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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Lambrakis K, Khan E, van den Merkhof A, Papendick C, Chuang A, Zhai Y, Eng-Frost J, Rocheleau S, Lehman SJ, Blyth A, Briffa T, Quinn S, French JK, Cullen L, Chew DP. Impacts of high sensitivity troponin T reporting on care and outcomes in clinical practice: Interactions between low troponin concentrations and participant sex within two randomized clinical trials. Int J Cardiol 2023; 393:131396. [PMID: 37769972 DOI: 10.1016/j.ijcard.2023.131396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 09/10/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The impacts of high sensitivity cardiac troponin (hs-cTn) reporting on downstream interventions amongst suspected acute coronary syndrome (ACS) in the emergency department (ED), especially amongst those with newly identified hs-cTn elevations and in consideration of well-established sex-related disparities, has not been critically evaluated to date. This investigation explores the impact of hs-cTnT reporting on care and outcomes, particularly by participant sex. METHODS Two similarly ED-based randomized controlled trials conducted between July 2011 to March 2013 (n = 1988) and August 2015 to April 2019 (n = 3378) were comparatively evaluated. Clinical outcomes were adjudicated to the Fourth Universal Definition of MI. Changes in practice were assessed at 30 days, and death or MI were explored to 12 months. RESULTS The HS-Troponin study demonstrated no difference in death or MI with unmasking amongst those with hs-cTnT <30 ng/L, whereas the RAPID TnT study demonstrated a significantly higher rate. In RAPID TnT, there was significant increase in death or MI associated with unmasking for females with hs-cTnT <30 ng/L (masked: 11[1.5%], unmasked: 25[3.4%],HR: 2.27,95%C.I.:1.87-2.77,P < 0.001). Less cardiac stress testing with unmasking amongst those <30 ng/L was observed in males in both studies, which was significant in RAPID TnT (masked: 92[12.0%], unmasked: 55[7.0%], P = 0.008). In RAPID TnT, significantly higher rates of angiography in males were observed with unmasking, with no such changes amongst females <30 ng/L (masked: 28[3.7%], unmasked: 51[6.5%],P = 0.01). CONCLUSION Compared with males, there were no evident impacts on downstream practices for females with unmasking in RAPID TnT, likely representing missed opportunities to reduce late death or MI.
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Affiliation(s)
- Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia.
| | - Ehsan Khan
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, 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, the Netherlands
| | - Cynthia Papendick
- South Australian Department of Health, Adelaide, Australia; School of Medicine, University of Adelaide, Adelaide, Australia
| | - Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Yuze Zhai
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
| | | | | | - Sam J Lehman
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Andrew Blyth
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Stephen Quinn
- Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
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Van de Werf F, Ristić AD, Averkov OV, Arias-Mendoza A, Lambert Y, Kerr Saraiva JF, Sepulveda P, Rosell-Ortiz F, French JK, Musić LB, Vandenberghe K, Bogaerts K, Westerhout CM, Pagès A, Danays T, Bainey KR, Sinnaeve P, Goldstein P, Welsh RC, Armstrong PW. STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial. Circulation 2023; 148:753-764. [PMID: 37439219 DOI: 10.1161/circulationaha.123.064521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/16/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND ST-segment-elevation myocardial infarction (STEMI) guidelines recommend pharmaco-invasive treatment if timely primary percutaneous coronary intervention (PCI) is unavailable. Full-dose tenecteplase is associated with an increased risk of intracranial hemorrhage in older patients. Whether pharmaco-invasive treatment with half-dose tenecteplase is effective and safe in older patients with STEMI is unknown. METHODS STREAM-2 (Strategic Reperfusion in Elderly Patients Early After Myocardial Infarction) was an investigator-initiated, open-label, randomized, multicenter study. Patients ≥60 years of age with ≥2 mm ST-segment elevation in 2 contiguous leads, unable to undergo primary PCI within 1 hour, were randomly assigned (2:1) to half-dose tenecteplase followed by coronary angiography and PCI (if indicated) 6 to 24 hours after randomization, or to primary PCI. Efficacy end points of primary interest were ST resolution and the 30-day composite of death, shock, heart failure, or reinfarction. Safety assessments included stroke and nonintracranial bleeding. RESULTS Patients were assigned to pharmaco-invasive treatment (n=401) or primary PCI (n=203). Median times from randomization to tenecteplase or sheath insertion were 10 and 81 minutes, respectively. After last angiography, 85.2% of patients undergoing pharmaco-invasive treatment and 78.4% of patients undergoing primary PCI had ≥50% resolution of ST-segment elevation; their residual median sums of ST deviations were 4.5 versus 5.5 mm, respectively. Thrombolysis In Myocardial Infarction flow grade 3 at last angiography was ≈87% in both groups. The composite clinical end point occurred in 12.8% (51/400) of patients undergoing pharmaco-invasive treatment and 13.3% (27/203) of patients undergoing primary PCI (relative risk, 0.96 [95% CI, 0.62-1.48]). Six intracranial hemorrhages occurred in the pharmaco-invasive arm (1.5%): 3 were protocol violations (excess anticoagulation in 2 and uncontrolled hypertension in 1). No intracranial bleeding occurred in the primary PCI arm. The incidence of major nonintracranial bleeding was low in both groups (<1.5%). CONCLUSIONS Halving the dose of tenecteplase in a pharmaco-invasive strategy in this early-presenting, older STEMI population was associated with electrocardiographic changes that were at least comparable to those after primary PCI. Similar clinical efficacy and angiographic end points occurred in both treatment groups. The risk of intracranial hemorrhage was higher with half-dose tenecteplase than with primary PCI. If timely PCI is unavailable, this pharmaco-invasive strategy is a reasonable alternative, provided that contraindications to fibrinolysis are observed and excess anticoagulation is avoided. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02777580.
