs-cTn assay in clinical use. A risk stratification algorithm was derived and validated. The primary diagnostic outcome was index AMI (Types 1 and 2). The primary safety outcome was 30-day major adverse cardiac events incorporating AMI and cardiac death. RESULTS Overall, 81 (5.5%) and 88 (4.9%) patients in the derivation and validation cohorts, respectively, had AMI. The 2-h algorithm defined 66.1% as low risk with a sensitivity of 98.8% [95% confidence interval (CI) 89.3%-99.9%] and a negative predictive value of 99.9 (95% CI 99.2%-100%) for index AMI in the derivation cohort. In the validation cohort, 53.3% were low risk with a sensitivity of 98.9% (95% CI 92.4%-99.8%) and a negative predictive value of 99.9% (95% CI 99.3%-100%) for index AMI. The high-risk metrics identified 5.4% of patients with a specificity of 98.5% (95% CI 96.6%-99.4%) and a positive predictive value of 74.5% (95% CI 62.7%-83.6%) for index AMI. CONCLUSIONS A 2-h algorithm using a POC hs-cTnI concentration enables safe and efficient risk assessment of patients with suspected AMI. The short turnaround time of POC testing may support significant efficiencies in the management of the large proportion of emergency patients with suspected AMI.
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Affiliation(s)
- Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029 Queensland, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Musk Avenue, Kelvin Grove, 4059 Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia
| | - Jaimi Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029 Queensland, Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Musk Avenue, Kelvin Grove, 4059 Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia
| | - William Parsonage
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Musk Avenue, Kelvin Grove, 4059 Queensland, Australia
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Laura Stephensen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029 Queensland, Australia
| | - Stephen W Smith
- Department of Emergency Medicine at Hennepin Healthcare/Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital and Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Isuru Ranasinghe
- Faculty of Medicine, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Niranjan Gaikwad
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | | | - Ehsan Mahmoodi
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Karen Schulz
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
- Clinical and Forensic Toxicology Laboratory, Hennepin Healthcare/Hennepin County Medical Center, Minneapolis, MN, USA
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Jeyaprakash P, Pathan F, Sivapathan S, Robledo KP, Madan K, Khor L, Yu C, Madronio C, Hallani H, Low G, Nundlall N, Burgess S, Fernandes C, Parikh D, Loh H, Mansberg R, Nguyen D, Ozawa K, Porter TR, Negishi K. Sonothrombolysis Before and After Percutaneous Coronary Intervention Provides the Largest Myocardial Salvage in ST Segment Elevation Myocardial Infarction. J Am Soc Echocardiogr 2024:S0894-7317(24)00349-3. [PMID: 38986920 DOI: 10.1016/j.echo.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Sonothrombolysis is a therapeutic application of ultrasound with ultrasound contrast for patients with ST elevation myocardial infarction (STEMI). Recent trials demonstrated that sonothrombolysis, delivered before and after primary percutaneous coronary intervention (pPCI), increases infarct vessel patency, improves microvascular flow, reduces infarct size, and improves ejection fraction. However, it is unclear whether pre-pPCI sonothrombolysis is essential for therapeutic benefit. We designed a parallel 3-arm sham-controlled randomized controlled trial to address this. METHODS Patients presenting with first STEMI undergoing pPCI within 6 hours of symptom onset were randomized 1:1:1 into 3 arms: sonothrombolysis pre-/post-pPCI (group 1), sham pre- sonothrombolysis post-pPCI (group 2), and sham pre-/post-pPCI (group 3). Our primary end point was infarct size (percentage of left ventricular mass) assessed by cardiac magnetic resonance imaging at day 4 ± 2. Secondary end points included myocardial salvage index (MSI) and echocardiographic parameters at day 4 ± 2 and 6 months. RESULTS Our trial was ceased early due to the COVID pandemic. From 122 patients screened between September 2020 and June 2021, 51 patients (age 60, male 82%) were included postrandomization. Median sonothrombolysis took 5 minutes pre-pPCI and 15 minutes post-, without significant door-to-balloon delay. There was a trend toward reduction in median infarct size between group 1 (8% [interquartile range, 4,11]), group 2 (11% [7, 19]), or group 3 (15% [9, 22]). Similarly there was a trend toward improved MSI in group 1 (79% [64, 85]) compared to groups 2 (51% [45, 70]) and 3 (48% [37, 73]) No major adverse cardiac events occurred during hospitalization. CONCLUSIONS Pre-pPCI sonothrombolysis may be key to improving MSI in STEMI. Multicenter trials and health economic analyses are required before clinical translation.
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Affiliation(s)
- Prajith Jeyaprakash
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Faraz Pathan
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Shanthosh Sivapathan
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Kristy P Robledo
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Kedar Madan
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Lynn Khor
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Christopher Yu
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Christine Madronio
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Hisham Hallani
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Gary Low
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia
| | - Nishant Nundlall
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Sonya Burgess
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Clyne Fernandes
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Devang Parikh
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Han Loh
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Robert Mansberg
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Diep Nguyen
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Koya Ozawa
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia
| | - Thomas R Porter
- Department of Cardiology, University of Nebraska, Lincoln, Nebraska
| | - Kazuaki Negishi
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia.
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5
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Livori AC, Ademi Z, Ilomäki J, Nelson AJ, Bell JS, Morton JI. Patterns of 12-Month Post-Myocardial Infarction Medication Use According to Revascularisation Strategy: Analysis of 15,339 Admissions in Victoria, Australia. Heart Lung Circ 2024:S1443-9506(24)00615-2. [PMID: 38964944 DOI: 10.1016/j.hlc.2024.04.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/27/2024] [Accepted: 04/11/2024] [Indexed: 07/06/2024]
Abstract
AIM Clinical guidelines recommend secondary prevention medications following myocardial infarction (MI) regardless of revascularisation strategy. Studies suggest that there is variation in post-MI medication use following percutaneous coronary intervention (PCI) and coronary artery bypass grafts (CABG). We investigated initial dispensing and 12-month patterns of medication use according to revascularisation strategy following non-ST-elevation MI (NSTEMI). METHOD We included all public and private hospital admissions for NSTEMI for patients aged ≥30 years in Victoria, Australia, between July 2012 and June 2017. We investigated initial dispensing of P2Y12 inhibitors (P2Y12i), statins (total and high intensity), angiotensin-converting-enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB), and beta blockers within 60 days after discharge. Twelve-month post-MI medication use was estimated as the proportion of days covered (PDC) over a 12-month period from the date of hospital discharge. Analyses were performed using adjusted regression models, stratified by revascularisation strategy. RESULTS There were 15,399 admissions for NSTEMI: 11,754 with PCI and 3,645 with CABG. Following adjustments, predicted probability of initial dispensing in the PCI and CABG groups, respectively, was 0.94 (95% confidence interval 0.93-0.95) vs 0.17 (0.13-0.21) for P2Y12i; 0.69 (0.66-0.71) vs 0.42 (0.37-0.48) for ACEi/ARB; 0.59 (0.57-0.62) vs 0.69 (0.64-0.74) for beta blockers; 0.89 (0.87-0.91) vs 0.89 (0.85-0.92) for statins; and 0.60 (0.57-0.62) vs 0.69 (0.63-0.73) for high intensity statins. The 12-month PDC in the PCI and CABG groups, respectively, was 0.82 (0.80-0.83) vs 0.12 (0.09-0.15) for P2Y12i; 0.62 (0.60-0.65) vs 0.43 (0.39-0.48) for ACEi/ARB; 0.53 (0.51-0.55) vs 0.632 (0.58-0.66) for beta blockers; 0.79 (0.78-0.81) vs 0.78 (0.74-0.81) for statins; and 0.49 (0.47-0.51) vs 0.55 (0.50-0.59) for high intensity statins. CONCLUSIONS Post-discharge dispensing of secondary prevention medications differed with respect to revascularisation strategy from 2012 to 2017, despite clear evidence of benefit during this period. Interventions may be needed to address possible clinician and patient uncertainty about the benefits of secondary prevention medications, regardless of revascularisation strategy.
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Affiliation(s)
- Adam C Livori
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Vic, Australia; Pharmacy Department, Grampians Health, Ballarat, Vic, Australia.
| | - Zanfina Ademi
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Adam J Nelson
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia; Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Monash Data Futures Institute, Monash University, Melbourne, Vic, Australia
| | - Jedidiah I Morton
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Vic, Australia; Department of Epidemiology, Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
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Ganes A, Henderson J, Samuel R, Segan L, Hiew C, Hutchison A. Early coronary angiography in NSTEMI: a regional Victorian perspective. Intern Med J 2024. [PMID: 38958050 DOI: 10.1111/imj.16465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 06/12/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Current guidelines highlight a paucity of evidence guiding optimal timing for non-ST-elevation myocardial infarction (NSTEMI) in high-risk and non-high-risk cases. AIM We assessed long-term major adverse cardiovascular events (MACEs) in NSTEMI patients undergoing early (<24 h) versus delayed (>24 h) coronary angiography at 6 years. Secondary end-points included all-cause mortality and cumulative MACE outcomes. METHODS Baseline characteristics and clinical outcomes were assessed among 355 patients presenting to a tertiary regional hospital between 2017 and 2018. Cox proportional hazard models were generated for MACE and all-cause mortality outcomes, adjusting for the Global Registry of Acute Coronary Events (GRACE) score, patient demographics, biomarkers and comorbidities. RESULTS Two hundred and seventy patients were included; 147 (54.4%) and 123 (45.6%) underwent early and delayed coronary angiography respectively. Median time to coronary angiography was 13.3 and 45.4 h respectively. At 6 years, 103 patients (38.1%) experienced MACE; 41 in the early group and 62 in the delayed group (hazard ratio (HR) = 2.23; 95% confidence interval (CI) = 1.50-3.31). After multivariable adjustment, the delayed group had higher rates of MACE (HR = 1.79; 95% CI = 1.19-2.70), all-cause mortality (HR = 2.76; 95% CI = 1.36-5.63) and cumulative MACE (incidence rate ratio = 1.54; 95% CI = 1.12-2.11). Subgroup analysis of MACE outcomes in rural and weekend NSTEMI presentations was not significant between early and delayed coronary angiography (HR = 1.49; 95% CI = 0.83-2.62). CONCLUSION Higher MACE rates in the delayed intervention group suggest further investigation is needed. Randomised control trials would be well suited to assess the role of early invasive intervention across all NSTEMI risk groups.
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Affiliation(s)
- Anand Ganes
- Department of Cardiology, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - James Henderson
- Department of Cardiology, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | | | | | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Adam Hutchison
- Department of Cardiology, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
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Perona M, Cooklin A, Thorpe C, O’Meara P, Rahman MA. Symptomology, Outcomes and Risk Factors of Acute Coronary Syndrome Presentations without Cardiac Chest Pain: A Scoping Review. Eur Cardiol 2024; 19:e12. [PMID: 39081484 PMCID: PMC11287626 DOI: 10.15420/ecr.2023.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/10/2024] [Indexed: 08/02/2024] Open
Abstract
For patients experiencing acute coronary syndrome, early symptom recognition is paramount; this is challenging without chest pain presentation. The aims of this scoping review were to collate definitions, proportions, symptoms, risk factors and outcomes for presentations without cardiac chest pain. Full-text peer reviewed articles covering acute coronary syndrome symptoms without cardiac chest pain were included. MEDLINE, CINAHL, Scopus and Embase were systematically searched from 2000 to April 2023 with adult and English limiters; 41 articles were selected from 2,954. Dyspnoea was the most reported (n=39) and most prevalent symptom (11.6-72%). Neurological symptoms, fatigue/weakness, nausea/ vomiting, atypical chest pain and diaphoresis were also common. Advancing age appeared independently associated with presentations without cardiac chest pain; however, findings were mixed regarding other risk factors (sex and diabetes). Patients without cardiac chest pain had worse outcomes: increased mortality, morbidity, greater prehospital and intervention delays and suboptimal use of guideline driven care. There is a need for structured data collection, analysis and interpretation.
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Affiliation(s)
- Meriem Perona
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe UniversityVictoria, Australia
- Ambulance VictoriaMelbourne, Australia
| | - Amanda Cooklin
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe UniversityVictoria, Australia
| | | | - Peter O’Meara
- Department of Paramedicine, Monash UniversityMelbourne, Australia
| | - Muhammad Aziz Rahman
- Institute of Health and Wellbeing, Federation University AustraliaMelbourne, Australia
- Faculty of Public Health, Universitas AirlanggaSurabaya, Indonesia
- Department of Non-Communicable Diseases, Bangladesh University of Health SciencesDhaka, Bangladesh
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8
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Pickering JW, Devlin G, Body R, Aldous S, Jaffe AS, Apple FS, Mills N, Troughton RW, Kavsak P, Peacock WF, Cullen L, Lord SJ, Müller C, Joyce L, Frampton C, Lacey CJ, Richards AM, Pitama S, Than M. Protocol for Improving Care by FAster risk-STratification through use of high sensitivity point-of-care troponin in patients presenting with possible acute coronary syndrome in the EmeRgency department (ICare-FASTER): a stepped-wedge cluster randomised quality improvement initiative. BMJ Open 2024; 14:e083752. [PMID: 38871661 PMCID: PMC11177684 DOI: 10.1136/bmjopen-2023-083752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Clinical assessment in emergency departments (EDs) for possible acute myocardial infarction (AMI) requires at least one cardiac troponin (cTn) blood test. The turn-around time from blood draw to posting results in the clinical portal for central laboratory analysers is ~1-2 hours. New generation, high-sensitivity, point-of-care cardiac troponin I (POC-cTnI) assays use whole blood on a bedside (or near bedside) analyser that provides a rapid (8 min) result. This may expedite clinical decision-making and reduce length of stay. Our purpose is to determine if utilisation of a POC-cTnI testing reduces ED length of stay. We also aim to establish an optimised implementation process for the amended clinical pathway. METHODS AND ANALYSIS This quality improvement initiative has a pragmatic multihospital stepped-wedge cross-sectional cluster randomised design. Consecutive patients presenting to the ED with symptoms suggestive of possible AMI and having a cTn test will be included. Clusters (comprising one or two hospitals each) will change from their usual-care pathway to an amended pathway using POC-cTnI-the 'intervention'. The dates of change will be randomised. Changes occur at 1 month intervals, with a minimum 2 month 'run-in' period. The intervention pathway will use a POC-cTnI measurement as an alternate to the laboratory-based cTn measurement. Clinical decision-making steps and logic will otherwise remain unchanged. The POC-cTnI is the Siemens (Erlangen Germany) Atellica VTLi high-sensitivity cTnI assay. The primary outcome is ED length of stay. The safety outcome is cardiac death or AMI within 30 days for patients discharged directly from the ED. ETHICS AND DISSEMINATION Ethics approval has been granted by the New Zealand Southern Health and Disability Ethics Committee, reference 21/STH/9. Results will be published in a peer-reviewed journal. Lay and academic presentations will be made. Māori-specific results will be disseminated to Māori stakeholders. TRIAL REGISTRATION NUMBER ACTRN12619001189112.