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Affiliation(s)
- Frans Van de Werf
- Department of Cardiovascular Sciences, KU Leuven, Belgium (F.V.d.W., K.V., P.S.)
| | - Arsen D Ristić
- Department of Cardiology, University Clinical Center of Serbia, University of Belgrade, Serbia (A.D.R)
| | - Oleg V Averkov
- Pirogov Russian National Research Medical University and City Clinical Hospital #15, Moscow, Russian Federation (O.V.A.)
| | | | - Yves Lambert
- Centre Hospitalier de Versailles, SAMU 78 and Mobile Intensive Care Unit, France (Y.L.)
| | - José F Kerr Saraiva
- Cardiology Discipline, Pontifical Catholic University of Campinas School of Medicine, Brazil (J.F.K.S.)
| | | | | | - John K French
- School of Medicine, University of New South Wales, Sydney, Department of Cardiology, Liverpool Hospital, Sydney, School of Medicine, Western Sydney University, New South Wales, Australia (J.K.F.)
| | - Ljilja B Musić
- Cardiology Clinic, University Clinical Center of Montenegro, University of Podgorica, Medical Faculty (L.B.M.)
| | - Katleen Vandenberghe
- Department of Cardiovascular Sciences, KU Leuven, Belgium (F.V.d.W., K.V., P.S.)
| | - Kris Bogaerts
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), KU Leuven, Leuven and University Hasselt, Belgium (K.B.)
| | - Cynthia M Westerhout
- The Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research {Canadian VIGOUR Centre}, University of Alberta, Edmonton (C.M.W., K.R.B., R.C.W., P.W.A.)
| | - Alain Pagès
- Boehringer Ingelheim GmbH, Ingelheim am Rhein, Germany (A.P.)
| | | | - Kevin R Bainey
- The Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research {Canadian VIGOUR Centre}, University of Alberta, Edmonton (C.M.W., K.R.B., R.C.W., P.W.A.)
| | - Peter Sinnaeve
- Department of Cardiovascular Sciences, KU Leuven, Belgium (F.V.d.W., K.V., P.S.)
| | - Patrick Goldstein
- Emergency Department and SAMU, Lille University Hospital, France (P.G.)
| | - Robert C Welsh
- The Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research {Canadian VIGOUR Centre}, University of Alberta, Edmonton (C.M.W., K.R.B., R.C.W., P.W.A.)
| | - Paul W Armstrong
- The Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research {Canadian VIGOUR Centre}, University of Alberta, Edmonton (C.M.W., K.R.B., R.C.W., P.W.A.)
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Cho KK, French JK, Figtree GA, Chow CK, Kozor R. Rapid access chest pain clinics in Australia and New Zealand. Med J Aust 2023; 219:168-172. [PMID: 37544013 DOI: 10.5694/mja2.52043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 08/08/2023]
Abstract
Chest pain is the second most common reason for adult emergency department presentations. Most patients have low or intermediate risk chest pain, which historically has led to inpatient admission for further evaluation. Rapid access chest pain clinics represent an innovative outpatient pathway for these low and intermediate risk patients, and have been shown to be safe and reduce hospital costs. Despite variations in rapid access chest pain clinic models, there are limited data to determine the most effective approach. Developing a national framework could be beneficial to provide sites with evidence, possible models, and business cases. Multicentre data analysis could enhance understanding and monitoring of the service.
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Affiliation(s)
| | | | - Gemma A Figtree
- Royal North Shore Hospital, University of Sydney, Sydney, NSW
- University of Sydney, Sydney, NSW
| | - Clara K Chow
- University of Sydney, Sydney, NSW
- Westmead Applied Research Centre and Westmead Hospital, Sydney, NSW
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Xu J, Lo S, Mussap CJ, French JK, Rajaratnam R, Kadappu K, Premawardhana U, Nguyen P, Juergens CP, Leung DY. Early Effects of Ticagrelor Versus Clopidogrel on Peripheral Endothelial Function After Non-ST-Elevation Acute Coronary Syndrome and Assessment of Its Relationship With Coronary Microvascular Function. Am J Cardiol 2023; 201:16-24. [PMID: 37348152 DOI: 10.1016/j.amjcard.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/26/2023] [Accepted: 06/01/2023] [Indexed: 06/24/2023]
Abstract
Peripheral endothelial dysfunction is an independent predictor of adverse long-term prognosis after acute coronary syndrome. Data are lacking on the effects of oral P2Y12-inhibitors on peripheral endothelial function in non-ST-elevation acute coronary syndrome (NSTEACS). Furthermore, the relation between peripheral endothelial function and invasive indexes of coronary microvascular function in NSTEACS is unclear. Between March 2018 and July 2020, hospitalized patients with NSTEACS were randomized (1:1) to ticagrelor or clopidogrel. Peripheral endothelial function was assessed with brachial artery flow-mediated vasodilation (FMD). Invasive indexes of coronary microvascular function were obtained using an intracoronary pressure-temperature sensor-tipped wire. In 70 patients included, mean age was 58.6 years, 78.6% (n = 55) were male and 20% (n = 14) had diabetes mellitus. Compared with clopidogrel, ticagrelor significantly improved FMD (14.2 ± 5.4% vs 8.9 ± 5.3%, p <0.001) after a median treatment time of 41.2 hours. The FMD was significantly correlated with the index of microcirculatory resistance (IMR) measured in the infarct-related artery (r = -0.38, p = 0.001), with a stronger correlation found in those who did not have percutaneous coronary intervention (r = -0.52, p = 0.03). Using receiver operating characteristic curve analysis, an FMD of 8.2% identified an IMR of >34 as the threshold, with 77.6% sensitivity and 52.4% specificity. In patients who did not have a percutaneous coronary intervention, an FMD of 11.49% identified an IMR of >34 with 84.6% sensitivity and 80% specificity. In conclusion, ticagrelor significantly improved peripheral endothelial function compared with clopidogrel in patients with NSTEACS. There was a significant correlation between brachial artery FMD and IMR of the infarct-related artery.
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Affiliation(s)
- James Xu
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Christian J Mussap
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Rohan Rajaratnam
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Krishna Kadappu
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia; Macarthur Clinical School, Western Sydney University, Sydney, Australia
| | - Upul Premawardhana
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia; Macarthur Clinical School, Western Sydney University, Sydney, Australia
| | - Phong Nguyen
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia; Macarthur Clinical School, Western Sydney University, Sydney, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
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Jamal J, Jamal S, OLoughlin A, Juergens CP, Mussap C, French JK. DISPARITIES IN STEMI OUTCOMES AMONGST INDIGENOUS AND NON-INDIGENOUS AUSTRALIANS: A 5 YEAR OBSERVATIONAL COHORT STUDY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01406-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Jamal J, Idris H, Faour A, Yang W, McLean A, Burgess S, Shugman I, Oloughlin A, Leung D, Mussap CJ, Juergens CP, Lo S, French JK. Reperfusion strategy and late clinical outcomes of patients with ST-elevation myocardial infarction (STEMI) in the absence of standard modifiable risk factors (SMuRFs). Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
There is growing evidence that patients presenting with STEMI in the absence of standard modifiable cardiovascular risk factors (SMuRFs; smoking, hypertension, hypercholesterolemia, diabetes) have poorer outcomes compared to those with atleast one SMuRF. It has been hypothesised that this may be in part due to decreased administration of pharmacotherapies in the post-infarct period due to perceived low risk. Long term outcomes of patients without SMuRFs based on reperfusion strategy received during the index admission have not been investigated.
Purpose
We sought to analyse late clinical outcomes of STEMI patients with and without SMuRFs based on reperfusion strategy received during the index admission.
Methods
All patients who underwent PCI between 2003 and 2014 were identified from a PCI centre STEMI database. Late clinical outcomes of patients with and without SMuRFs were analysed overall and based on reperfusion strategy [primary PCI (pPCI) vs pharmaco-invasive PCI (PI-PCI)]. Propensity matching was used to account for differences in baseline characteristics between the groups.
Results
Amongst 2,091 STEMI patients, 531 (25%) had no SMuRFs (51% pPCI, 49% PI-PCI) and 1560 (75%) had ≥1 SMuRF (52% pPCI, 48% PI-PCI). Unadjusted late mortality in SMuRF-less patients was 13.4% (18.8% pPCI, 7.7% PI-PCI) and for those with ≥1 SMuRF was 9.7% (11.0% pPCI, 8.4% PI-PCI). After propensity-matching clinical and angiographic characteristics, 5 year mortality rates were significantly higher for patients without SMuRFs compared to those with SMuRFs [HR 1.36, CI: 1.03–1.81, p=0.031]. This difference was attenuated for patients who underwent pPCI [HR 1.72, CI: 1.22–2.43, p=0.002]. Interestingly, this discrepancy was not observed amongst individuals who underwent pharmaco-invasive PCI [HR 1.13, CI: 0.53–1.48, p=0.638], as SMuRF-less patients had similar mortality rates to their counterparts. Long term rates of reinfarction, stent thrombosis and target vessel revascularisation were similar between the groups. Additionally, there was no significant difference in rates of stroke and major bleeding amongst all 4 subgroups.
Conclusion
Patients presenting with STEMI in the absence of SMuRFs have increased overall late mortality compared to those with at least one SMuRF. However, this difference was not observed in patients who underwent a pharmaco-invasive strategy, whereby patients without SMuRFs had similar outcomes to those with SMuRFs after adjusting for confounders. Our findings suggest the use of a pharmaco-invasive strategy in appropriate SMuRF-less patients presenting with STEMI.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- J Jamal
- Liverpool Hospital , Sydney , Australia
| | - H Idris
- Liverpool Hospital , Sydney , Australia
| | - A Faour
- Liverpool Hospital , Sydney , Australia
| | - W Yang
- Liverpool Hospital , Sydney , Australia
| | - A McLean
- Liverpool Hospital , Sydney , Australia
| | - S Burgess
- Liverpool Hospital , Sydney , Australia
| | - I Shugman
- Liverpool Hospital , Sydney , Australia
| | | | - D Leung
- Liverpool Hospital , Sydney , Australia
| | | | | | - S Lo
- Liverpool Hospital , Sydney , Australia
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8
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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9
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Faour A, Pahn R, Cherrett C, Gibbs O, Lintern K, Mussap CJ, Rajaratnam R, Leung DY, Taylor DA, Faddy SC, Lo S, Juergens CP, French JK. Late Outcomes of Patients With Prehospital ST-Segment Elevation and Appropriate Cardiac Catheterization Laboratory Nonactivation. J Am Heart Assoc 2022; 11:e025602. [PMID: 35766276 PMCID: PMC9333384 DOI: 10.1161/jaha.121.025602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with suspected ST-segment-elevation myocardial infarction (STEMI) and cardiac catheterization laboratory nonactivation (CCL-NA) or cancellation have reportedly similar crude and higher adjusted risks of death compared with those with CCL activation, though reasons for these poor outcomes are not clear. We determined late clinical outcomes among patients with prehospital ECG STEMI criteria who had CCL-NA compared with those who had CCL activation. Methods and Results We identified consecutive prehospital ECG transmissions between June 2, 2010 to October 6, 2016. Diagnoses according to the Fourth Universal Definition of myocardial infarction (MI), particularly rates of myocardial injury, were adjudicated. The primary outcome was all-cause death. Secondary outcomes included cardiovascular death/MI/stroke and noncardiovascular death. To explore competing risks, cause-specific hazard ratios (HRs) were obtained. Among 1033 included ECG transmissions, there were 569 (55%) CCL activations and 464 (45%) CCL-NAs (1.8% were inappropriate CCL-NAs). In the CCL activation group, adjudicated index diagnoses included MI (n=534, 94%, of which 99.6% were STEMI and 0.4% non-STEMI), acute myocardial injury (n=15, 2.6%), and chronic myocardial injury (n=6, 1.1%). In the CCL-NA group, diagnoses included MI (n=173, 37%, of which 61% were non-STEMI and 39% STEMI), chronic myocardial injury (n=107, 23%), and acute myocardial injury (n=47, 10%). At 2 years, the risk of all-cause death was higher in patients who had CCL-NA compared with CCL activation (23% versus 7.9%, adjusted risk ratio, 1.58, 95% CI, 1.24-2.00), primarily because of an excess in noncardiovascular deaths (adjusted HR, 3.56, 95% CI, 2.07-6.13). There was no significant difference in the adjusted risk for cardiovascular death/MI/stroke between the 2 groups (HR, 1.23, 95% CI, 0.87-1.73). Conclusions CCL-NA was not primarily attributable to missed STEMI, but attributable to "masquerading" with high rates of non-STEMI and myocardial injury. These patients had worse late outcomes than patients who had CCL activation, mainly because of higher rates of noncardiovascular deaths.