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Affiliation(s)
- John W Pickering
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Emergency, Christchurch Hospital, Christchurch, New Zealand
| | - Gerard Devlin
- Waikato District Health Board, Hamilton, New Zealand
- Heart Foundation of New Zealand, Auckland, New Zealand
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, The Victoria University of Manchester Campus, Manchester, UK
| | - Sally Aldous
- Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Fred S Apple
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas Mills
- The University of Edinburgh Centre for Cardiovascular Science, Edinburgh, UK
| | - Richard W Troughton
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | | | - W Frank Peacock
- Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Louise Cullen
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Emergency and Trauma Centre, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
| | - Sarah J Lord
- The School of Medicine, University of Notre Dame Australia - Darlinghurst Campus, Darlinghurst, New South Wales, Australia
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Christian Müller
- Division of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Laura Joyce
- Emergency, Christchurch Hospital, Christchurch, New Zealand
- Surgery and Critical Care, University of Otago Christchurch, Christchurch, New Zealand
| | - Chris Frampton
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Cameron James Lacey
- Māori Indigenous Health Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Arthur M Richards
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Suzanne Pitama
- Māori Indigenous Health Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Martin Than
- Medicine, University of Otago Christchurch, Christchurch, New Zealand
- Emergency, Christchurch Hospital, Christchurch, New Zealand
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9
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Cullen L, Greenslade JH, Stephensen L, Ranasinghe I, Gaikwad N, Khorramshahi Bayat M, Mahmoodi E, Than M, Apple F, Parsonage W. External validation of a rapid algorithm using high-sensitivity troponin assay results for evaluating patients with suspected acute myocardial infarction. Emerg Med J 2024; 41:313-319. [PMID: 38316538 DOI: 10.1136/emermed-2023-213539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/22/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE We sought to validate the clinical performance of a rapid assessment pathway incorporating the Siemens Atellica IM high sensitivity cardiac troponin I (hs-cTnI) assay in patients presenting to the emergency department (ED) with suspected acute myocardial infarction (AMI). METHODS This was a multicentre prospective observational study of adult ED patients presenting to five Australian hospitals between November 2020 and September 2021. Participants included those with symptoms of suspected AMI (without ST-segment elevation MI on presentation ECG). The Siemen's Atellica IM hs-cTnI laboratory-based assay was used to measure troponin concentrations at admission and after 2-3 hours and cardiologists adjudicated final diagnoses. The HighSTEACS diagnostic algorithm was evaluated, incorporating hs-cTnI concentrations at presentation and absolute changes within the first 2 to 3 hours. The primary outcome was index AMI, including type 1 or 2 non-ST segment elevation MI (NSTEMI) or ST-elevation MI (STEMI) following presentation. 30-day major adverse cardiac outcomes (including AMI, urgent revascularisation or cardiac death) were also reported. The trial was registered with the Australian and New Zealand Clinical Trials Registry. RESULTS 1994 patients were included. The average age was 56.2 years (SD=15.6), and 44.9% were women. 118 (5.9%) patients had confirmed index AMI. The 2-hour algorithm defined 61.3% of patients as low risk. Sensitivity was 99.1% (94.0%-99.9%) and negative predictive value was 99.9% (99.3%-100%). 24.4% of patients were deemed intermediate risk. When applying the parameters for high risk, 252 (14.3%) were identified, with a specificity of 91.5% (88.7%-93.6%) and a PPV of 42.0% (35.6-48.7%). CONCLUSIONS A 2-hour algorithm based on the HighSTEACS strategy using the Siemens Atellica IM hs-cTnI laboratory-based assay enables safe and efficient risk assessment of emergency patients with suspected AMI. TRIAL REGISTRATION NUMBER ACTRN12621000053820.
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Affiliation(s)
- Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women\'s Hospital, Herston, Queensland, Australia
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Laura Stephensen
- Department of Emergency Medicine, Royal Brisbane and Women\'s Hospital, Herston, Queensland, Australia
- School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Isuru Ranasinghe
- Cardiology, The University of Queensland, Saint Lucia, Queensland, Australia
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | | | | | - Ehsan Mahmoodi
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Fred Apple
- Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - William Parsonage
- Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
- Queensland University of Technology, Brisbane, Queensland, Australia
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10
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Paradissis C, Cottrell N, Coombes ID, Wang WYS, Barras MA. Unplanned Rehospitalisation due to Medication Harm following an Acute Myocardial Infarction. Cardiology 2024:1-15. [PMID: 38615668 DOI: 10.1159/000538773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/28/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION The contribution of medication harm to rehospitalisation and adverse patient outcomes after an acute myocardial infarction (AMI) needs exploration. Rehospitalisation is costly to both patients and the healthcare facility. Following an AMI, patients are at risk of medication harm as they are often older and have multiple comorbidities and polypharmacy. This study aimed to quantify and evaluate medication harm causing unplanned rehospitalisation after an AMI. METHODS This was a retrospective cohort study of patients discharged from a quaternary hospital post-AMI. All rehospitalisations within 18 months were identified using medical record review and coding data. The primary outcome measure was medication harm rehospitalisation. Preventability, causality, and severity assessments of medication harm were conducted. RESULTS A total of 1,564 patients experienced an AMI, and 415 (26.5%) were rehospitalised. Eighty-nine patients (5.7% of total population; 6.0% of those discharged) experienced a total of 101 medication harm events. Those with medication harm were older (p = 0.007) and had higher rates of heart failure (p = 0.005), chronic kidney disease (p = 0.046), chronic obstructive pulmonary disease (p = 0.037), and a prior history of ischaemic heart disease (p = 0.005). Gastrointestinal bleeding, acute kidney injury, and hypotension were the most common medication harm events. Forty percent of events were avoidable, and 84% were classed as "serious." Furosemide, antiplatelets, and angiotensin-converting enzyme inhibitors were the most commonly implicated medications. The median time to medication harm rehospitalisation was 79 days (interquartile range: 16-200 days). CONCLUSION Medication harm causes unplanned rehospitalisation in 5.7% of all AMI patients (1 in 17 patients; 6.0% of those discharged). The majority of harm was serious and occurred within the first 200 days of discharge. This study highlights that measures to attenuate the risk of medication harm rehospitalisation are essential, including post-discharge medication management.
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Affiliation(s)
- Chariclia Paradissis
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Neil Cottrell
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Ian D Coombes
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - William Y S Wang
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Michael A Barras
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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11
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Stanesby O, Armstrong MK, Otahal P, Goode JP, Fraser BJ, Negishi K, Kidokoro T, Winzenberg T, Juonala M, Wu F, Kelly RK, Xi B, Viikari JSA, Raitakari OT, Daniels SR, Tomkinson GR, Magnussen CG. Tracking of serum lipid levels from childhood to adulthood: Systematic review and meta-analysis. Atherosclerosis 2024; 391:117482. [PMID: 38569384 DOI: 10.1016/j.atherosclerosis.2024.117482] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND AND AIMS The utility of lipid screening in pediatric settings for preventing adult atherosclerotic cardiovascular diseases partly depends on the lifelong tracking of lipid levels. This systematic review aimed to quantify the tracking of lipid levels from childhood and adolescence to adulthood. METHODS We systematically searched MEDLINE, Embase, Web of Science, and Google Scholar in March 2022. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; ID: CRD42020208859). We included cohort studies that measured tracking of lipids from childhood or adolescence (<18 years) to adulthood (≥18) with correlation or tracking coefficients. We estimated pooled correlation and tracking coefficients using random-effects meta-analysis. Risk of bias was assessed with a review-specific tool. RESULTS Thirty-three studies of 19 cohorts (11,020 participants) were included. The degree of tracking from childhood and adolescence to adulthood differed among lipids. Tracking was observed for low-density lipoprotein cholesterol (pooled r = 0.55-0.65), total cholesterol (pooled r = 0.51-0.65), high-density lipoprotein cholesterol (pooled r = 0.46-0.57), and triglycerides (pooled r = 0.32-0.40). Only one study included tracking of non-high-density lipoprotein cholesterol (r = 0.42-0.59). Substantial heterogeneity was observed. Study risk of bias was moderate, mostly due to insufficient reporting and singular measurements at baseline and follow-up. CONCLUSIONS Early-life lipid measurements are important for predicting adult levels. However, further research is needed to understand the tracking of non-high-density lipoprotein cholesterol and the stability of risk classification over time, which may further inform pediatric lipid screening and assessment strategies.
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Affiliation(s)
- Oliver Stanesby
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia
| | | | - Petr Otahal
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - James P Goode
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Brooklyn J Fraser
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Kazuaki Negishi
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, Sydney, Australia; Nepean Hospital, Sydney, Australia
| | - Tetsuhiro Kidokoro
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, Australia; Faculty of Sport Science, Nippon Sport Science University, Tokyo, Japan
| | - Tania Winzenberg
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Markus Juonala
- Department of Medicine, University of Turku, Turku, Finland; Division of Medicine, Turku University Hospital, Turku, Finland
| | - Feitong Wu
- Baker Heart and Diabetes Institute, Melbourne, Australia; Baker Department of Cardiometabolic Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Rebecca K Kelly
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Bo Xi
- Department of Epidemiology, School of Public Health/Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jorma S A Viikari
- Department of Medicine, University of Turku, Turku, Finland; Division of Medicine, Turku University Hospital, Turku, Finland
| | - Olli T Raitakari
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland; Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland; Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland
| | - Stephen R Daniels
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Grant R Tomkinson
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Costan G Magnussen
- Baker Heart and Diabetes Institute, Melbourne, Australia; Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, Australia; Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland; Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland.
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12
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Lim J, King J, Williams T, Boyle A. Unchanged cellular inflammatory response following recurrent ST-elevation myocardial infarction. Int J Cardiol 2024; 398:131656. [PMID: 38104725 DOI: 10.1016/j.ijcard.2023.131656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 11/14/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Recurrent ST-elevation myocardial infarctions (STEMIs) are associated with poorer prognosis. A diminished haematopoietic response has been proposed as the mechanism responsible for this, but has yet to be validated in human studies. We therefore aim to map out the leukocyte response, and its subtypes, following the first and second STEMI to identify if the inflammatory response is dampened after recurrent myocardial infarctions. METHODS Retrospective cohort study of patients presenting with recurrent STEMI undergoing percutaneous coronary intervention. Full blood counts were taken within 24 h of each admission, and daily thereafter. The primary outcome was whether there were any qualitative or quantitative difference in leukocyte cell response (and its subtypes) between first and second STEMI. RESULTS Thirty-one patients (mean age 59 years [SD 14.9], 26 males [83.9%]) with an average of 3.1 years between infarcts were included in the study. Overall, between first and second STEMI, similar mean leukocyte response (and its subtypes) was observed from admission to day three post PCI. Similarly, the peak leukocyte response (and its subtypes) was similar between the two STEMIs, even after adjusting for infarct size. CONCLUSIONS In recurrent STEMIs, there is no long-term memory effect on the cellular inflammatory response leading to diminished peripherally circulating leucocytes, and its subtypes.
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Affiliation(s)
- Joyce Lim
- Heart and Stroke Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia
| | - James King
- Department of Medicine, Flinders Medical Centre, Belford Park, SA, Australia
| | - Trent Williams
- Heart and Stroke Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia; Department of Cardiology, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Andrew Boyle
- Heart and Stroke Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia; College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, Australia; Department of Cardiology, John Hunter Hospital, New Lambton Heights, NSW, Australia.
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13
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Freene N, Carroll SJ, Flynn A, Bowen S, Holley R, Rodway K, Niyonsenga T, Davey R. Activity counseling early postelective percutaneous coronary intervention (ACE-PCI): Mixed-methods pilot randomized controlled trial. Health Sci Rep 2024; 7:e1963. [PMID: 38505683 PMCID: PMC10948586 DOI: 10.1002/hsr2.1963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 01/12/2024] [Accepted: 02/22/2024] [Indexed: 03/21/2024] Open
Abstract
Background Physical activity (PA) levels of people with coronary heart disease are low in the first 30 days after percutaneous coronary intervention (PCI), increasing the risk of recurrent cardiac events. Following PCI, PA counseling delivered by a physiotherapist before discharge may increase the PA levels of patients. Preliminary work is required to determine the effects of the counseling session compared to usual care. Objectives To investigate the feasibility and potential efficacy of a brief physiotherapist-led PA counseling session immediately after an elective PCI compared to usual care for improved PA early post-PCI. Methods Using concealed allocation and blinded assessments, eligible participants (n = 30) were randomized to a physiotherapist-led PA counseling session (30 min) or usual care (nurse-led PA advice < 5 min). The primary outcome was daily minutes of moderate-to-vigorous PA (accelerometry; 3 weeks). Secondary outcomes included cardiac rehabilitation intention, anxiety and depression levels (Hospital Anxiety and Depression Scale), and quality-of-life (MacNew questionnaire). Recruitment, retention, and attrition were assessed for feasibility. Semistructured interviews were conducted with 13 participants to determine intervention acceptability, and barriers and enablers to PA. Results Between and within-group comparisons were not significant in intention-to-treat analyses. All feasibility criteria were met except for retention and attrition of participants. At 3 weeks, only 25% of participants were planning to attend cardiac rehabilitation, with no between-group differences. Increased PA at 3 weeks was associated with participants that were younger, without other chronic disease,s and more active immediately following discharge. Interviews revealed personal, environmental, and program-based themes for barriers and enablers to PA. Conclusions A physiotherapist-led PA counseling session may not improve PA levels early post-elective PCI compared to very brief PA advice delivered by nurses. A larger multicentre randomized controlled trial is feasible with minor modifications to participant follow-up. Further research is required.
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Affiliation(s)
- Nicole Freene
- Department of PhysiotherapyUniversity of CanberraBruceAustralian Capital TerritoryAustralia
- Health Research InstituteUniversity of CanberraBruceAustralian Capital TerritoryAustralia
| | - Suzanne J. Carroll
- Health Research InstituteUniversity of CanberraBruceAustralian Capital TerritoryAustralia
| | - Allyson Flynn
- Department of PhysiotherapyUniversity of CanberraBruceAustralian Capital TerritoryAustralia
| | - Sarah Bowen
- National Capital Private HospitalGarranAustralian Capital TerritoryAustralia
| | - Roslyn Holley
- National Capital Private HospitalGarranAustralian Capital TerritoryAustralia
| | - Kerry Rodway
- National Capital Private HospitalGarranAustralian Capital TerritoryAustralia
| | - Theo Niyonsenga
- Health Research InstituteUniversity of CanberraBruceAustralian Capital TerritoryAustralia
| | - Rachel Davey
- Health Research InstituteUniversity of CanberraBruceAustralian Capital TerritoryAustralia
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14
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Stanesby O, Zhou Z, Fonseca R, Kidokoro T, Otahal P, Fraser BJ, Wu F, Juonala M, Viikari JSA, Raitakari OT, Tomkinson GR, Magnussen CG. Tracking of apolipoprotein B levels measured in childhood and adolescence: systematic review and meta-analysis. Eur J Pediatr 2024; 183:569-580. [PMID: 38051379 PMCID: PMC10912277 DOI: 10.1007/s00431-023-05350-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/13/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023]
Abstract
To quantify the tracking of apolipoprotein B (apoB) levels from childhood and adolescence and compare the tracking of apoB with low-density lipoprotein (LDL) cholesterol, a systematic search of MEDLINE, Embase, Web of Science, and Google Scholar was performed in October 2023 (PROSPERO protocol: CRD42022298663). Cohort studies that measured tracking of apoB from childhood/adolescence (< 19 years) with a minimum follow-up of 1 year, using tracking estimates such as correlation coefficients or tracking coefficients, were eligible. Pooled correlations were estimated using random-effects meta-analysis. Risk of bias was assessed with a review-specific tool. Ten studies of eight unique cohorts involving 4677 participants met the inclusion criteria. Tracking of apoB was observed (pooled r = 0.63; 95% confidence interval [CI] = 0.53-0.71; I2 = 96%) with no significant sources of heterogeneity identified. Data from five cohorts with tracking data for both lipids showed the degree of tracking was similar for apoB (pooled r = 0.59; 95% CI = 0.55-0.63) and LDL cholesterol (pooled r = 0.58; 95% CI = 0.47-0.68). Study risk of bias was moderate, mostly due to attrition and insufficient reporting. CONCLUSION ApoB levels track strongly from childhood, but do not surpass LDL cholesterol in this regard. While there is strong evidence that apoB is more effective at predicting ASCVD risk than LDL cholesterol in adults, there is currently insufficient evidence to support its increased utility in pediatric settings. This also applies to tracking data, where more comprehensive data are required. WHAT IS KNOWN • Apolipoprotein B is a known cause of atherosclerotic cardiovascular disease. • Apolipoprotein B levels are not typically measured in pediatric settings, where low-density lipoprotein cholesterol remains the primary lipid screening measure. WHAT IS NEW • This meta-analysis of 10 studies showed apolipoprotein B levels tracked strongly from childhood but did not exceed low-density lipoprotein cholesterol in this regard. • More comprehensive tracking data are needed to provide sufficient evidence for increased utility of apolipoprotein B in pediatric settings.
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Affiliation(s)
- Oliver Stanesby
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Zhen Zhou
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Tetsuhiro Kidokoro
- Research Institute for Health and Sport Science, Nippon Sport Science University, Tokyo, Japan
| | - Petr Otahal
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Brooklyn J Fraser
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Feitong Wu
- Baker Heart and Diabetes Institute, Melbourne, Australia
- Baker Department of Cardiometabolic Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Markus Juonala
- Department of Medicine, University of Turku, Turku, Finland
- Division of Medicine, Turku University Hospital, Turku, Finland
| | - Jorma S A Viikari
- Department of Medicine, University of Turku, Turku, Finland
- Division of Medicine, Turku University Hospital, Turku, Finland
| | - Olli T Raitakari
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
- Centre for Population Health Research, University of Turkuand, Turku University Hospital, Turku, Finland
- Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland
| | - Grant R Tomkinson
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Costan G Magnussen
- Baker Heart and Diabetes Institute, Melbourne, Australia.
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Allied Health and Human Performance, University of South Australia, Adelaide, Australia.
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.
- Centre for Population Health Research, University of Turkuand, Turku University Hospital, Turku, Finland.
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15
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Alazrag W, Idris H, Saad YM, Etaher A, Ren S, Ferguson I, Juergens C, Chew DP, Otton J, Middleton PM, French JK. Management and outcomes with 5-year mortality of patients with mildly elevated high-sensitivity troponin T levels not meeting criteria for myocardial infarction. Emerg Med Australas 2024; 36:62-70. [PMID: 37705175 DOI: 10.1111/1742-6723.14298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 05/12/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVES To examine management and outcomes of patients presenting to EDs with symptoms suggestive of acute coronary syndrome, who have mild non-dynamically elevated high-sensitivity troponin T (HsTnT) levels, not meeting the fourth universal definition of myocardial infarction (MI) criteria (observation group). METHODS Consecutive patients presenting to the ED with symptoms suggestive of acute coronary syndrome at Liverpool Hospital, Sydney, Australia, those having ≥2 HsTnT levels after initial assessment were adjudicated according to the fourth universal definition of MI, as MI ruled-in, MI ruled-out, or myocardial injury in whom MI is neither ruled-in nor ruled-out (>1 level ≥15 ng/L, called observation group); follow-up was 5 years. RESULTS Of 2738 patients, 547 were in the observation group, of whom 62% were admitted to hospital, 52% to cardiac services, whereas 97% of MI ruled-in patients and 21% of MI ruled-out patients were admitted; P < 0.001. Non-invasive testing occurred in 42% of observation group patients (36% had echo-cardiography), and 16% had coronary angiography. Of observation group patients, MI rates were 1.5% during hospitalisation and 4% during the following year, similar to that in those with MI ruled-in, among those with MI ruled-out, the MI rate was 0.2%. The 1-year death rate was 13% among observation group patients and 11% MI ruled-in patients (P = 0.624), whereas at 5 years among observation group patients, type 1 MI and type 2 MI were 48%, 26% and 58%, respectively (P = 0.001). CONCLUSION Very few unselected consecutive patients attending ED, with minor stable HsTnT elevation, had MI, although most had chronic myocardial injury. Late mortality rates among observation group patients were higher than those with confirmed type 1 MI but lower than those with type 2 MI.
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Affiliation(s)
- Weaam Alazrag
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Hanan Idris
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Yousef Me Saad
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Aisha Etaher
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shiquan Ren
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Ian Ferguson
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Craig Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- South Australian Department of Health, Adelaide, South Australia, Australia
| | - James Otton
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Paul M Middleton
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
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16
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Schon C, Felismino A, de Sá J, Corte R, Ribeiro T, Bruno S. Efficacy of early cardiac rehabilitation after acute myocardial infarction: Randomized clinical trial protocol. PLoS One 2024; 19:e0296345. [PMID: 38198457 PMCID: PMC10781044 DOI: 10.1371/journal.pone.0296345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/08/2023] [Indexed: 01/12/2024] Open
Abstract
The acute myocardial infarction (AMI) present high mortality rate that may be reduced with cardiac rehabilitation. Despite its good establishment in outpatient care, few studies analyzed cardiac rehabilitation during hospitalization. Thus, this study aims to clarify the safety and efficacy of early cardiac rehabilitation after AMI. This will be a clinical, controlled, randomized trial with blind outcome evaluation and a superiority hypothesis. Twenty-four patients with AMI will be divided into two groups (1:1 allocation ratio). The intervention group will receive an individualized exercise-based cardiac rehabilitation protocol during hospitalization and a semi-supervised protocol after hospital discharge; the control group will receive conventional care. The primary outcomes will be the cardiac remodeling assessed by cardiac magnetic resonance imaging, functional capacity assessed by maximal oxygen consumption, and cardiac autonomic balance examined via heart rate variability. Secondary outcomes will include safety and the total exercise dose provided during the protocol. Statistical analysis will consider the intent-to-treat analysis. Trial registration. Trial registration number: Brazilian Registry of Clinical Trials (ReBEC) (RBR- 9nyx8hb).
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Affiliation(s)
- Caroline Schon
- University Hospital Onofre Lopes, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Amanda Felismino
- University Hospital Onofre Lopes, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Joceline de Sá
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Renata Corte
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Tatiana Ribeiro
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, RN, Brazil
| | - Selma Bruno
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, RN, Brazil
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17
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Rodríguez-Ramos MA, Santos-Medina M, Dueñas-Herrera A, Prohías Martínez JA, Rivas-Estany E. A collaborative approach to develop indicators for quality of care for ST segment Elevation Myocardial Infarction in networks without coronary intervention: A position paper. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2024; 35:91-100. [PMID: 37599539 DOI: 10.3233/jrs-220057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND Data about performance measures (PM) in patients with ST segment Elevation Myocardial Infarction (STEMI) in low- and middle-income countries is really scarce. One of the reasons is the lack of appropriate measures for these scenarios where coronary intervention is not the standard treatment. OBJECTIVE This study aimed to develop a set of PM and quality markers for patients with STEMI in these countries. METHODS Two investigators systematically reviewed existing guidelines and scientific literature to identify potential PM by referring to documents searched through PubMed from 2010 through 2019, using terms "Myocardial Infarction", "STEMI", "quality indicator", and "performance measure". A modified Delphi technique, involving multidisciplinary panel interview, was used. A 15-member multidisciplinary expert panel individually rated each potential indicator on a scale of 1 (lowest) to 5 (highest) during three rounds. All indicators that received a median score ≥4.5, in final round without significant disagreement were included as PM. RESULTS Through the consensus-building process, 84 potential indicators were found, of which 10 were proposed as performance measures and 2 as quality metrics, as follows: Pre-Hospital Electrocardiogram; Patients with reperfusion therapy; Pre-hospital Reperfusion; Ischemic time less than 120 minutes; System delay time less than 90 minutes; In-hospital Mortality; Complete in-hospital Treatment; Complete in-hospital Treatment in patients with Heart Failure; 30 day-Re-admissions; 30 day-mortality; Patients with in-hospital stress test performed; and, Patients included in rehabilitation programs. CONCLUSION This document provides the official set of PM of attention in ST segment Elevation Myocardial Infarction of the Cuban Society of Cardiology and Cuban National Group of Cardiology.
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Affiliation(s)
| | | | - Alfredo Dueñas-Herrera
- Department of Preventive Cardiology, Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba
| | | | - Eduardo Rivas-Estany
- Department of Preventive Cardiology, Institute of Cardiology and Cardiovascular Surgery, Havana, Cuba
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18
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Kerr AJ, Choi Y, Williams MJ, Stewart RA, White HD, Devlin G, Selak V, Lee MAW, El-Jack S, Adamson PD, Fairley S, Jackson RT, Poppe K. Paired risk scores to predict ischaemic and bleeding risk twenty-eight days to one year after an acute coronary syndrome. Heart 2023; 109:1827-1836. [PMID: 37558394 DOI: 10.1136/heartjnl-2023-322830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/03/2023] [Indexed: 08/11/2023] Open
Abstract
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.
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Affiliation(s)
- Andrew J Kerr
- Department of Medicine, The University of Auckland, Auckland, New Zealand
- Cardiology Department, Middlemore Hospital, Auckland, New Zealand
- Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Yeunhyang Choi
- Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | | | - Ralph Ah Stewart
- Cardiology Department, Greenlane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Harvey D White
- Cardiology Department, Greenlane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | | | - Vanessa Selak
- Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | | | | | - Philip D Adamson
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Sarah Fairley
- Cardiology Department, Wellington Hospital, Wellington, New Zealand
| | - Rodney T Jackson
- Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Katrina Poppe
- Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
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19
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Livori MClinPharm AC, Ademi Z, Ilomäki J, Pol D, Morton JI, Bell JS. Use of secondary prevention medications in metropolitan and non-metropolitan areas: an analysis of 41,925 myocardial infarctions in Australia. Eur J Prev Cardiol 2023:zwad360. [PMID: 37987181 DOI: 10.1093/eurjpc/zwad360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/08/2023] [Accepted: 11/16/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND People in remote areas may have more difficulty accessing healthcare following myocardial infarction (MI) than people in metropolitan areas. We determined whether remoteness was associated with initial and 12-month use of secondary prevention medications following MI in Victoria, Australia. METHOD We included all people alive at least 90 days post-discharge following MI between July 2012 and June 2017 in Victoria, Australia (n=41,925). We investigated dispensing of P2Y12 inhibitors (P2Y12i), statins, ACE-inhibitors or angiotensin receptor blockers (ACEI/ARBs), and beta-blockers within 90 days post-discharge. We estimated 12-month medication use using proportion of days covered (PDC). Remoteness was determined using the Accessibility/Remoteness Index of Australia (ARIA). Data were analyzed using adjusted parametric regression models stratified by STEMI and NSTEMI. RESULTS There were 10,819 STEMI admissions and 31,106 NSTEMI admissions. Following adjustment across NSTEMI and STEMI, there were no medication classes dispensed in the 90-days post-discharge that differed in a clinically significant way from the least remote (ARIA=0) to the most remote (ARIA=4.8) areas. The largest difference for NSTEMI were ACEi/ARB, with 71%(95%CI 70-72%) versus 80%(76%-83%). For STEMI, it was statins with 89%(88-90%) versus 95%(91-97%). Predicted PDC for STEMI and NSTEMI were not clinically significant across remoteness, with the largest difference in NSTEMI being P2Y12i with 48%(47-50%) versus 55%(51-59%), and in STEMI it was ACEi/ARB with 68%(67-69%) versus 76%(70-80%). CONCLUSION Remoteness does not appear to be a clinically significant driver for medication use following MI. Possible differences in cardiovascular outcomes in metropolitan and non-metropolitan areas are not likely to be explained by access to secondary prevention medications.
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Affiliation(s)
- Adam C Livori MClinPharm
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, VIC, Australia
- Grampians Health, Ballarat, VIC, Australia
| | - Zanfina Ademi
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Monash Data Futures Institute, Monash University, Melbourne, VIC, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Derk Pol
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jedidiah I Morton
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, VIC, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Monash Data Futures Institute, Monash University, Melbourne, VIC, Australia
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20
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Dang D, Dowling C, Zaman S, Cameron J, Kuhn L. Predictors of radial to femoral artery crossover during primary percutaneous coronary intervention in ST-elevation myocardial infarction: A systematic review and meta-analysis. Aust Crit Care 2023; 36:915-923. [PMID: 36496332 DOI: 10.1016/j.aucc.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 10/31/2022] [Accepted: 10/31/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In contrast to traditional femoral artery access, radial artery access for primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) is associated with reduced mortality and bleeding but has higher crossover rates. Therefore, factors associated with crossover warrant exploration as crossover due to technical challenges associated with the radial route may be mitigated. OBJECTIVE The objective of this study was to identify predictors of radial access failure or crossover to femoral access in PPCI. METHODS A systematic review and meta-analysis was undertaken according to the Joanna Briggs Institute Systematic Reviews Checklist with searches conducted in Medline, EMBASE, CINAHL, and SCOPUS databases. Inclusion criteria for this study included patients with STEMI; PPCI; and primary research identifying predictors of radial access failures and/or crossovers, published in English, and after 2010. This study was registered with PROSPERO (CRD42020167122). Statistical analysis was performed using IBM SPSS Statistics for Windows version 26.0 (IBM Corp, Armonk, NY) and RevMan version 5.4 (Cochrane Collaboration, London, United Kingdom) with meta-analysis conducted by using the DerSimonian and Laird random-effects method. The National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was utilised for quality and risk of bias assessment, with EndNote software used for citations. RESULTS Eight observational studies met inclusion criteria, comprising 12,621 patients. Risk of bias of these studies was assessed using the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The mean age was 61.2 ± 12.0 years, and 75.3% were male. Crossover from transradial to transfemoral artery occurred in 529 (4.2%) patients. Reasons for radial access failure included failed puncture (35.3%), peripheral occlusion or tortuosity (24.5%), and radial artery spasm (20.1%). Predictors of crossover included older age (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.44-2.65; p < 0.001), female sex (OR, 2.10; 95% Cl, 1.58-2.80; p < 0.001), weight ≤65 kg (OR, 2.95; 95% CI, 1.95-4.46; p < 0.001), and previous percutaneous coronary intervention (OR, 2.80; 95% Cl, 1.74-4.52; p < 0.001). CONCLUSION Older age, female sex, weight ≤65 kg, and previous percutaneous coronary intervention were predictors of crossover or failure from the radial to femoral artery. As these predictors are known to be associated with high bleeding and mortality, they should not preclude attempting a radial-first approach in all patients with STEMI. However, as these results were unadjusted, this study warrants further research to thoroughly investigate predictors of radial artery crossover.
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Affiliation(s)
- Denee Dang
- School of Nursing and Midwifery, Monash University, Melbourne, Australia; MonashHeart, Monash Health, Melbourne, Australia; Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia.
| | - Cameron Dowling
- MonashHeart, Monash Health, Melbourne, Australia; Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia
| | - Sarah Zaman
- Westmead Applied Research Centre, University of Sydney, Sydney, Australia; Cardiology Department, Westmead Hospital, Sydney, Australia; School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Jan Cameron
- School of Nursing and Midwifery, Monash University, Melbourne, Australia
| | - Lisa Kuhn
- School of Nursing and Midwifery, Monash University, Melbourne, Australia; Monash Emergency Research Collaborative, Monash Health, Melbourne, Australia
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21
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Verdicchio C, Freene N, Hollings M, Maiorana A, Briffa T, Gallagher R, Hendriks JM, Abell B, Brown A, Colquhoun D, Howden E, Hansen D, Reading S, Redfern J. A Clinical Guide for Assessment and Prescription of Exercise and Physical Activity in Cardiac Rehabilitation. A CSANZ Position Statement. Heart Lung Circ 2023; 32:1035-1048. [PMID: 37516652 DOI: 10.1016/j.hlc.2023.06.854] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 07/31/2023]
Abstract
Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise and physical activity as core components. This position statement provides pragmatic, evidence-based guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic exercise, resistance exercise and physical activity have been addressed, including progression and safety considerations.