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Affiliation(s)
- Amir Faour
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales
| | - Reece Pahn
- The University of New South Wales Sydney New South Wales
| | - Callum Cherrett
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | - Oliver Gibbs
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | - Karen Lintern
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | - Christian J Mussap
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - Rohan Rajaratnam
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - David A Taylor
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | | | - Sidney Lo
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales
| | - John K French
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales.,Ingham Institute Sydney New South Wales
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10
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Xu J, Lo S, Mussap CJ, French JK, Rajaratnam R, Kadappu K, Premawardhana U, Nguyen P, Juergens CP, Leung DY. Impact of Ticagrelor Versus Clopidogrel on Coronary Microvascular Function After Non-ST-Segment-Elevation Acute Coronary Syndrome. Circ Cardiovasc Interv 2022; 15:e011419. [PMID: 35369712 DOI: 10.1161/circinterventions.121.011419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction after acute coronary syndrome is an important predictor of long-term prognosis. Data is lacking on the effects of oral P2Y12-inhibitors on coronary microvascular function in non-ST-segment-elevation acute coronary syndrome. The aim of this study was to compare the acute effects of ticagrelor versus clopidogrel pretreatment on coronary microvascular function in non-ST-segment-elevation acute coronary syndrome patients. METHODS Hospitalized non-ST-segment-elevation acute coronary syndrome patients were randomized (1:1) to ticagrelor or clopidogrel. The index of microcirculatory resistance, coronary flow reserve, and resistive reserve ratio were obtained using an intracoronary pressure-temperature sensor-tipped wire. RESULTS In total, 128 patients were randomized between March 2018 and July 2020. Mean age 59.2±11.8 years, 84% were male, mean Global Registry of Acute Coronary Events score was 93.7±24.5. Intracoronary physiological measurements were obtained in 118 patients (60 ticagrelor, 58 clopidogrel). In the infarct-related artery, the ticagrelor group had lower baseline index of microcirculatory resistance (22.0 [13.0-34.9] versus 27.7 [19.3-29.8]; P=0.02) and higher baseline resistive reserve ratio (3.0 [2.3-4.4] versus 2.4 [1.7-3.4]; P=0.01) compared with the clopidogrel group. A total of 88 patients underwent percutaneous coronary intervention (PCI; 45 ticagrelor, 43 clopidogrel). The ticagrelor group had lower post-PCI index of microcirculatory resistance (22.0 [15.0-29.0] versus 27.0 [18.5-47.5]; P=0.02) and higher post-PCI resistive reserve ratio (3.0 [1.8-3.8] versus 1.8 [1.5-3.4]; P=0.006) compared with the clopidogrel group. The coronary flow reserve was not significantly different between the 2 groups at baseline or post-PCI. No between-group differences were seen in any of the indices in the non-infarct-related artery. CONCLUSIONS In non-ST-segment-elevation acute coronary syndrome patients, ticagrelor significantly improved coronary microvascular function before and after PCI compared with clopidogrel. REGISTRATION URL: https://www.anzctr.org.au; Unique identifier: ACTRN12618001610224.
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Affiliation(s)
- James Xu
- Department of Cardiology, Liverpool Hospital, Sydney, Australia (J.X., S.L., C.J.M., J.K.P., R.P.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, Australia (J.X., S.L., C.J.M., J.K.P., R.P.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Christian J Mussap
- Department of Cardiology, Liverpool Hospital, Sydney, Australia (J.X., S.L., C.J.M., J.K.P., R.P.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, Australia (J.X., S.L., C.J.M., J.K.P., R.P.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Rohan Rajaratnam
- Department of Cardiology, Liverpool Hospital, Sydney, Australia (J.X., S.L., C.J.M., J.K.P., R.P.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Krishna Kadappu
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia (K.K., U.P., P.N., C.P.J., D.Y.L.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Upul Premawardhana
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia (K.K., U.P., P.N., C.P.J., D.Y.L.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Phong Nguyen
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia (K.K., U.P., P.N., C.P.J., D.Y.L.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Craig P Juergens
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia (K.K., U.P., P.N., C.P.J., D.Y.L.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Dominic Y Leung
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia (K.K., U.P., P.N., C.P.J., D.Y.L.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
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11
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Jamal J, Idris H, Yang W, McLean A, Burgess S, Faour A, Shugman IM, O’Loughlin A, Mussap C, Juergens CP, Lo S, French JK. LATE CLINICAL OUTCOMES OF PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION(STEMI) TREATED BY EITHER PHARMACO-INVASIVE OR PRIMARY PCI. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01662-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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Khan E, Lambrakis K, Nazir SA, Chuang A, Halabi A, Tiver K, Briffa T, Cullen LA, Horsfall M, French JK, Sun BC, Chew DP. Implementation of more sensitive cardiac troponin T assay in a state-wide health service. Int J Cardiol 2022; 347:66-72. [PMID: 34774641 DOI: 10.1016/j.ijcard.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/30/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Abstract
AIMS Explore the impact of deploying high-sensitivity (hs) cardiac troponin T (cTnT) assay across a state-wide health service. METHODS AND RESULTS Presentations to emergency departments of six tertiary hospitals between January 2008 and August 2019 were included; standard cTnT assay was superseded by hs-cTnT in June 2011 without changing the reference range (≥30 ng/L reported as elevated), despite cTnT level of 30 ng/L being equivalent to ∼44 ng/L with hs-cTnT. Clinical outcomes were captured using state-wide linked health records. Interrupted time series analyses were used adjusted for seasonality and multiple co-morbidities using propensity score matching allowing for correlation within hospitals. In total, 614,847 presentations had ≥1 troponin measurement. Clinical ordering of troponin decreased throughout the study with no increase in elevated measurements amongst those tested with hs-cTnT. Small but statistically significant changes in index myocardial infarction (MI) diagnosis (-0.36%/year, 95%CI [confidence interval]:-0.48, -0.24,p < 0.001) and invasive coronary angiography (0.12%/year,95%CI:0, 0.24,p = 0.02) were seen, with no impact on death/MI at 30 days or 3-year survival in episodes of care (EOCs) with elevated cTnT after hs-cTnT implementation. Length of stay (LOS) was shorter among those with an elevated hs-cTnT (-4.44 h/year, 95%CI:-5.27, -3.60, p < 0.001). Non-elevated cTnT EOCs demonstrated shorter total LOS and improved 3-year survival (adjusted hazard ratio:0.90, 95%CI:0.83, 0.97,p = 0.008) although death/MI at 30 days was unchanged using hs-cTnT. CONCLUSION Widespread implementation of hs-cTnT without altering clinical thresholds reported to clinicians provided significantly shorter LOS without a clinically significant impact on clinical outcomes. A safer cohort with non-elevated cTnT was identified by hs-cTnT compared to the standard cTnT assay.