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Affiliation(s)
- Christian Verdicchio
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Centre for Heart Rhythm Disorders, University of Adelaide, SAHMRI and Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Nicole Freene
- Physiotherapy, Faculty of Health, University of Canberra, Canberra, ACT, Australia; Health Research Institute, University of Canberra, Canberra, ACT, Australia
| | - Matthew Hollings
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Andrew Maiorana
- Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia; Curtin School of Allied Health, Curtin University, Perth, WA, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Robyn Gallagher
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jeroen M Hendriks
- Centre for Heart Rhythm Disorders, University of Adelaide, SAHMRI and Royal Adelaide Hospital, Adelaide, SA, Australia; Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Bridget Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Qld, Australia
| | - Alex Brown
- Telethon Kids Institute, Australian National University, Canberra, ACT, Australia
| | - David Colquhoun
- Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia; Faculty of Medicine, Wesley Medical Centre, Brisbane, Qld, Australia
| | - Erin Howden
- Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Vic, Australia
| | - Dominique Hansen
- UHasselt, REVAL/BIOMED (Rehabilitation Research Centre), Hasselt University, Hasselt, Belgium
| | - Stacey Reading
- Department of Exercise Sciences, University of Auckland, Auckland, New Zealand
| | - Julie Redfern
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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22
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Rocheleau S, Eng-Frost J, Lambrakis K, Khan E, Chiang B, Wattchow N, Steele S, Lorensini S, Lehman SJ, Papendick C, Chew DP. Twelve-Month Outcomes of Patients With Myocardial Injury not Due to Type-1 Myocardial Infarction. Heart Lung Circ 2023; 32:978-985. [PMID: 37225600 DOI: 10.1016/j.hlc.2023.04.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 03/14/2023] [Accepted: 04/20/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Diagnosis of acute myocardial infarction (AMI) requires a combination of elevated cardiac troponins, and clinical or echocardiographic evidence of coronary ischaemia. Identification of patients with a high likelihood of coronary plaque rupture (Type 1 myocardial infarction [MI]) is crucial as it is these patients for whom coronary intervention has been well-established to provide benefit and reduce subsequent coronary ischemic events. However, high-sensitivity cardiac troponin (hs-cTn) assays have increasingly identified patients with hs-cTn elevations not due to Type 1 MI where recommendations for ongoing care are currently limited. Understanding the profile and clinical outcomes for these patients may inform the development of an emerging evidence-base. METHODS Using two previously published studies (hs-cTnT study n=1,937, RAPID-TnT study n=3,270) and the Fourth Universal Definition of MI, index presentations of patients to South Australian emergency departments with suspected AMI, defined by high sensitivity cardiac troponin T (hs-cTnT) greater than the upper reference limit (14 ng/L) and without obvious corresponding ischaemia on electrocardiogram (ECG), were classified as either Type 1 MI (T1MI), Type 2 MI (T2MI), acute myocardial injury (AI), or chronic myocardial injury (CI). Patients with non-elevated hs-cTnT (defined as <14 ng/L) were excluded. Outcomes assessed included death, MI, unstable angina, and non-coronary cardiovascular events within 12 months. RESULTS In total, 1,192 patients comprising 164 (13.8%) T1MI, 173 (14.5%) T2MI/AI, and 855 (71.7%) CI were included. The rate of death or recurrent acute coronary syndrome was greatest in patients with T1MI, but also occurred with moderate frequency in Type 2 MI/AI and CI (T1MI: 32/164 [19.5%]; T2MI/AI: 24/173 [13.1%]; CI:116/885 [13.6%]; p=0.008). Of all the deaths observed, 74% occurred among those with an initial index diagnostic classification of CI. After adjusting for age, gender and baseline comorbidities, the relative hazard ratios for non-coronary cardiovascular readmissions were similar across all groups: Type 2 MI/AI: 1.30 (95% confidence interval 0.99-1.72, p=0.062); CI: 1.10 (95% confidence interval 0.61-2.00, p=0.75). CONCLUSIONS Non-T1MI accounted for the majority of patients presenting with elevated hs-cTnT without ischaemia on ECG. Patients with T1MI had the highest rates of death or recurrent AMI; however patients with T2MI/AI and CI experienced a substantial rate of non-coronary cardiovascular re-hospitalisations.
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Affiliation(s)
- Simon Rocheleau
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Joanne Eng-Frost
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia; South Australian Department of Health, Adelaide, SA, Australia
| | - Ehsan Khan
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Brian Chiang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Naomi Wattchow
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Simon Steele
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Scott Lorensini
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Sam J Lehman
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | | | - Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, Adelaide, SA, Australia; South Australian Department of Health, Adelaide, SA, Australia.
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23
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Bae DH, Park S, Kim M, Kim S, Choi WG, Bae JW, Hwang KK, Kim DW, Cho MC, Lee JH. Cardiac osteosarcoma: a case report and literature review. Front Cardiovasc Med 2023; 10:1215389. [PMID: 37492160 PMCID: PMC10364321 DOI: 10.3389/fcvm.2023.1215389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/16/2023] [Indexed: 07/27/2023] Open
Abstract
Background Primary cardiac tumors are rare, and malignant primary cardiac tumors are even rarer. Cardiac osteosarcoma is a very rare type of malignant primary cardiac tumor with limited reported cases. We present a case report of cardiac osteosarcoma and review its characteristics and the related literature. Case summary A 44-year-old female patient without a specific medical history presented with intermittent dyspnea that started 1 month prior to presentation. A heterogeneous mass was observed in the left atrium on echocardiography and a large mass was observed in the left atrium on computed tomography. Surgery was performed under the suspicion of atypical cardiac myxoma, and the tumor was successfully removed. However, postoperative histopathological examination revealed cardiac osteosarcoma. The patient underwent chemotherapy and has been well maintained without recurrence for 10 years. Conclusion We present a case report of the echocardiographic features and treatment strategies for cardiac osteosarcoma, an extremely rare cardiac tumor. Multimodal imaging can be helpful; however, a histological diagnosis through surgical resection is essential. Appropriate treatment and follow-up based on histological findings are necessary.
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Affiliation(s)
- Dae-Hwan Bae
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Sangshin Park
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Min Kim
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Sangmin Kim
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
- Department of Cardiology, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Woong Gil Choi
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
- Department of Cardiology, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Jang-Whan Bae
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
- Department of Cardiology, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Kyung-Kuk Hwang
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
- Department of Cardiology, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Dong-Woon Kim
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
- Department of Cardiology, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Myeong-Chan Cho
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Ju-Hee Lee
- Department of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea
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24
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Eng-Frost J, Rocheleau S, Lambrakis K, Khan E, van den Merkhof A, Papendick C, Lehman S, Chiang B, Wattchow N, Steele S, Lorensini S, McCann M, George K, Vaile J, De Pasquale C, French J, Chew D. Contrasting the potential benefits of early invasive coronary angiography in acute and chronic myocardial injury patterns. PLoS One 2023; 18:e0286157. [PMID: 37319181 PMCID: PMC10270641 DOI: 10.1371/journal.pone.0286157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 05/10/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND In cases of evolving myocardial injury not definitively attributed to coronary ischaemia precipitated by plaque rupture, referral for invasive coronary angiography (ICA) may be influenced by observed troponin profiles. We sought to explore association between early ICA and elevated high-sensitivity troponin T (hs-cTnT) concentrations with and without dynamic changes, to examine if there may be a hs-cTnT threshold associated with benefit from an initial ICA strategy. METHODS Using published studies (hs-cTnT study n = 1937, RAPID-TnT study n = 3270) and the Fourth Universal Definition of Myocardial Infarction (MI), index presentations of patients with hs-cTnT concentrations 5-14ng/L were classified as 'non-elevated' (NE). Hs-cTnT greater than upper reference limit (14ng/L) were classified as 'elevated hs-cTnT with dynamic change' (encompassing acute myocardial injury, Type 1 MI, and Type 2 MI), or 'non-dynamic hs-cTnT elevation' (chronic myocardial injury). Patients with hs-cTnT <5ng/L and/or eGFR<15mmol/L/1.73m2 were excluded. ICA was performed within 30 days of admission. Primary outcome was defined as composite endpoint of death, MI, or unstable angina at 12 months. RESULTS Altogether, 3620 patients comprising 837 (23.1%) with non-dynamic hs-cTnT elevations and 332 (9.2%) with dynamic hs-cTnT elevations were included. Primary outcome was significantly higher with dynamic and non-dynamic hs-cTnT elevations (Dynamic: HR: 4.13 95%CI:2.92-5.82; p<0.001 Non-dynamic: HR: 2.39 95% confidence interval [CI]:1.74-3.28, p<0.001). Hs-cTnT thresholds where benefit from initial ICA strategy appeared to emerge was observed at 110ng/L and 50ng/L in dynamic and non-dynamic elevations, respectively. CONCLUSION Early ICA appears to portend benefit in hs-cTnT elevations with and without dynamic changes, and at lower hs-cTnT threshold in non-dynamic hs-cTnT elevation. Differences compel further investigation.
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Affiliation(s)
- Joanne Eng-Frost
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Simon Rocheleau
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Ehsan Khan
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Anke van den Merkhof
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Faculty of Medical Sciences, University of Groningen, Groningen, Netherlands
| | | | - Sam Lehman
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Brian Chiang
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Naomi Wattchow
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Simon Steele
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Scott Lorensini
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Michael McCann
- Department of Cardiology, Fiona Stanley Hospital, Perth, Australia
| | - Kate George
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Julian Vaile
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Carmine De Pasquale
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - John French
- Department of Cardiology, Liverpool Hospital, Sydney, Australia
| | - Derek Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
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25
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Livori AC, Lukose D, Bell JS, Webb GI, Ilomäki J. Did Australia's COVID-19 Restrictions Impact Statin Incidence, Prevalence or Adherence? Curr Probl Cardiol 2023; 48:101576. [PMID: 36586705 PMCID: PMC9797214 DOI: 10.1016/j.cpcardiol.2022.101576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 12/30/2022]
Abstract
COVID-19 restrictions may have an unintended consequence of limiting access to cardiovascular care. Australia implemented adaptive interventions (eg, telehealth consultations, digital image prescriptions, continued dispensing, medication delivery) to maintain medication access. This study investigated whether COVID-19 restrictions in different jurisdictions coincided with changes in statin incidence, prevalence and adherence. Analysis of a 10% random sample of national medication claims data from January 2018 to December 2020 was conducted across 3 Australian jurisdictions. Weekly incidence and prevalence were estimated by dividing the number statin initiations and any statin dispensing by the Australian population aged 18-99 years. Statin adherence was analyzed across the jurisdictions and years, with adherence categorized as <40%, 40%-79% and ≥80% based on dispensing per calendar year. Overall, 309,123, 315,703 and 324,906 people were dispensed and 39,029, 39,816, and 44,979 initiated statins in 2018, 2019, and 2020 respectively. Two waves of COVID-19 restrictions in 2020 coincided with no meaningful change in statin incidence or prevalence per week when compared to 2018 and 2019. Incidence increased 0.3% from 23.7 to 26.2 per 1000 people across jurisdictions in 2020 compared to 2019. Prevalence increased 0.14% from 158.5 to 159.9 per 1000 people across jurisdictions in 2020 compared to 2019. The proportion of adults with ≥80% adherence increased by 3.3% in Victoria, 1.4% in NSW and 1.8% in other states and territories between 2019 and 2020. COVID-19 restrictions did not coincide with meaningful changes in the incidence, prevalence or adherence to statins suggesting adaptive interventions succeeded in maintaining access to cardiovascular medications.
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Affiliation(s)
- Adam C Livori
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, VIC, Australia.
| | - Dickson Lukose
- Monash Data Futures Institute, Monash University, Melbourne, VIC, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, VIC, Australia; Monash Data Futures Institute, Monash University, Melbourne, VIC, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Geoffrey I Webb
- Monash Data Futures Institute, Monash University, Melbourne, VIC, Australia; Department of Data Science and Artificial Intelligence, Monash University, Melbourne, VIC, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical, Sciences, Monash University, Melbourne, VIC, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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26
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Brownlee E, Greenslade JH, Kelly A, Meek RA, Parsonage WA, Cullen L. Snapshot of suspected acute coronary syndrome assessment processes in the emergency department: A national cross-sectional survey. Emerg Med Australas 2023; 35:261-268. [PMID: 36334914 PMCID: PMC10946811 DOI: 10.1111/1742-6723.14115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/21/2022] [Accepted: 10/01/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The Snapshot of Suspected ACS Assessment (SSAASY) study aims to describe the assessment processes for patients with suspected acute coronary syndrome (ACS) in Australian EDs, and to compare these processes with the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (NHFA/CSANZ) guidelines. METHODS Between March and May 2021, a cross-sectional survey of Australian EDs was undertaken to investigate the assessment strategies used within the ED. All public and private hospitals identified as having dedicated EDs were invited to participate. Respondents provided data on hospital, ED and cardiac service characteristics. They also provided data on the risk stratification process recommended within their department (risk scores, troponin testing, objective testing for coronary artery disease). Awareness of the NHFA/CSANZ guidelines was assessed. RESULTS Responses were received from 109/162 departments (67%). Most sites (n = 100, 92%) reported using dedicated protocols developed by ED clinicians that included risk stratification scores. Highly sensitive troponin assays were used at 103 (94%) sites. Serial troponin testing was performed over 2 h for low-risk patients in 53 (49%) sites and 2-3 h for intermediate and high-risk patients in 74 (68%) sites. Further investigations included exercise stress tests (48%) and stress echocardiography (38%), with 45% of sites ordering outpatient investigations. CONCLUSIONS The SSAASY study reported the strategies used to assess suspected ACS. In line with current NHFA/CSANZ guidelines, highly sensitive troponin assays are widely utilised. However, serial sampling intervals were longer than guideline recommendations, suggesting a translational gap between guidelines and clinical practice.
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Affiliation(s)
- Emily Brownlee
- Emergency and Trauma CentreRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
| | - Jaimi H Greenslade
- Emergency and Trauma CentreRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQueenslandAustralia
| | - Anne‐Maree Kelly
- Department of Medicine, Western Health, Melbourne Medical SchoolThe University of MelbourneMelbourneVictoriaAustralia
- Joseph Epstein Centre for Emergency Medicine Research, Western HealthMelbourneVictoriaAustralia
| | - Robert A Meek
- Department of Emergency MedicineMonash HealthMelbourneVictoriaAustralia
- Department of Medicine, School of Clinical Sciences at Monash HealthMonash UniversityMelbourneVictoriaAustralia
| | - William A Parsonage
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQueenslandAustralia
- Department of CardiologyRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
| | - Louise Cullen
- Emergency and Trauma CentreRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQueenslandAustralia
- Faculty of MedicineThe University of QueenslandBrisbaneQueenslandAustralia
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27
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Premaratne M, Garcia GP, Thomas W, Hameed S, Leadbeatter A, Htun N, Dwivedi G, Kaye DM. Opportunities and Challenges of Computed Tomography Coronary Angiography in the Investigation of Chest Pain in the Emergency Department-A Narrative Review. Heart Lung Circ 2023; 32:307-314. [PMID: 36621394 DOI: 10.1016/j.hlc.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 11/02/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
Chest pain is one of the most common presentations to emergency departments. However, only 5.1% will be diagnosed with an acute coronary syndrome, representing considerable time and expense in the diagnosis and investigation of the patients eventually found not to be suffering from an acute coronary syndrome. PubMed and Medline databases were searched with variations of the terms "chest pain", "emergency department", "computed tomography coronary angiography". After review, 52 articles were included. Computed tomography coronary angiography (CTCA) is a class I endorsement for investigating chest pain in major international societal guidelines. CTCA offers excellent sensitivity and negative predictive value in identifying patients with coronary disease, with prognostic data impacting patient management. If CTCA is to be applied to all comers, it is pertinent to discuss the advantages and potential pitfalls if use in the Australian system is to be increased.
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Affiliation(s)
- Manuja Premaratne
- Department of Medicine, Cardiology, Peninsula Health, Melbourne, Vic, Australia.
| | | | - William Thomas
- Department of Radiology, Peninsula Health, Melbourne, Vic, Australia
| | - Shaiq Hameed
- Department of Medicine, Peninsula Health, Melbourne, Vic, Australia
| | | | - Nay Htun
- Department of Medicine, Cardiology, Peninsula Health, Melbourne, Vic, Australia
| | - Girish Dwivedi
- Department of Cardiology, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
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28
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Livori AC, Prosser A, Levkovich B. Clinical outcome measures in the assessment of impact of pharmacists in cardiology ambulatory care: A systematic review. Res Social Adm Pharm 2023; 19:432-444. [PMID: 36253283 DOI: 10.1016/j.sapharm.2022.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 09/01/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022]
Abstract
AIMS Pharmacists are involved in the care of patients with cardiac disease within the ambulatory setting across multiple modes of delivery and practice settings. There is a lack of consensus surrounding the assessments used to measure the impact of pharmacist care. This heterogeneity may undermine confidence and limit utilisation of pharmacists in cardiology ambulatory care. A systematic review was conducted to understand how pharmacist interventions in cardiology ambulatory care were assessed and the impacts of these interventions on patient-centred outcomes. METHODS AND RESULTS A comprehensive search was conducted of MEDLINE, CINAHL Plus, Cochrane Register of Randomised Controlled Trials and EMBASE from 2000 to 2020 with search terms involving pharmacist interventions among cardiology patients in the ambulatory care setting; with studies restricted to randomised controlled trials. Search results were independently screened by two reviewers. The Cochrane Risk of Bias in Randomised Trials tool was used for quality assessment of the included studies. Assessments of pharmacist impact were analysed and compared to established quality indicators of cardiology care. The search produced 3380 individual studies, following screening, 26 studies involving 9013 participants met inclusion criteria. Across the 26 included studies, eleven different intervention types were identified. Four main outcome measures assessing the impact of these interventions were identified: direct measure of cardiovascular disease risk factor, major adverse cardiovascular events, medication adherence, validated risk score for cardiovascular events. There was a high degree of variance in both the way these interventions influenced the outcome as well the outcome measures selected to assess the impact of the intervention. Of the 26 studies, sixteen listed positive impacts on primary outcomes and the remaining 10 listed neutral effects. CONCLUSION Several outcome measures have been used to assess the impact of pharmacist intervention in cardiology ambulatory care. Aligning outcome measures with known indicators of cardiology care quality, as well as more detailed descriptions of intervention, will provide clinicians vital information in designing effective and measurable interventions in cardiology ambulatory care.
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Affiliation(s)
- Adam C Livori
- Ballarat Health Services, Victoria, Australia; Monash University, Victoria, Australia.
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29
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Turner D, Yu J, Murphy D, Chiew A. Triage to electrocardiogram sign-off time in patients with acute coronary syndrome at a metropolitan Sydney hospital. Emerg Med Australas 2023. [PMID: 36796425 DOI: 10.1111/1742-6723.14181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVE To compare the time from triage to ECG sign-off in patients with acute coronary syndrome, before and after the introduction of an electronic medical record-integrated ECG workflow system (Epiphany). Additionally, to assess for any correlation between patient characteristics and ECG sign-off times. METHODS A retrospective, single-centre cohort study was performed at Prince of Wales Hospital, Sydney. Patients were included if they were over 18 years, presented to Prince of Wales Hospital ED during 2021, had an ED diagnosis code of 'ACS', 'UA', 'NSTEMI' or 'STEMI' and were subsequently admitted under the cardiology team. ECG sign-off times and demographic data were compared between patients presenting prior to 29 June (pre-Epiphany group) and those presenting after (post-Epiphany group). Those without ECGs signed-off were excluded. RESULTS There were 200 patients (100 each group) included in the statistical analysis. There was a significant decrease in the median triage to ECG sign-off time, from 35 min (IQR 18-69) pre-Epiphany, to 21 min (IQR 13-37) post-Epiphany. There were only 10 (5%) patients in the pre-Epiphany group and 16 (8%) in the post-Epiphany group, who had ECG sign-off times less than the 10-min. There was no correlation between gender, triage category, age or time of shift with triage to ECG sign-off time. CONCLUSIONS The introduction of the Epiphany system has significantly reduced the triage to ECG sign-off time in the ED. Despite this, there remains a large proportion of patients with acute coronary syndrome who do not have an ECG signed-off within the guideline-recommended 10 min.
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Affiliation(s)
- Dane Turner
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Jennifer Yu
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Cardiology Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - David Murphy
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Angela Chiew
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
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30
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Jamal J, Idris H, Faour A, Yang W, McLean A, Burgess S, Shugman I, Wales K, O'Loughlin A, Leung D, Mussap CJ, Juergens CP, Lo S, French JK. Late outcomes of ST-elevation myocardial infarction treated by pharmaco-invasive or primary percutaneous coronary intervention. Eur Heart J 2023; 44:516-528. [PMID: 36459120 DOI: 10.1093/eurheartj/ehac661] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 09/08/2022] [Accepted: 11/02/2022] [Indexed: 12/03/2022] Open
Abstract
AIMS Pharmaco-invasive percutaneous coronary intervention (PI-PCI) is recommended for patients with ST-elevation myocardial infarction (STEMI)who are unable to undergo timely primary PCI (pPCI). The present study examined late outcomes after PI-PCI (successful reperfusion followed by scheduled PCI or failed reperfusion and rescue PCI)compared with timely and late pPCI (>120 min from first medical contact). METHODS AND RESULTS All patients with STEMI presenting within 12 h of symptom onset, who underwent PCI during their initial hospitalization at Liverpool Hospital (Sydney), from October 2003 to March 2014, were included. Amongst 2091 STEMI patients (80% male), 1077 (52%)underwent pPCI (68% timely, 32% late), and 1014 (48%)received PI-PCI (33% rescue, 67% scheduled). Mortality at 3 years was 11.1% after pPCI (6.7% timely, 20.2% late) and 6.2% after PI-PCI (9.4% rescue, 4.8% scheduled); P < 0.01. After propensity matching, the adjusted mortality hazard ratio (HR) for timely pPCI compared with scheduled PCI was 0.9 (95% CIs 0.4-2.0) and compared with rescue PCI was 0.5 (95% CIs 0.2-0.9). The adjusted mortality HR for late pPCI, compared with scheduled PCI was 2.2 (95% CIs 1.2-3.1)and compared with rescue PCI, it was 1.5 (95% CIs 0.7-2.0). CONCLUSION Patients who underwent late pPCI had higher mortality rates than those undergoing a pharmaco-invasive strategy. Despite rescue PCI being required in a third of patients, a pharmaco-invasive approach should be considered when delays to PCI are anticipated, as it achieves better outcomes than late pPCI.
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Affiliation(s)
- Javeria Jamal
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,School of Medicine, Western Sydney University, Gilchrist Drive, Sydney, NSW 2170, Australia.,South Western Sydney Clinical School, The University of New South Wales, Elizabeth Street, Sydney, NSW 2170, Australia
| | - Hanan Idris
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,Omar Al-Mukhtar University, QP56+8X6Al, Bayda, Libya.,Fiona Stanley hospital, Robin Warren Dr, WA 6150, Australia
| | - Amir Faour
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,South Western Sydney Clinical School, The University of New South Wales, Elizabeth Street, Sydney, NSW 2170, Australia
| | - Wesley Yang
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,South Western Sydney Clinical School, The University of New South Wales, Elizabeth Street, Sydney, NSW 2170, Australia
| | - Alison McLean
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,South Western Sydney Clinical School, The University of New South Wales, Elizabeth Street, Sydney, NSW 2170, Australia
| | - Sonya Burgess
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,Cardiology Department, Nepean Hospital, Derby St, Sydney 2747, Australia.,The University of Sydney, Camperdown, Sydney, NSW 2006, Australia
| | - Ibrahim Shugman
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,Cardiology Department, Campbelltown Hospital, Therry Rd, Sydney, NSW 2560, Australia
| | - Kathryn Wales
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia
| | - Aiden O'Loughlin
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,School of Medicine, Western Sydney University, Gilchrist Drive, Sydney, NSW 2170, Australia.,Cardiology Department, Campbelltown Hospital, Therry Rd, Sydney, NSW 2560, Australia
| | - Dominic Leung
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,South Western Sydney Clinical School, The University of New South Wales, Elizabeth Street, Sydney, NSW 2170, Australia
| | - Christian Julian Mussap
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,South Western Sydney Clinical School, The University of New South Wales, Elizabeth Street, Sydney, NSW 2170, Australia
| | - Craig Phillip Juergens
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,South Western Sydney Clinical School, The University of New South Wales, Elizabeth Street, Sydney, NSW 2170, Australia
| | - Sidney Lo
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia
| | - John Kerswell French
- Department of Cardiology, Elizabeth Street, Liverpool Hospital, Sydney, NSW 2170, Australia.,School of Medicine, Western Sydney University, Gilchrist Drive, Sydney, NSW 2170, Australia.,South Western Sydney Clinical School, The University of New South Wales, Elizabeth Street, Sydney, NSW 2170, Australia
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31
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Gebremichael LG, Beleigoli A, Champion S, Nesbitt K, Bulto LN, Pinero de Plaza MA, Pearson V, Noonan S, Hendriks JM, Hines S, Clark RA. Effectiveness of cardiac rehabilitation programs in improving medication adherence in patients with cardiovascular disease: a systematic review protocol. JBI Evid Synth 2022; 20:2986-2994. [PMID: 36081378 DOI: 10.11124/jbies-21-00457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The objective of this review is to measure the effectiveness of cardiac rehabilitation programs versus standard care on medication adherence in patients with cardiovascular disease. INTRODUCTION Poor adherence to long-term medications increases the risk of morbidity and mortality, and decreases quality of life in patients with cardiovascular diseases. Several strategies have been trialed to improve medication adherence, one of which is cardiac rehabilitation programs. Although evidence has indicated that such programs increase medication adherence, the extent of their effectiveness and translation into clinical practice is not well documented. Our systematic review will collect and analyze the available evidence for clinical practice implementation. INCLUSION CRITERIA The search will aim to locate randomized controlled trials. Where randomized controlled trials are not available, quasi-experimental studies, case-control studies, observational studies, and other study designs will be included. Studies that measure effectiveness of cardiac rehabilitation programs compared with standard care on medication adherence in cardiovascular disease patients will be included. METHODS Databases, including MEDLINE (Ovid), Emcare (Ovid), Embase (Ovid), Cochrane CENTRAL, Scopus, CINAHL (EBSCO), and unpublished sources will be searched. Articles in English and non-English-language articles with an English abstract, published from database inception to the present, will be included. Articles will be screened and reviewed by 2 independent reviewers for inclusion. Critical appraisal tools will be applied to the included studies. Data will be extracted using the appropriate extraction tools and synthesized for the objectives of the study. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42021284705.
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Affiliation(s)
- Lemlem G Gebremichael
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Alice Springs, NT, Australia
| | - Alline Beleigoli
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Alice Springs, NT, Australia
| | - Stephanie Champion
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Alice Springs, NT, Australia
| | - Katie Nesbitt
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Alice Springs, NT, Australia
| | - Lemma N Bulto
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Alice Springs, NT, Australia
| | - Maria Alejandra Pinero de Plaza
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Alice Springs, NT, Australia.,National Health and Medical Research Council, Transdisciplinary Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, SA, Australia
| | - Vincent Pearson
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Sara Noonan
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Jeroen M Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Alice Springs, NT, Australia.,Centre for Heart Rhythm Disorders, University of Adelaide and the Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sonia Hines
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Alice Springs, NT, Australia.,Flinders Rural and Remote Health, NT, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Robyn A Clark
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Alice Springs, NT, Australia
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32
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Huang S, Guo N, Duan X, Zhou Q, Zhang Z, Luo L, Ge L. Association between the blood urea nitrogen to creatinine ratio and in‑hospital mortality among patients with acute myocardial infarction: A retrospective cohort study. Exp Ther Med 2022; 25:36. [PMID: 36569431 PMCID: PMC9764047 DOI: 10.3892/etm.2022.11735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 10/21/2022] [Indexed: 11/30/2022] Open
Abstract
The present study aimed to determine the association between the blood urea nitrogen (BUN) and creatinine (Cr) ratio and in-hospital mortality in patients with acute myocardial infarction (AMI). The present retrospective cohort study included adult patients (≥18 years of age) who were admitted to the intensive care unit (ICU) with a primary diagnosis of AMI. Medical records were obtained from the electronic ICU collaborative research database, which includes data from throughout continental USA. Data included demographic characteristics, vital signs, laboratory tests and comorbidities. The clinical endpoint was in-hospital mortality. The Cox proportional hazards model was used to evaluate the prognostic values of the basic BUN/Cr ratio and the Kaplan-Meier method was used to plot survival curves. Subgroup analyses were performed to measure mortality across various subgroups. In total, 5,965 eligible patients were included. In the Cox regression analysis, after being adjusted for age, sex, ethnicity and other confounding factors, the BUN/Cr ratio was found to be a significant risk predictor of in-hospital mortality. There was a non-linear relationship between the BUN/Cr ratio and in-hospital mortality after adjusting for potential confounders. A two-piecewise regression model was used to obtain a threshold inflection point value of 18. Furthermore, after adjusting for additional confounding factors (age, sex, ethnicity, BMI, heart rate, oxygen saturation, platelets, total protein, AMI category, heart failure, history of diabetes, history of hypertension, percutaneous coronary intervention, and administration of norepinephrine, dopamine and epinephrine), the BUN/Cr ratio remained a significant predictor of in-hospital mortality (third vs. first tertile: Hazard ratio, 1.50; 95% CI, 1.08-2.09; P<0.05). The Kaplan-Meier curve for tertiles of the BUN/Cr ratio indicated that in-hospital mortality rates were highest when the BUN/Cr ratio was ≥18.34 after adjustment for age, sex and ethnicity (P<0.05). The present findings demonstrated that a higher BUN/Cr ratio was associated with an increased risk of in-hospital mortality in patients with non-ST-segment elevation myocardial infarction. These results support a revision of how the prognosis of patients with AMI is predicted.