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Affiliation(s)
- Ehsan Khan
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Sheraz A Nazir
- Department of Cardiology, University Hospitals of Coventry & Warwickshire NHS Trust, Coventry, CV2 2DX, UK; Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health for Research (NIHR) Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QF, UK
| | - Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Amera Halabi
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Kathryn Tiver
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Louise A Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Matthew Horsfall
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Benjamin C Sun
- Center for Policy Research-Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, United States of America
| | - Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia; South Australian Department of Health, Adelaide, Australia.
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13
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Chuang MYA, Gnanamanickam ES, Karnon J, Lambrakis K, Horsfall M, Blyth A, Seshadri A, Nguyen MT, Briffa T, Cullen LA, Quinn S, French JK, Chew DP. Cost effectiveness of a 1-hour high-sensitivity troponin-T protocol: An analysis of the RAPID-TnT trial. Int J Cardiol Heart Vasc 2022; 38:100933. [PMID: 35024428 PMCID: PMC8728427 DOI: 10.1016/j.ijcha.2021.100933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/17/2021] [Indexed: 11/12/2022]
Abstract
This is the first randomised evaluation of the cost-effectiveness of a 0/1-hour high-sensitivity troponin protocol and has implications on clinical practice on a health system level. The results demonstrate that the 0/1-hour hs-cTnT protocol is safe and does not incur excess resource compared to the conventional 0/3-hour protocol. Whilst this cost-effectiveness analysis demonstrates superior ED efficiency and equivalent safety and resource associated with the 0/1-hour hs-cTnT protocol, further refinements in subsequent management is necessary to facilitate large-scale adaptation.
Background To understand the economic impact of an accelerated 0/1-hour high-sensitivity troponin-T (hs-cTnT) protocol. Objective To conduct a patient-level economic analysis of the RAPID-TnT randomised trial in patients presenting with suspected acute coronary syndrome (ACS). Methods An economic evaluation was conducted with 3265 patients randomised to either the 0/1-hour hs-cTnT protocol (n = 1634) or the conventional 0/3-hour standard-of-care protocol (n = 1631) with costs reported in Australian dollars. The primary clinical outcome was all-cause mortality or new/recurrent myocardial infarction. Results Over 12-months, mean per patient costs were numerically higher in the 0/1-hour arm compared to the conventional 0/3-hour arm (by $472.49/patient, 95% confidence interval [95 %CI]: $-1,380.15 to $2,325.13, P = 0.617) with no statistically significant difference in primary outcome (0/1-hour: 62/1634 [3.8%], 0/3-hour: 82/1631 [5.0%], HR: 1.32 [95 %CI: 0.95–1.83], P = 0.100). The mean emergency department (ED) length of stay (LOS) was significantly lower in the 0/1-hour arm (by 0.62 h/patient, 95 %CI: 0.85 to 0.39, P < 0.001), but the subsequent 12-month unplanned inpatient costs was numerically higher (by $891.22/patient, 95 %CI: $-96.07 to 1,878.50, P = 0.077). Restricting the analysis to patients with hs-cTnT concentrations ≤ 29 ng/L, mean per patient cost remained numerically higher in the 0/1-hour arm (by $152.44/patient, 95 %CI:$-1,793.11 to $2,097.99, P = 0.988), whilst the reduction in ED LOS was more pronounced (by 0.70 h/patient, 95 %CI: 0.45–0.95, P < 0.001). Conclusions There were no differences in resource utilization between the 0/1-hour hs-cTnT protocol versus the conventional 0/3-hour protocol for the assessment of suspected ACS, despite improved initial ED efficiency. Further refinements in strategies to improve clinical outcomes and subsequent management efficiency are needed.
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Affiliation(s)
- Ming-Yu Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | - Emmanuel S Gnanamanickam
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | - Jonathan Karnon
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | | | - Andrew Blyth
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | - Anil Seshadri
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | - Mau T Nguyen
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Louise A Cullen
- School of Medicine, University of Adelaide, Adelaide, Australia.,Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Stephen Quinn
- Department of Health Science and Biostatistics, Swinburne University of Technology, Melbourne, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia.,South Australian Department of Health, Adelaide, Australia
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14
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Femia G, French JK, Juergens C, Leung D, Lo S. Right ventricular myocardial infarction: pathophysiology, clinical implications and management. Rev Cardiovasc Med 2021; 22:1229-1240. [PMID: 34957766 DOI: 10.31083/j.rcm2204131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/11/2021] [Accepted: 09/23/2021] [Indexed: 11/06/2022] Open
Abstract
Right ventricular myocardial infarction (RVMI) and right ventricular (RV) failure are complications from an acute occlusion of a dominant right coronary artery (RCA) or left anterior descending (LAD) artery. Although some patients have good long-term RV recovery, RVMI is associated with high rates of in-hospital morbidity and mortality driven by hemodynamic compromise, cardiogenic shock, and electrical complications. As such, it is important to identify specific clinical signs and symptoms, initiate resuscitation and commence reperfusion therapy with fibrinolytic therapy or percutaneous coronary intervention. This review will discuss RVMI pathophysiology, describe the current diagnostic measures, highlight current therapies, and explore future management options.
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Affiliation(s)
- Giuseppe Femia
- Department of Cardiology, Liverpool Hospital, 2170 Liverpool, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, 2006 Sydney, NSW, Australia.,School of Medicine, Western Sydney University, 2560 Campbelltown, NSW, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, 2170 Liverpool, NSW, Australia.,School of Medicine, Western Sydney University, 2560 Campbelltown, NSW, Australia.,South Western Clinical School, UNSW, 2170 Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, 2170 Liverpool, NSW, Australia
| | - Craig Juergens
- Department of Cardiology, Liverpool Hospital, 2170 Liverpool, NSW, Australia.,South Western Clinical School, UNSW, 2170 Liverpool, NSW, Australia
| | - Dominic Leung
- Department of Cardiology, Liverpool Hospital, 2170 Liverpool, NSW, Australia.,South Western Clinical School, UNSW, 2170 Liverpool, NSW, Australia
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, 2170 Liverpool, NSW, Australia.,South Western Clinical School, UNSW, 2170 Liverpool, NSW, Australia
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15
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Faour A, Collins N, Williams T, Khan A, Juergens CP, Lo S, Walters DL, Chew DP, French JK. Reperfusion After Fibrinolytic Therapy (RAFT): An open-label, multi-centre, randomised controlled trial of bivalirudin versus heparin in rescue percutaneous coronary intervention. PLoS One 2021; 16:e0259148. [PMID: 34699549 PMCID: PMC8547635 DOI: 10.1371/journal.pone.0259148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The safety and efficacy profile of bivalirudin has not been examined in a randomised controlled trial of patients undergoing rescue PCI. OBJECTIVES We conducted an open-label, multi-centre, randomised controlled trial to compare bivalirudin with heparin ± glycoprotein IIb/IIIa inhibitors (GPIs) in patients undergoing rescue PCI. METHODS Between 2010-2015, we randomly assigned 83 patients undergoing rescue PCI to bivalirudin (n = 42) or heparin ± GPIs (n = 41). The primary safety endpoint was any ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) bleeding at 90 days. The primary efficacy endpoint was infarct size measured by peak troponin levels as a multiple of the local upper reference limit (Tn/URL). Secondary endpoints included periprocedural change in haemoglobin adjusted for red cells transfused, TIMI (Thrombolysis in Myocardial Infarction) bleeding, ST-segment recovery and infarct size determined by the Selvester QRS score. RESULTS The trial was terminated due to slow recruitment and futility after an interim analysis of 83 patients. The primary safety endpoint occurred in 6 (14%) patients in the bivalirudin group (4.8% GPIs) and 3 (7.3%) in the heparin ± GPIs group (54% GPIs) (risk ratio, 1.95, 95% confidence interval [CI], 0.52-7.3, P = 0.48). Infarct size was similar between the two groups (mean Tn/URL, 730 [±675] for bivalirudin, versus 984 [±1585] for heparin ± GPIs, difference, 254, 95% CI, -283-794, P = 0.86). There was a smaller decrease in the periprocedural haemoglobin level with bivalirudin than heparin ± GPIs (-7.5% [±15] versus -14% [±17], difference, -6.5%, 95% CI, -0.83-14, P = 0.0067). The rate of complete (≥70%) ST-segment recovery post-PCI was higher in patients randomised to heparin ± GPIs compared with bivalirudin. CONCLUSIONS Whether bivalirudin compared with heparin ± GPI reduces bleeding in rescue PCI could not be determined. Slow recruitment and futility in the context of lower-than-expected bleeding event rates led to the termination of this trial (ANZCTR.org.au, ACTRN12610000152022).
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Affiliation(s)
- Amir Faour
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Nicholas Collins
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Trent Williams
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Arshad Khan
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Craig P. Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Darren L. Walters
- University of Queensland, Brisbane, Queensland, Australia
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Derek P. Chew
- Department of Cardiology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - John K. French
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute and Western Sydney University, Sydney, New South Wales, Australia
- * E-mail:
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16
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Etaher A, Chew DP, Frost S, Saad YM, Ferguson I, Nguyen TL, Juergens CP, French JK. Prognostic Implications of High-Sensitivity Troponin T Levels Among Patients Attending Emergency Departments and Evaluated for an Acute Coronary Syndrome. Am J Med 2021; 134:1019-1028.e1. [PMID: 33812862 DOI: 10.1016/j.amjmed.2021.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/31/2021] [Accepted: 03/01/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND With increasing age, patients with suspected acute coronary syndromes (ACS) and elevated high-sensitivity troponin T (HsTnT) levels, type-1 myocardial infarction (MI) is diagnosed less often, though associations among these factors, gender, and prognosis is unclear. METHODS Patients presenting to the emergency department (ED) with potential ACS who underwent HsTnT testing were prospectively identified and followed. Diagnoses were adjudicated according to the Fourth Universal Definition of MI as follows: type-1 MI, type-2 MI, acute myocardial injury, chronic myocardial injury, and other diagnoses. Age in years was categorized: younger (<65); elderly (65-79), and very elderly (≥80). RESULTS Among 2738 patients with HsTnT measurements, 1611 were suitable for adjudication (42% ages 65 years and younger). Type-2 MI and chronic myocardial injury diagnoses were more common in those ages 65 years and older, whereas younger patients had more type-1 MI diagnoses. Late mortality rates at median 41 months (interquartile range [IQR] 10-57) were 44% (223 out of 506) in those ages 80 years and older, 22% (92 out of 423) in patients 65-79 years, and 7% (46 out of 682) in those 65 years and younger, irrespective of adjudicated diagnoses, log rank P ≤ .001. On multivariable analyses, the adjusted mortality hazard ratios for increasing HsTnT levels irrespective of diagnoses were attenuated in those age 80 years and older compared to younger patients. CONCLUSIONS Patients ages 65 years and older constituted ~60% of ED attendances of patients with suspected ACS, and more had type 2 MI and chronic myocardial injury diagnoses compared to younger patients. The relative mortality impact of HsTnT levels was lower among elderly patients irrespective of adjudicated diagnoses.
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Affiliation(s)
- Aisha Etaher
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Department of Emergency, Liverpool Hospital, Sydney, NSW, Australia
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, North Tce, SA, Australia
| | - Steven Frost
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Sydney, NSW, Australia; Western Sydney University, Sydney, NSW, Australia
| | - Yousef M Saad
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Ian Ferguson
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Department of Emergency, Liverpool Hospital, Sydney, NSW, Australia
| | - Tuan L Nguyen
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; South Australian Health and Medical Research Institute, North Tce, SA, Australia; Ingham Institute for Applied Medical Research, Sydney, NSW, Australia; Western Sydney University, Sydney, NSW, Australia.