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Affiliation(s)
- Sulan Huang
- Department of Cardiovascular Medicine, The First People's Hospital of Changde, Changde, Hunan 415000, P.R. China
| | - Ning Guo
- Department of Cardiovascular Medicine, The First People's Hospital of Changde, Changde, Hunan 415000, P.R. China
| | - Xiangjie Duan
- Department of Infectious Disease, The First People's Hospital of Changde, Changde, Hunan 415000, P.R. China
| | - Quan Zhou
- Department of Science and Education, The First People's Hospital of Changde, Changde, Hunan 415000, P.R. China
| | - Zhixiang Zhang
- Department of Cardiovascular Medicine, The First People's Hospital of Changde, Changde, Hunan 415000, P.R. China
| | - Li Luo
- Department of Cardiovascular Medicine, The First People's Hospital of Changde, Changde, Hunan 415000, P.R. China
| | - Liangqing Ge
- Department of Cardiovascular Medicine, The First People's Hospital of Changde, Changde, Hunan 415000, P.R. China,Correspondence to: Dr Liangqing Ge, Department of Cardiovascular Medicine, The First People's Hospital of Changde, 818 Renmin Road, Changde, Hunan 415000, P.R. China
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Stephensen L, Greenslade J, Starmer K, Starmer G, Stone R, Bonnin R, Brazzale A, Drahm‐Butler T, Campbell V, Davis T, Mowatt E, Brown N, Proctor K, Ashover S, Milburn T, McCormack L, Graves N, Gatton M, Mahoney R, Parsonage W, Cullen L. Clinical characteristics of Aboriginal and Torres Strait Islander emergency department patients with suspected acute coronary syndrome. Emerg Med Australas 2022; 35:442-449. [PMID: 36410371 DOI: 10.1111/1742-6723.14138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/30/2022] [Accepted: 10/26/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To describe the demographics, presentation characteristics, clinical features and cardiac outcomes for Aboriginal and Torres Strait Islander patients who present to a regional cardiac referral centre ED with suspected acute coronary syndrome (ACS). METHODS This was a single-centre observational study conducted at a regional referral hospital in Far North Queensland, Australia from November 2017 to September 2018 and January 2019 to December 2019. Study participants were 278 Aboriginal and Torres Strait Islander people presenting to an ED and investigated for suspected ACS. The main outcome measure was the proportion of patients with ACS at index presentation and differences in characteristics between those with and without ACS. RESULTS ACS at presentation was diagnosed in 38.1% of patients (n = 106). The mean age of patients with ACS was 53.5 years (SD 9.5) compared with 48.7 years (SD 12.1) in those without ACS (P = 0.001). Patients with ACS were more likely to be male (63.2% vs 39.0%, P < 0.001), smokers (70.6% vs 52.3%, P = 0.002), have diabetes (56.6% vs 38.4%, P = 0.003) and have renal impairment (24.5% vs 10.5%, P = 0.002). CONCLUSIONS Aboriginal and Torres Strait Islander patients with suspected ACS have a high burden of traditional cardiac risk factors, regardless of whether they are eventually diagnosed with ACS. These patients may benefit from assessment for coronary artery disease regardless of age at presentation.
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Affiliation(s)
- Laura Stephensen
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Jaimi Greenslade
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Katrina Starmer
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
- Royal Flying Doctor Service Cairns Base Cairns Queensland Australia
| | - Greg Starmer
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Richard Stone
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Robert Bonnin
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Anthony Brazzale
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Tileah Drahm‐Butler
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Virginia Campbell
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Tania Davis
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Elizabeth Mowatt
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Nathan Brown
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
| | - Karlie Proctor
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Sarah Ashover
- Promoting Value‐Based Care in the Emergency Department Clinical Excellence Queensland, Queensland Health Brisbane Queensland Australia
| | - Tanya Milburn
- Promoting Value‐Based Care in the Emergency Department Clinical Excellence Queensland, Queensland Health Brisbane Queensland Australia
| | - Louise McCormack
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
| | | | - Michelle Gatton
- School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Ray Mahoney
- School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
- Australian e‐Health Research Centre Commonwealth Scientific and Industrial Research Organisation Canberra Australian Capital Territory Australia
- College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - William Parsonage
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Louise Cullen
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
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Percival M, Freeman C, Cottrell N. Feasibility of a collaborative pharmacist prescribing model for patients with chronic disease(s) attending Australian general practices: a preliminary study. Int J Clin Pharm 2022; 45:502-508. [PMID: 36342565 DOI: 10.1007/s11096-022-01488-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/12/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Pharmacists working in general practices provide medication reviews with recommendations to general practitioners (GPs) to optimise medications. We describe a model where the pharmacist is empowered with increased responsibility to implement agreed recommendations through collaborative prescribing. AIM To assess a collaborative pharmacist prescribing model incorporating increased pharmacist responsibility, for patients with chronic diseases in general practice. METHOD This was a pre-test-post-test quasi experimental pilot study using a pharmacist embedded in three Australian general practices. A pharmaceutical care plan was developed with patients and their GP to identify drug related problems (DRPs). The pharmacist discussed recommendations to manage DRPs with the GP and implemented recommendations agreed by the GP and patient over the six-month study period. Outcome measures included acceptance and implementation rate of recommendations made by the pharmacist. RESULTS The pharmacist made 135 recommendations to optimise medicine use of which 126 (93.3%) were accepted by the GP. There were 105 (83.3%) implemented by the end of the study of which the pharmacist implemented 62 (49.3%). CONCLUSION Compared to other Australian studies using a general practice pharmacist model, this study suggested increased pharmacist responsibility through collaborative prescribing led to high acceptance and implementation rates of recommendations to manage DRPs.
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Affiliation(s)
- Matthew Percival
- School of Pharmacy, Pharmacy Australia Centre of Excellence, The University of Queensland, 20 Cornwall Street, Woolloongabba, Brisbane, QLD, 4102, Australia.
- Gold Coast Hospital and Health Service, 1 Hospital Boulevard, Southport, QLD, 4215, Australia.
| | - Christopher Freeman
- School of Pharmacy, Pharmacy Australia Centre of Excellence, The University of Queensland, 20 Cornwall Street, Woolloongabba, Brisbane, QLD, 4102, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4072, Australia
- Metro North Health, Brisbane, QLD, 4029, Australia
| | - Neil Cottrell
- School of Pharmacy, Pharmacy Australia Centre of Excellence, The University of Queensland, 20 Cornwall Street, Woolloongabba, Brisbane, QLD, 4102, Australia
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Moxon JV, Kraeuter AK, Phie J, Juliano S, Anderson G, Standley G, Sealey C, White RP, Golledge J. Serum angiopoietin-1 concentration does not distinguish patients with ischaemic stroke from those presenting to hospital with ischaemic stroke mimics. BMC Cardiovasc Disord 2022; 22:462. [PMID: 36333663 PMCID: PMC9636674 DOI: 10.1186/s12872-022-02918-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background A previous study found that circulating angiopoietin-1 (angpt-1) concentrations were significantly lower in patients who had a recent ischaemic stroke compared to healthy controls. The primary aim of this study was to assess whether serum angpt-1 could be used as a diagnostic test of ischemic stroke in patients presenting to hospital as an emergency. Exploratory analyses investigated the association of proteins functionally related to angpt-1 (angpt-2, Tie-2, matrix metalloproteinase-9 and vascular endothelial growth factors A, C and D) with ischaemic stroke diagnosis. Methods Patients presenting to Townsville University Hospital for emergency assessment of stroke-like symptoms were consecutively recruited and provided a blood sample. After assessment by a consultant neurologist, patients were grouped into those who did, or did not have ischaemic stroke. The potential for serum angpt-1 to diagnose ischaemic stroke was assessed using receiver operator characteristic (ROC) curves. Cross-sectional analyses appraised inter-group differences in the serum concentration of other proteins. Results One-hundred and twenty-six patients presenting to Townsville University Hospital for emergency assessment of stroke-like symptoms were recruited (median time from symptom onset to hospital presentation: 2.6 (inter-quartile range: 1.2–4.6) hours). Serum angpt-1 had poor ability to diagnose ischaemic stroke in analyses using the whole cohort, or in sensitivity analyses (area under the ROC curve 0.51 (95% CI: 0.41–0.62) and 0.52 (95% CI: 0.39–0.64), respectively). No associations of serum angpt-1 concentration with ischaemic stroke severity, symptom duration or aetiology were observed. Serum concentrations of the other assessed proteins did not differ between patient groups. Conclusions Serum angpt-1 concentration is unlikely to be useful for emergency diagnosis of ischaemic stroke. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02918-w.
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Lancini D, Greenslade J, Martin P, Prasad S, Atherton J, Parsonage W, Aldous S, Than M, Cullen L. Chest pain workup in the presence of atrial fibrillation: impacts on troponin testing, myocardial infarction diagnoses, and long-term prognosis. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:772-781. [PMID: 35925661 DOI: 10.1093/ehjacc/zuac090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/25/2022] [Accepted: 07/15/2022] [Indexed: 06/15/2023]
Abstract
AIMS Patients presenting to the emergency department (ED) with chest pain require evaluation for acute coronary syndrome (ACS). Atrial fibrillation (AF) can lead to troponin (cTn) elevation in the absence of ACS. There is limited evidence informing the impact of AF on the diagnostic performance of cTn testing for the diagnosis of Type 1 myocardial infarction (T1MI), or the association between AF and long-term outcomes in this context. METHODS AND RESULTS This study used the IMPACT and ADAPT study databases to compile a combined cohort of 3496 adults presenting to ED with chest pain between 2007 and 2014, with early cTn testing during ED workup. The mean age was 56.6 years, and 40.2% were female. Outcomes included adjudicated diagnoses for the index admission and mortality to 1-year after presentation. The specificity of initial cTn testing for T1MI diagnosis was lower for patients in AF compared with those not in AF (79.2% vs. 95.4%, P < 0.001), largely due to a relative increase in Type 2 myocardial infarction diagnoses. Sensitivity for T1MI did not differ between patients with or without AF (88.5% vs. 91.5%, P = 0.485). AF was associated with increased 1-year mortality (10.4% vs. 2.3%, P < 0.001), although this was not significant on multivariable analysis. CONCLUSION The specificity of serial cTn testing for the diagnosis of T1MI in patients presenting to ED with chest pain is reduced in the presence of AF. Further studies are needed to establish whether optimised cTn thresholds for patients with AF can improve workup and outcomes.
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Affiliation(s)
- Daniel Lancini
- Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Jaimi Greenslade
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Australian Centre for Health Sciences Innovation, Centre for Healthcare Transformation, School of Public Health, Queensland University of Technology, Kelvin Grove, Australia
| | - Paul Martin
- Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Sandhir Prasad
- Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- School of Medicine, Griffith University, Gold Coast, Australia
| | - John Atherton
- Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - William Parsonage
- Cardiology Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Australian Centre for Health Sciences Innovation, Centre for Healthcare Transformation, School of Public Health, Queensland University of Technology, Kelvin Grove, Australia
| | - Sally Aldous
- Cardiology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Australian Centre for Health Sciences Innovation, Centre for Healthcare Transformation, School of Public Health, Queensland University of Technology, Kelvin Grove, Australia
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Rao A, DiGiacomo M, Phillips JL, Hickman LD. Health professionals' perspectives of integrating meditation into cardiovascular care: A descriptive qualitative study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e4450-e4460. [PMID: 35611693 PMCID: PMC10084326 DOI: 10.1111/hsc.13849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 04/19/2022] [Accepted: 05/05/2022] [Indexed: 06/15/2023]
Abstract
Preliminary research suggests that meditation may provide benefits in psychological health and well-being in people with cardiovascular disease (CVD). However, little is known about health professionals' perceptions of the barriers and facilitators to integrating meditation into CVD. A descriptive qualitative study design with semi-structured interviews was used to explore the acceptability of integrating meditation into outpatient CVD programs and the organisational factors that may affect its integration. Clinicians were recruited through purposive and snowball sampling. E-mail addresses were obtained from publicly listed profiles of cardiovascular and relevant health organisations. Interview questions included perspectives of organising or delivering meditation within a health setting, format of meditation delivery, organisational or other factors that facilitate or present barriers to integrating meditation into clinical practice, and perceived risks associated with integrating meditation in clinical settings. Verbatim transcripts were thematically analysed using an inductive approach and the Braun and Clarke (2006) method to identify themes within barriers and facilitators to implementation. Eighteen predominately female (61%) senior nursing and medical professionals (61%), as well as health managers (17%), psychologists (11%) and allied health professionals (11%), aged 40-60 years were interviewed between 18 May 2017 and 29 March 2018 in Australia via telephone, or face-to-face at a university or the participants' workplace. Three key themes were identified including: enhancing awareness of meditation within a biomedical model of care, building the evidence for meditation in CVD and finding an organisational fit for meditation in cardiovascular care. Meditation was perceived to sit outside the existing health service structure, which prioritised the delivery of medical care. Health professionals perceived that some physicians did not recognise the potential for meditation to improve cardiovascular outcomes while others acknowledged meditation's positive benefits as a safe, low-cost strategy. The benefits of meditation were perceived as subjective, based on preliminary evidence. Health professionals perceived that aligning meditation with health organisational objectives and integrating meditation into outpatient cardiac rehabilitation and community-based secondary prevention pathways is needed. A fully powered clinical trial is required to strengthen the evidence regarding the role of meditation for psychological health in CVD. Generating clinician engagement and support is necessary to enhance awareness of meditation's use in cardiovascular secondary prevention.
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Affiliation(s)
- Angela Rao
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of HealthUniversity of Technology SydneySydneyNew South WalesAustralia
| | - Michelle DiGiacomo
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of HealthUniversity of Technology SydneySydneyNew South WalesAustralia
| | - Jane L. Phillips
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of HealthUniversity of Technology SydneySydneyNew South WalesAustralia
- School of NursingQueensland University of TechnologyKelvin GroveQueenslandAustralia
| | - Louise D. Hickman
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of HealthUniversity of Technology SydneySydneyNew South WalesAustralia
- University of WollongongWollongongNew South WalesAustralia
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Matthews S, Atkins B, Walton N, Mitchell JA, Jennings G, Buttery AK. Development and Use of a Cardiac Clinical Guideline Mobile App in Australia: Acceptability and Multi-Methods Study. JMIR Form Res 2022; 6:e35599. [PMID: 35930350 PMCID: PMC9391980 DOI: 10.2196/35599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/03/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022] Open
Abstract
Background Implementation of clinical guidelines into routine practice remains highly variable. Strategies to increase guideline uptake include developing digital tools and mobile apps for use in clinical practice. The National Heart Foundation of Australia in collaboration with the Cardiac Society of Australia and New Zealand published 3 key cardiac clinical guidelines, including the Australian clinical guidelines for the (1) prevention and detection of atrial fibrillation, (2) detection and management of heart failure, and (3) management of acute coronary syndromes. To improve access and uptake for health care providers, we developed the Smart Heart Guideline App. Objective This study aims to evaluate the acceptability, implementation, and usability of an Australian-specific cardiac guidelines mobile app. Methods We used an iterative multiple methods development and implementation approach. First, we conducted a cross-sectional web-based survey with end users (n=504 health professionals) in 2017 to determine the acceptability of an Australian-specific cardiac clinical guidelines mobile app. Second, the Smart Heart Guidelines app was created using a design, user testing, and revision process. The app includes interactive algorithms and flowcharts to inform diagnosis and management at the point of care. The freely available app was launched in October 2019 on iOS and Android operating systems and promoted and implemented using multiple methods. Third, data from 2 annual national cross-sectional general practitioner (GP) surveys in 2019 and 2020 were evaluated to understand the awareness and use of the clinical guidelines and the app. Fourth, data from the app stores were analyzed between October 1, 2019, and June 30, 2021, to evaluate usage. Results Most health professionals surveyed (447/504, 89%) reported accessing resources electronically, and most (318/504, 63%) reported that they would use an Australian-specific cardiac guidelines app. GPs surveyed in 2019 were aware of the heart failure (159/312, 51%) and atrial fibrillation (140/312, 45%) guidelines, and in 2020, a total of 34 of 189 (18%) reported that they were aware of the app. The app was downloaded 11,313 times (7483, 66% from the Apple App Store; 3830, 34% from Google Play) during the first 20-month period. Most downloads (6300/7483, 84%) were a result of searching for the app in the stores. Monthly download rates varied. App Store data showed that people used the app twice (on average 2.06 times) during the 20 months. Many (3256/3830, 85%) Android users deleted the app. Conclusions Health professionals supported the development of the Smart Heart Guidelines app. Although initial downloads were promising, the frequency of using the app was low and deletion rates were high. Further evaluation of users’ experience of the most and least useful components of the app is needed.