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17
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Jamal J, O'Loughlin A, French JK. A fibrinolysis-first strategy for ST-elevation myocardial infarction in the COVID-19 era. Int J Cardiol 2021; 342:125. [PMID: 34343531 PMCID: PMC8325381 DOI: 10.1016/j.ijcard.2021.07.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 07/30/2021] [Indexed: 11/21/2022]
Affiliation(s)
- Javeria Jamal
- School of Medicine, Western Sydney University, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia; Liverpool Hospital, Sydney, Australia.
| | - Aiden O'Loughlin
- School of Medicine, Western Sydney University, Sydney, Australia
| | - John K French
- School of Medicine, Western Sydney University, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia; Liverpool Hospital, Sydney, Australia
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18
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Khan E, Lambrakis K, Blyth A, Seshadri A, Edmonds MJR, Briffa T, Cullen LA, Quinn S, Horsfall M, Morton E, French JK, Papendick C, Nelson AJ, Chew DP. Classification performance of clinical risk scoring in suspected acute coronary syndrome beyond a rule-out troponin profile. Eur Heart J Acute Cardiovasc Care 2021; 10:1038-1047. [PMID: 34195809 DOI: 10.1093/ehjacc/zuab040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/19/2021] [Accepted: 05/22/2021] [Indexed: 11/15/2022]
Abstract
AIMS High-sensitivity cardiac troponin strategies can provide risk stratification in patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). This study evaluated whether clinical risk scoring improves the classification performance of a rule-out profile in suspected ACS. METHODS AND RESULTS Patients presenting to ED with suspected ACS as part of the RAPID-TnT trial randomized to the intervention arm were included. Results ≥5 ng/L were available for all participants in this analysis. We evaluated the Thrombolysis In Myocardial Infarction (TIMI) risk score, History ECG Age Risk factors Troponin (HEART) score, and Emergency Department Assessment of Chest pain Score (EDACS) in addition to a rule-out profile based on the 0/1-h high-sensitivity cardiac troponin T protocol (<5 ng/L or ≤12 ng/L and a change of <3 ng/L at 1-h) using test performance parameters focusing on low-risk groups to identify the primary endpoint (TIMI ≤ 1, HEART ≤ 3, EDACS < 16). Primary endpoint was a composite of type 1/2 myocardial infarction (MI) at index presentation and all-cause mortality or type 1/2 MI at 30 days. A total of 3378 participants were enrolled between August 2015 and April 2019 of which 108 were ineligible/withdrew consent (intervention arm: n = 1638). Sensitivity, specificity, negative predictive value (NPV), and area under the curve (AUC) of the rule-out profile was 94.4%, 76.8%, 99.6%, and 0.86, respectively with 72.9% identified as 'low-risk'. Adding the clinical risk scores did not improve the sensitivity, NPV, or AUC with significantly lower specificity and 'low-risk' classified participants. CONCLUSIONS Addition of clinical risk scores to rule-out profile did not demonstrate improved classification performance for identifying the composite of type 1/2 MI at index presentation and all-cause mortality or type 1/2 MI at 30 days. CLINICAL TRIALS REGISTRATION URL: https://www.anzctr.org.au. Reg. No. ACTRN12615001379505.
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Affiliation(s)
- Ehsan Khan
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Andrew Blyth
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Anil Seshadri
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Michael J R Edmonds
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Clifton Street, Nedlands, Perth, WA 6009, Australia
| | - Louise A Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD 4029, Australia
- School of Public Health, Queensland University of Technology, George Street, Brisbane, QLD 4000, Australia
- School of Medicine, University of Queensland, St Lucia, Brisbane, QLD 4072, Australia
| | - Stephen Quinn
- Department of Statistics, Swinburne University of Technology, John Street, Hawthorne, Melbourne, VIC 3122, Australia
- Department of Health Science and Biostatistics, Swinburne University of Technology, John Street, Hawthorne, Melbourne, VIC 3122, Australia
| | - Matthew Horsfall
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Erin Morton
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Elizabeth & Goulburn Street, Liverpool, Sydney, NSW 2170, Australia
| | - Cynthia Papendick
- School of Population and Global Health, University of Western Australia, Clifton Street, Nedlands, Perth, WA 6009, Australia
| | - Adam J Nelson
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
- South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia
- School of Medicine, University of Adelaide, North Terrrace, Adelaide, SA 5000, Australia
| | - Derek P Chew
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
- School of Population and Global Health, University of Western Australia, Clifton Street, Nedlands, Perth, WA 6009, Australia
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Burgess SN, Juergens CP, Mussap CJ, Lo STH, French JK. Cardiogenic Shock, the Residual SYNTAX Score, and Prognosis: Corroborative "Real-World" Data. J Am Coll Cardiol 2021; 77:2871-2872. [PMID: 34082919 DOI: 10.1016/j.jacc.2021.02.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/22/2021] [Indexed: 10/21/2022]
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20
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French JK. A good report card, but there is room for improving care for patients with myocardial infarction. Med J Aust 2021; 214:512-513. [PMID: 34046900 DOI: 10.5694/mja2.51110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- John K French
- Liverpool Hospital, Sydney, NSW.,Ingham Institute for Applied Medical Research, Western Sydney University, Sydney, NSW.,University of New South Wales, Sydney, NSW
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21