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Affiliation(s)
- Stacey Matthews
- National Heart Foundation of Australia, Melbourne, Australia
- Royal Melbourne Hospital, Cardiothoracic Surgery Unit, Parkville, Australia
| | - Brooke Atkins
- National Heart Foundation of Australia, Melbourne, Australia
| | - Natalie Walton
- National Heart Foundation of Australia, Melbourne, Australia
| | | | - Garry Jennings
- National Heart Foundation of Australia, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, Australia
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van Wyk GW, Berkovsky S, Fraile Navarro D, Coiera E. Comparing health outcomes between coronary interventions in frail patients aged 75 years or older with acute coronary syndrome: a systematic review. Eur Geriatr Med 2022; 13:1057-1069. [PMID: 35908241 PMCID: PMC9553773 DOI: 10.1007/s41999-022-00667-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022]
Abstract
Aim To assess the current evidence comparing the health outcomes of coronary interventions in frail patients aged 75 years or older with acute coronary syndrome. Findings Available studies are observational and limited by incomplete statistical adjustment required for robust causal analysis. There may be a signal for improved outcomes in acute coronary syndrome patients treated invasively vs conservatively. Message Robust studies are needed to inform the optimal selection of coronary interventions in frail older patients with acute coronary syndrome. Purpose To assess current evidence comparing the impact of available coronary interventions in frail patients aged 75 years or older with different subtypes of acute coronary syndrome (ACS) on health outcomes. Methods Scopus, Embase and PubMed were systematically searched in May 2022 for studies comparing outcomes between coronary interventions in frail older patients with ACS. Studies were excluded if they provided no objective assessment of frailty during the index admission, under-represented patients aged 75 years or older, or included patients with non-ACS coronary disease without presenting results for the ACS subgroup. Following data extraction from the included studies, a qualitative synthesis of results was undertaken. Results Nine studies met all eligibility criteria. All eligible studies were observational. Substantial heterogeneity was observed across study designs regarding ACS subtypes included, frailty assessments used, coronary interventions compared, and outcomes studied. All studies were assessed to be at high risk of bias. Notably, adjustment for confounders was limited or not adequately reported in all studies. The comparative assessment suggested a possible efficacy signal for invasive treatment relative to conservative treatment but possibly at the risk of increased bleeding events. Conclusions There is a paucity of evidence comparing health outcomes between different coronary interventions in frail patients aged 75 years or older with ACS. Available evidence is at high risk of bias. Given the growing importance of ACS in frail patients aged 75 years or older, new studies are needed to inform optimal ACS care for this population. Future studies should rigorously adjust for confounders.
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Affiliation(s)
- Gregory W van Wyk
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW, 2113, Australia.
| | - Shlomo Berkovsky
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW, 2113, Australia
| | - David Fraile Navarro
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW, 2113, Australia
| | - Enrico Coiera
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Rd, Macquarie Park, NSW, 2113, Australia
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Spitzer S, di Lego V, Kuhn M, Roth C, Berger R. Socioeconomic environment and survival in patients after ST-segment elevation myocardial infarction (STEMI): a longitudinal study for the City of Vienna. BMJ Open 2022; 12:e058698. [PMID: 35820761 PMCID: PMC9280908 DOI: 10.1136/bmjopen-2021-058698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES This study investigates the relationship between socioeconomic environment (SEE) and survival after ST-segment elevation myocardial infarction (STEMI) separately for women and men in the City of Vienna, Austria. DESIGN Hospital-based observational data of STEMI patients are linked with district-level information on SEE and the mortality register, enabling survival analyses with a 19-year follow-up (2000-2018). SETTING The analysis is set at the main tertiary care hospital of the City of Vienna. On weekends, it is the only hospital in charge of treating STEMIs and thus provides representative data for the Viennese population. PARTICIPANTS The study comprises a total of 1481 patients with STEMI, including women and men aged 24-94 years. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome measures are age at STEMI and age at death. We further distinguish between deaths from coronary artery disease (CAD), deaths from acute coronary syndrome (ACS), and other causes of death. SEE is proxied via mean individual gross income from employment in each municipal district. RESULTS Results are based on Kaplan-Meier survival probability estimates, Cox proportional hazard regressions and competing risk models, always using age as the time scale. Descriptive findings suggest a socioeconomic gradient in the age at death after STEMI. This finding is, however, not supported by the regression results. Female patients with STEMI have better survival outcomes, but only for deaths related to CAD (HR: 0.668, 95% CIs 0.452 to 0.985) and other causes of deaths (HR: 0.627, 95% CIs 0.444 to 0.884), and not for deaths from the more acute ACS. CONCLUSIONS Additional research is necessary to further disentangle the interaction between SEE and age at STEMI, as our findings suggest that individuals from poorer districts have STEMI at younger ages, which indicates vulnerability in regard to health conditions in these neighbourhoods.
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Affiliation(s)
- Sonja Spitzer
- Department of Demography, University of Vienna, Wittgenstein Centre for Demography and Global Human Capital (IIASA, OeAW, University of Vienna), Wien, Austria
| | - Vanessa di Lego
- Vienna Institute of Demography, Austrian Academy of Sciences, Wittgenstein Centre for Demography and Global Human Capital (IIASA, OeAW, University of Vienna), Wien, Austria
| | - Michael Kuhn
- Vienna Institute of Demography, Austrian Academy of Sciences, Wittgenstein Centre for Demography and Global Human Capital (IIASA, OeAW, University of Vienna), Wien, Austria
- Economic Frontiers Program, International Institute for Applied Systems Analysis, Laxenburg, Austria
| | - Christian Roth
- Department of Internal Medicine II, Cardiology, Medical University of Vienna, Wien, Austria
| | - Rudolf Berger
- Department of Internal Medicine II, Cardiology, Medical University of Vienna, Wien, Austria
- Department of Internal Medicine I, Cardiology and Nephrology, Hospital of St. John of God, Eisenstadt, Austria
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Greenslade JH, Berndt S, Stephensen L, Starmer K, Starmer G, Parsonage W, Lau V, Drahm‐Butler T, Davis T, Campbell V, Stone R, Bonnin R, Ashover S, Milburn T, Mowatt E, Proctor K, Brazzale A, Cullen LA. Value of single troponin values in the emergency department for excluding acute myocardial infarction in Aboriginal and Torres Strait Islander people. Med J Aust 2022; 217:48-49. [DOI: 10.5694/mja2.51544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/16/2022] [Accepted: 04/19/2022] [Indexed: 01/08/2023]
Affiliation(s)
- Jaimi H Greenslade
- Royal Brisbane and Women's Hospital Brisbane QLD
- Australian Centre for Health Services Innovation (AusHSI) University of Technology Brisbane QLD
| | - Sara Berndt
- Clinical Excellence, Queensland Department of Health Brisbane QLD
| | - Laura Stephensen
- Royal Brisbane and Women's Hospital Brisbane QLD
- Queensland University of Technology Brisbane QLD
| | | | | | - William Parsonage
- Royal Brisbane and Women's Hospital Brisbane QLD
- Australian Centre for Health Services Innovation (AusHSI) University of Technology Brisbane QLD
| | | | | | | | | | | | | | - Sarah Ashover
- Clinical Excellence, Queensland Department of Health Brisbane QLD
| | - Tanya Milburn
- Clinical Excellence, Queensland Department of Health Brisbane QLD
| | | | | | | | - Louise Ann Cullen
- Royal Brisbane and Women's Hospital Brisbane QLD
- The University of QueenslandBrisbaneQLD
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Biology, Bias, or Both? The Contribution of Sex and Gender to the Disparity in Cardiovascular Outcomes Between Women and Men. Curr Atheroscler Rep 2022; 24:701-708. [PMID: 35773564 PMCID: PMC9399064 DOI: 10.1007/s11883-022-01046-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2022] [Indexed: 11/24/2022]
Abstract
Purpose of Review Cardiovascular disease (CVD) is the leading cause of mortality and morbidity worldwide for both men and women. However, CVD is understudied, underdiagnosed, and undertreated in women. This bias has resulted in women being disproportionately affected by CVD when compared to men. The aim of this narrative review is to explore the contribution of sex and gender on CVD outcomes in men and women and offer recommendations for researchers and clinicians. Recent Findings Evidence demonstrates that there are sex differences (e.g., menopause and pregnancy complications) and gender differences (e.g., socialization of gender) that contribute to the inequality in risk, presentation, and treatment of CVD in women. Summary To start addressing the CVD issues that disproportionately impact women, it is essential that these sex and gender differences are addressed through educating health care professionals on gender bias; offering patient-centered care and programs tailored to women’s needs; and conducting inclusive health research.
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Cullen L, Stephensen L, Greenslade J, Starmer K, Starmer G, Stone R, Bonnin R, Brazzale A, Drahm-Butler T, Campbell V, Davis T, Mowatt E, Brown NJ, Proctor K, Ashover S, Milburn T, McCormack L, Graves N, Parsonage W. Emergency Department Assessment of Suspected Acute Coronary Syndrome Using the IMPACT Pathway in Aboriginal and Torres Strait Islander People. Heart Lung Circ 2022; 31:1029-1036. [PMID: 35337734 DOI: 10.1016/j.hlc.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The Improved Assessment of Chest pain Trial (IMPACT) pathway is an accelerated strategy for the assessment of emergency patients presenting with suspected acute coronary syndrome (ACS). The objective of this study was to report outcomes for Aboriginal and Torres Strait Islander patients deemed low-, intermediate-, or high-risk according to this pathway. DESIGN This was a prospective observational trial conducted between November 2017 and December 2019. SETTING Regional hospital in Far North Queensland. PARTICIPANTS Aboriginal and Torres Strait Islander people presenting to the Emergency Department with suspected ACS were asked to participate. Participants were stratified as low-, intermediate- or high-risk of ACS according to the IMPACT pathway. High-and intermediate risk patients were managed according to the IMPACT pathway. Management of low-risk patients included additional inpatient cardiac testing, which was not part of the original IMPACT pathway. MAIN OUTCOME MEASURES The primary outcome was acute coronary syndrome within 30-days. Secondary outcomes included length of stay and prevalence of objective testing. RESULTS A total of 155 participants were classified as either at low-risk (n=18 11.6%), intermediate-risk (n=87 56.1%), or high-risk (n=50 32.3%) of ACS. Thirty-day (30-day) ACS occurred in 29 (18.6%) patients, which included 26 (52.0%) high-risk patients and three (3.4%) intermediate-risk patients. No patients in the low-risk group were diagnosed with ACS during their index presentation or by 30-days. Median hospital length-of-stay was 11.9 hours (interquartile range [IQR] 5.3-20.2 hrs) for low- and 15.5 hours (IQR 5.9-29.2 hrs) for intermediate-risk patients. CONCLUSION The IMPACT pathway, which has been associated with reduced LOS in other settings, could be safely implemented for patients of Aboriginal and Torres Strait Islander origin, classifying two-thirds as low- or intermediate risk. However, a clinically significant proportion of Aboriginal and Torres Strait Islander patients experience cardiac events, which supports the need to provide early objective testing for coronary artery disease.
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Affiliation(s)
- Louise Cullen
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia; Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Qld, Australia.
| | - Laura Stephensen
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia; Metro North Hospital and Health Service, Queensland Health, Australia
| | - Jaimi Greenslade
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia; Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Qld, Australia
| | - Katrina Starmer
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Greg Starmer
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Richard Stone
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Robert Bonnin
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Anthony Brazzale
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | | | - Virginia Campbell
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Tania Davis
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Elizabeth Mowatt
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Nathan J Brown
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - Karlie Proctor
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Sarah Ashover
- Metro North Hospital and Health Service, Queensland Health, Australia; PROV-ED, Clinical Excellence Queensland, Queensland Health, Australia
| | - Tanya Milburn
- Metro North Hospital and Health Service, Queensland Health, Australia; PROV-ED, Clinical Excellence Queensland, Queensland Health, Australia
| | - Louise McCormack
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia
| | | | - William Parsonage
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia; Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Qld, Australia
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Faour A, Cherrett C, Gibbs O, Lintern K, Mussap CJ, Rajaratnam R, Leung DY, Taylor DA, Faddy SC, Lo S, Juergens CP, French JK. Utility of prehospital electrocardiogram interpretation in ST-segment elevation myocardial infarction utilizing computer interpretation and transmission for interventional cardiologist consultation. Catheter Cardiovasc Interv 2022; 100:295-303. [PMID: 35766040 PMCID: PMC9546148 DOI: 10.1002/ccd.30300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/25/2022] [Accepted: 06/04/2022] [Indexed: 12/26/2022]
Abstract
Objectives We examined the appropriateness of prehospital cardiac catheter laboratory activation (CCL‐A) in ST‐segment elevation myocardial infarction (STEMI) utilizing the University of Glasgow algorithm (UGA) and remote interventional cardiologist consultation. Background The incremental benefit of prehospital electrocardiogram (PH‐ECG) transmission on the diagnostic accuracy and appropriateness of CCL‐A has been examined in a small number of studies with conflicting results. Methods We identified consecutive PH‐ECG transmissions between June 2, 2010 and October 6, 2016. Blinded adjudication of ECGs, appropriateness of CCL‐A, and index diagnoses were performed using the fourth universal definition of MI. The primary outcome was the appropriate CCL‐A rate. Secondary outcomes included rates of false‐positive CCL‐A, inappropriate CCL‐A, and inappropriate CCL nonactivation. Results Among 1088 PH‐ECG transmissions, there were 565 (52%) CCL‐As and 523 (48%) CCL nonactivations. The appropriate CCL‐A rate was 97% (550 of 565 CCL‐As), of which 4.9% (n = 27) were false‐positive. The inappropriate CCL‐A rate was 2.7% (15 of 565 CCL‐As) and the inappropriate CCL nonactivation rate was 3.6% (19 of 523 CCL nonactivations). Reasons for appropriate CCL nonactivation (n = 504) included nondiagnostic ST‐segment elevation (n = 128, 25%), bundle branch block (n = 132, 26%), repolarization abnormality (n = 61, 12%), artefact (n = 72, 14%), no ischemic symptoms (n = 32, 6.3%), severe comorbidities (n = 26, 5.2%), transient ST‐segment elevation (n = 20, 4.0%), and others. Conclusions PH‐ECG interpretation utilizing UGA with interventional cardiologist consultation accurately identified STEMI with low rates of inappropriate and false‐positive CCL‐As, whereas using UGA alone would have almost doubled CCL‐As. The benefits of cardiologist consultation were identifying “masquerading” STEMI and avoiding unnecessary CCL‐As.
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Affiliation(s)
- Amir Faour
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Callum Cherrett
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Oliver Gibbs
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Karen Lintern
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Christian J Mussap
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Rohan Rajaratnam
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - David A Taylor
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Steve C Faddy
- New South Wales Ambulance, Sydney, New South Wales, Australia
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia.,Ingham Institute, Sydney, New South Wales, Australia
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45
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Butler DC, Paige E, Welsh J, Di Law H, Moon L, Banks E, Korda RJ. Factors related to under-treatment of secondary cardiovascular risk, including primary healthcare: Australian National Health Survey linked data analysis. Aust N Z J Public Health 2022; 46:533-539. [PMID: 35678999 DOI: 10.1111/1753-6405.13254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 02/01/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To inform national evidence gaps on cardiovascular disease (CVD) preventive medication use and factors relating to under-treatment - including primary healthcare engagement - among CVD survivors in Australia. METHODS Data from 884 participants with self-reported CVD from the 2014-15 National Health Survey were linked to primary care and pharmaceutical dispensing data for 2016 through the Multi-Agency Data Integration Project. Logistic regression quantified the relation of combined blood pressure- and lipid-lowering medication use to participant characteristics. RESULTS Overall, 94.8% had visited a general practitioner (GP) and 40.0% were on both blood pressure- and lipid-lowering medications. Medication use was least likely in: women versus men (OR=0.49[95%CI:0.37-0.65]), younger participants (e.g. 45-64y versus 65-85y: OR=0.58[0.42-0.79])and current versus never-smokers (OR=0.73[0.44-1.20]). Treatment was more likely in those with ≥9 versus ≤4 conditions (OR=2.15[1.39-3.31]), with ≥11 versus 0-2 GP visits/year (OR=2.62[1.53-4.48]) and with individual CVD risk factors (e.g. high blood pressure OR=3.13 [2.34-4.19]) versus without); the latter even accounting for GP service-use frequency. CONCLUSIONS Younger people, smokers, those with infrequent GP visits or without CVD risk factors were the least likely to be on medication. IMPLICATIONS FOR PUBLIC HEALTH Substantial under-treatment, even among those using GP services, indicates opportunities to prevent further CVD events in primary care.
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Affiliation(s)
- Danielle C Butler
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory
| | - Ellie Paige
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory
| | - Jennifer Welsh
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory
| | - Hsei Di Law
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory
| | - Lynelle Moon
- Australian Institute of Health and Welfare, Bruce, Australian Capital Territory
| | - Emily Banks
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory.,Sax Institute, Ultimo, New South Wales
| | - Rosemary J Korda
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory
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Verma KP, Marwick TH, Duarte C, Meikle P, Inouye M, Carrington MJ. Use of coronary computed tomography or polygenic risk scores to prompt action to reduce coronary artery disease risk: the CAPAR-CAD trial. Am Heart J 2022; 248:97-107. [PMID: 35218726 DOI: 10.1016/j.ahj.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/27/2022] [Accepted: 02/19/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The traditional primary prevention paradigm for coronary artery disease (CAD) centers on population-based algorithms to classify individual risk. However, this approach often misclassifies individuals and leaves many in the 'intermediate' category, for whom there is no clear preferred prevention strategy. Coronary artery calcium (CAC) and polygenic risk scoring (PRS) are 2 contemporary tools for risk prediction to enhance the impact of effective management. AIMS To determine how these CAC and PRS impact adherence to pharmacotherapy and lifestyle measures in asymptomatic individuals with subclinical atherosclerosis. METHODS The CAPAR-CAD study is a multicenter, open, randomized controlled trial in Victoria, Australia. Participants are self-selected individuals aged 40 to 70 years with no prior history of cardiovascular disease (CVD), intermediate 10-year risk for CAD as determined by the pooled cohort equation (PCE), and CAC scores >0. All participants will have a health assessment, a full CT coronary angiogram (CTCA), and PRS calculation. They will then be randomized to receive their risk presented either as PCE and CAC, or PCE and PRS. The intervention includes e-Health coaching focused on risk factor management, health education and pharmacotherapy, and follow-up to augment adherence to a statin medication. The primary endpoint is a change in low-density lipoprotein cholesterol (LDL-C) from baseline to 12 months. The secondary endpoint is between-group differences in behavior modification and adherence to statin pharmacotherapy. RESULTS As of July 31, 2021, we have screened 1,903 individuals. We present the results of the 574 participants deemed eligible after baseline assessment.
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Cartledge S, Driscoll A, Dinh D, O'Neil A, Thomas E, Brennan AL, Liew D, Lefkovits J, Stub D. Trends and Predictors of Cardiac Rehabilitation Referral Following Percutaneous Coronary Intervention: A Prospective, Multi-Site Study of 41,739 Patients From the Victorian Cardiac Outcomes Registry (2017-2020). Heart Lung Circ 2022; 31:1247-1254. [PMID: 35643797 DOI: 10.1016/j.hlc.2022.04.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 03/30/2022] [Accepted: 04/07/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Following percutaneous coronary intervention (PCI), outpatient cardiac rehabilitation (CR) is essential for secondary prevention. However uptake of CR is suboptimal, despite strong evidence demonstrating benefits. The aim of this study was to identify contemporary trends and predictors of CR referral of PCI patients in Victoria. METHODS A prospective, observational study using data extracted from the Victorian Cardiac Outcomes Registry was undertaken. A total of 41,739 patients were discharged following PCI over the study period (2017-2020) and included for analysis. RESULTS Cardiac rehabilitation referral was 85%, with an increasing trend over time (p<0.001). Multivariable modelling identifying the independent predictors of CR referral included hospitals with high volumes of ST-elevation myocardial infarction patients (STEMI) (OR 4.89, 95% CI 4.41-5.20), STEMI diagnosis (OR 1.90, 95% CI 1.69-2.14), or treatment in a private hospital (OR 1.45, 95% CI 1.33-1.57). Predictors of non-referral included cardiogenic shock (OR 0.54, 95% CI 0.41-0.71), aged over 75 years (OR 0.62, 95% CI 0.57-0.68) and previous PCI (OR 0.66, 95% CI 0.62-0.70). Percutaneous coronary intervention patients with an acute coronary syndrome who were referred to CR were also more likely to be prescribed four or more major preventive pharmacotherapies, compared to those who were not referred (90% vs 82.1%, p<0.001). CONCLUSION Our contemporary multicentre analysis showed generally high CR referral rates which have increased over time. However, more effort is needed to target patients treated in the public sector, low volume STEMI hospitals or with short lengths of stay.
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Affiliation(s)
- Susie Cartledge
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia.
| | - Andrea Driscoll
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; School of Nursing and Midwifery, Deakin University, Geelong, Vic, Australia; Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Diem Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Adrienne O'Neil
- Food and Mood Centre, IMPACT Institute, Deakin University, Geelong, Vic, Australia
| | - Emma Thomas
- Centre for Online Health, Centre for Health Services Research, The University of Queensland, Brisbane, Qld, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
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48
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Comparison of P2Y12 Inhibitors in Acute Coronary Syndromes in the Australian Population. Heart Lung Circ 2022; 31:1085-1092. [PMID: 35589483 DOI: 10.1016/j.hlc.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/26/2021] [Accepted: 03/27/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Clopidogrel in combination with aspirin after acute coronary syndromes (ACS) reduces recurrent ischaemic events compared to aspirin alone. Further reductions in events have been demonstrated when clopidogrel is replaced by ticagrelor or prasugrel albeit with increases in bleeding. There are few studies documenting the patterns of use of P2Y12 inhibitors or their association with outcomes in the Australian population. AIMS To describe the patterns of use of each P2Y12 inhibitor and to determine the associations between initial P2Y12 inhibitor use and outcomes. METHODS Data were extracted from Cooperative National Registry of ACS, Guideline Adherence and Clinical Events (CONCORDANCE)-a prospective database of patients presenting to 43 sites across Australia with ACS. Patients were stratified based on first antiplatelet agent received. Baseline clinical characteristics were compared between these patient groups and hospital investigations, management as well as in-hospital and 12 months outcomes (death, a composite of cardiac-related death, myocardial infarction, and stroke, and major bleeding) were compared between the three treatment cohorts after adjustment for differences in baseline characteristics. RESULTS Mean ages of the clopidogrel (n=7,537), ticagrelor (n=1,878), and prasugrel (n=347) cohorts were 65, 63, and 58 yrs respectively (p<0.0001), the mean Global Registry of Acute Coronary Events (GRACE) risk scores were 107, 104, and 102 (p=0.0016). The ticagrelor and prasugrel cohorts were more likely to receive percutaneous coronary intervention (PCI) (clopidogrel 52%, ticagrelor 66%, prasugrel 88%, p<0.0001), and evidence based medications (≥4 guideline indicated medications: clopidogrel 76%, ticagrelor 82%, prasugrel 93%, p<0.0001). Patients treated with ticagrelor and prasugrel were less likely to experience in-hospital death (clopidogrel 2.5%, ticagrelor 1.4%, prasugrel 1.2%, p=0.05), major adverse cardiac events (MACE) (clopidogrel 5.1%, ticagrelor 3.0%, prasugrel 3.5% [p=0.01]), or bleeding (clopidogrel 8.4%, ticagrelor 4.6%, prasugrel 7.5% [p<0.001]) compared to clopidogrel. These differences were no longer apparent after multivariable adjustment. There was no difference in outcomes between cohorts at 12 months. CONCLUSIONS In Australia, ticagrelor and prasugrel are used in younger patients who are more likely to undergo percutaneous coronary intervention (PCI) and receive evidence based therapy. Patients receiving clopidogrel were more likely to experience in hospital ischaemic or bleeding events but this was explained by their higher baseline risk. Selection of therapy was not associated with any difference in outcomes at 12-month follow-up, but our findings suggest there is room for improvement towards guideline-driven usage of P2Y12 inhibitors.
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Barnett A, Beasley R, Buchan C, Chien J, Farah CS, King G, McDonald CF, Miller B, Munsif M, Psirides A, Reid L, Roberts M, Smallwood N, Smith S. Thoracic Society of Australia and New Zealand Position Statement on Acute Oxygen Use in Adults: 'Swimming between the flags'. Respirology 2022; 27:262-276. [PMID: 35178831 PMCID: PMC9303673 DOI: 10.1111/resp.14218] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/28/2021] [Accepted: 01/03/2022] [Indexed: 12/14/2022]
Abstract
Oxygen is a life-saving therapy but, when given inappropriately, may also be hazardous. Therefore, in the acute medical setting, oxygen should only be given as treatment for hypoxaemia and requires appropriate prescription, monitoring and review. This update to the Thoracic Society of Australia and New Zealand (TSANZ) guidance on acute oxygen therapy is a brief and practical resource for all healthcare workers involved with administering oxygen therapy to adults in the acute medical setting. It does not apply to intubated or paediatric patients. Recommendations are made in the following six clinical areas: assessment of hypoxaemia (including use of arterial blood gases); prescription of oxygen; peripheral oxygen saturation targets; delivery, including non-invasive ventilation and humidified high-flow nasal cannulae; the significance of high oxygen requirements; and acute hypercapnic respiratory failure. There are three sections which provide (1) a brief summary, (2) recommendations in detail with practice points and (3) a detailed explanation of the reasoning and evidence behind the recommendations. It is anticipated that these recommendations will be disseminated widely in structured programmes across Australia and New Zealand.
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Affiliation(s)
- Adrian Barnett
- Department of Respiratory and Sleep MedicineMater Public HospitalSouth BrisbaneQueenslandAustralia
| | - Richard Beasley
- Medical Research Institute of New Zealand & Capital Coast District Health BoardWellingtonNew Zealand
| | - Catherine Buchan
- Department of Respiratory and Sleep MedicineThe Alfred HospitalMelbourneVictoriaAustralia
- Department of Immunology and Respiratory MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Jimmy Chien
- Department of Respiratory and Sleep MedicineWestmead Hospital, Ludwig Engel Centre for Respiratory Research and University of SydneySydneyNew South WalesAustralia
| | - Claude S. Farah
- Department of Respiratory Medicine, Concord HospitalMacquarie University and University of SydneySydneyNew South WalesAustralia
| | - Gregory King
- Department of Respiratory and Sleep Medicine, Royal North Shore HospitalWoolcock Institute of Medical Research and University of SydneySydneyNew South WalesAustralia
| | - Christine F. McDonald
- Department of Respiratory and Sleep MedicineAustin Health and University of MelbourneMelbourneVictoriaAustralia
| | - Belinda Miller
- Department of Respiratory MedicineThe Alfred Hospital and Monash UniversityMelbourneVictoriaAustralia
| | - Maitri Munsif
- Department of Respiratory and Sleep MedicineAustin Health and University of MelbourneMelbourneVictoriaAustralia
| | - Alex Psirides
- Intensive Care UnitWellington Regional Hospital, Capital and Coast District Health BoardWellingtonNew Zealand
| | - Lynette Reid
- Respiratory MedicineRoyal Hobart HospitalHobartTasmaniaAustralia
| | - Mary Roberts
- Department of Respiratory and Sleep MedicineWestmead Hospital, Ludwig Engel Centre for Respiratory Research and University of SydneySydneyNew South WalesAustralia
| | - Natasha Smallwood
- Department of Respiratory and Sleep MedicineThe Alfred HospitalMelbourneVictoriaAustralia
- Department of Immunology and Respiratory MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Sheree Smith
- School of Nursing and MidwiferyWestern Sydney UniversitySydneyNew South WalesAustralia
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Gullick J, Wu J, Chew D, Gale C, Yan AT, Goodman SG, Waters D, Hyun K, Brieger D. Objective risk assessment vs standard care for acute coronary syndromes-The Australian GRACE Risk tool Implementation Study (AGRIS): a process evaluation. BMC Health Serv Res 2022; 22:380. [PMID: 35317816 PMCID: PMC8941820 DOI: 10.1186/s12913-022-07750-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Structured risk-stratification to guide clinician assessment and engagement with evidence-based therapies may reduce care variance and improve patient outcomes for Acute Coronary Syndrome (ACS). The Australian Grace Risk score Intervention Study (AGRIS) explored the impact of the GRACE Risk Tool for stratification of ischaemic and bleeding risk in ACS. While hospitals in the active arm had a higher overall rate of invasive ACS management, there was neutral impact on important secondary prevention prescriptions/referrals, hospital performance measures, myocardial infarction and 12-month mortality leading to early trial cessation. Given the Grace Risk Tool is under investigation internationally, this process evaluation study provides important insights into the possible contribution of implementation fidelity on the AGRIS study findings. Methods Using maximum variation sampling, five hospitals were selected from the 12 centres enrolled in the active arm of AGRIS. From these facilities, 16 local implementation stakeholders (Cardiology advanced practice nurses, junior and senior doctors, study coordinators) consented to a semi-structured interview guided by the Theoretical Domains Framework. Directed Content Analysis of qualitative data was structured using the Capability/Opportunity/Motivation-Behaviour (COM-B) model. Results Physical capability was enhanced by tool usability. While local stakeholders supported educating frontline clinicians, non-cardiology clinicians struggled with specialist terminology. Physical opportunity was enhanced by the paper-based format but was hampered when busy clinicians viewed risk-stratification as one more thing to do, or when form visibility was neglected. Social opportunity was supported by a culture of research/evidence yet challenged by clinical workflow and rotating medical officers. Automatic motivation was strengthened by positive reinforcement. Reflective motivation revealed the GRACE Risk Tool as supporting but potentially overriding clinical judgment. Divergent professional roles and identity were a major barrier to integration of risk-stratification into routine Emergency Department practice. The cumulative result revealed poor form completion behaviors and a failure to embed risk-stratification into routine patient assessment, communication, documentation, and clinical practice behaviors. Conclusions Numerous factors negatively influenced AGRIS implementation fidelity. Given the prominence of risk assessment recommendations in United States, European and Australian guidelines, strategies that strengthen collaboration with Emergency Departments and integrate automated processes for risk-stratification may improve future translation internationally.
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Affiliation(s)
- Janice Gullick
- Susan Wakil School of Nursing & Midwifery, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
| | - John Wu
- Susan Wakil School of Nursing & Midwifery, and Site Services, University of Sydney Library, University of Sydney, Sydney, NSW, Australia
| | - Derek Chew
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Chris Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, England
| | - Andrew T Yan
- Department of Medicine, University of Toronto, St Michael's Hospital, Toronto, ON, Canada
| | - Shaun G Goodman
- Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Donna Waters
- Susan Wakil School of Nursing & Midwifery, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Karice Hyun
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Concord Repatriation General Hospital, ANZAC Research Institute, Concord West, Australia
| | - David Brieger
- Concord Clinical School, Concord Repatriation General Hospital, ANZAC Research Institute, Concord West, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, +61 2 9767 5000, Australia
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