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Lambrakis K, Papendick C, French JK, Quinn S, Blyth A, Seshadri A, Edmonds MJR, Chuang A, Khan E, Nelson AJ, Wright D, Horsfall M, Morton E, Karnon J, Briffa T, Cullen LA, Chew DP. Late Outcomes of the RAPID-TnT Randomized Controlled Trial: 0/1-Hour High-Sensitivity Troponin T Protocol in Suspected ACS. Circulation 2021; 144:113-125. [PMID: 33998255 DOI: 10.1161/circulationaha.121.055009] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High-sensitivity troponin assays are increasingly being adopted to expedite evaluation of patients with suspected acute coronary syndromes. Few direct comparisons have examined whether the enhanced performance of these assays at low concentrations leads to changes in care that improves longer-term outcomes. This study evaluated late outcomes of participants managed under an unmasked 0/1-hour high-sensitivity cardiac troponin T (hs-cTnT) protocol compared with a 0/3-hour masked hs-cTnT protocol. METHODS We conducted a multicenter prospective patient-level randomized comparison of care informed by unmasked 0/1-hour hs-cTnT protocol (reported to <5 ng/L) versus standard practice masked hs-cTnT testing (reported to ≤29 ng/L) assessed at 0/3 hours and followed participants for 12 months. Participants included were those presenting to metropolitan emergency departments with suspected acute coronary syndromes, without ECG evidence of coronary ischemia. The primary end point was time to all-cause death or myocardial infarction using Cox proportional hazards models adjusted for clustering within hospitals. RESULTS Between August 2015 and April 2019, we randomized 3378 participants, of whom 108 withdrew, resulting in 12-month follow-up for 3270 participants (masked: 1632; unmasked: 1638). Among these, 2993 (91.5%) had an initial troponin concentration of ≤29 ng/L. Deployment of the 0/1-hour hs-cTnT protocol was associated with reductions in functional testing. Over 12-month follow-up, there was no difference in invasive coronary angiography (0/1-hour unmasked: 232/1638 [14.2%]; 0/3-hour masked: 202/1632 [12.4%]; P=0.13), although an increase was seen among patients with hs-cTnT levels within the masked range (0/1-hour unmasked arm: 168/1507 [11.2%]; 0/3-hour masked arm: 124/1486 [8.3%]; P=0.010). By 12 months, all-cause death and myocardial infarction did not differ between study arms overall (0/1-hour: 82/1638 [5.0%] versus 0/3-hour: 62/1632 [3.8%]; hazard ratio, 1.32 [95% CI, 0.95-1.83]; P=0.10). Among participants with initial troponin T concentrations ≤29 ng/L, unmasked hs-cTnT reporting was associated with an increase in death or myocardial infarction (0/1-hour: 55/1507 [3.7%] versus 0/3-hour: 34/1486 [2.3%]; hazard ratio, 1.60 [95% CI, 1.05-2.46]; P=0.030). CONCLUSIONS Unmasked hs-cTnT reporting deployed within a 0/1-hour protocol did not reduce ischemic events over 12-month follow-up. Changes in practice associated with the implementation of this protocol may be associated with an increase in death and myocardial infarction among those with newly identified troponin elevations. Registration: URL: https://www.anzctr.org.au; Unique identifier: ACTRN12615001379505.
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Affiliation(s)
- Kristina Lambrakis
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide (K.L., A.B., A.S., A.C., E.K., E.M., J.K., D.P.C.)
- South Australian Department of Health, Adelaide (K.L., C.P., A.B., A.S., M.J.R.E., A.C., E.K., A.J.N., D.W., M.H., D.P.C.)
| | - Cynthia Papendick
- South Australian Department of Health, Adelaide (K.L., C.P., A.B., A.S., M.J.R.E., A.C., E.K., A.J.N., D.W., M.H., D.P.C.)
- School of Medicine, University of Adelaide, Australia (C.P., A.J.N.)
| | - John K French
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia (J.K.F.)
| | - Stephen Quinn
- Department of Statistics, Data Science and Epidemiology (S.Q.), Swinburne University of Technology, Melbourne, Australia
| | - Andrew Blyth
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide (K.L., A.B., A.S., A.C., E.K., E.M., J.K., D.P.C.)
- South Australian Department of Health, Adelaide (K.L., C.P., A.B., A.S., M.J.R.E., A.C., E.K., A.J.N., D.W., M.H., D.P.C.)
| | - Anil Seshadri
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide (K.L., A.B., A.S., A.C., E.K., E.M., J.K., D.P.C.)
- South Australian Department of Health, Adelaide (K.L., C.P., A.B., A.S., M.J.R.E., A.C., E.K., A.J.N., D.W., M.H., D.P.C.)
| | - Michael J R Edmonds
- South Australian Department of Health, Adelaide (K.L., C.P., A.B., A.S., M.J.R.E., A.C., E.K., A.J.N., D.W., M.H., D.P.C.)
| | - Anthony Chuang
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide (K.L., A.B., A.S., A.C., E.K., E.M., J.K., D.P.C.)
- South Australian Department of Health, Adelaide (K.L., C.P., A.B., A.S., M.J.R.E., A.C., E.K., A.J.N., D.W., M.H., D.P.C.)
| | - Ehsan Khan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide (K.L., A.B., A.S., A.C., E.K., E.M., J.K., D.P.C.)
- South Australian Department of Health, Adelaide (K.L., C.P., A.B., A.S., M.J.R.E., A.C., E.K., A.J.N., D.W., M.H., D.P.C.)
| | - Adam J Nelson
- South Australian Department of Health, Adelaide (K.L., C.P., A.B., A.S., M.J.R.E., A.C., E.K., A.J.N., D.W., M.H., D.P.C.)
- School of Medicine, University of Adelaide, Australia (C.P., A.J.N.)
| | - Deborah Wright
- South Australian Department of Health, Adelaide (K.L., C.P., A.B., A.S., M.J.R.E., A.C., E.K., A.J.N., D.W., M.H., D.P.C.)
| | - Matthew Horsfall
- South Australian Department of Health, Adelaide (K.L., C.P., A.B., A.S., M.J.R.E., A.C., E.K., A.J.N., D.W., M.H., D.P.C.)
| | - Erin Morton
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide (K.L., A.B., A.S., A.C., E.K., E.M., J.K., D.P.C.)
| | - Jonathan Karnon
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide (K.L., A.B., A.S., A.C., E.K., E.M., J.K., D.P.C.)
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth (T.B.)
| | - Louise A Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Australia (L.A.C.)
- School of Public Health, Queensland University of Technology, Brisbane, Australia (L.A.C.)
- School of Medicine, University of Queensland, Brisbane, Australia (L.A.C.)
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide (K.L., A.B., A.S., A.C., E.K., E.M., J.K., D.P.C.)
- South Australian Health and Medical Research Institute, Adelaide (D.P.C.)
- South Australian Department of Health, Adelaide (K.L., C.P., A.B., A.S., M.J.R.E., A.C., E.K., A.J.N., D.W., M.H., D.P.C.)
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22
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Etaher A, Gibbs OJ, Saad YM, Frost S, Nguyen TL, Ferguson I, Juergens CP, Chew D, French JK. Type-II myocardial infarction and chronic myocardial injury rates, invasive management, and 4-year mortality among consecutive patients undergoing high-sensitivity troponin T testing in the emergency department. Eur Heart J Qual Care Clin Outcomes 2021; 6:41-48. [PMID: 31111144 DOI: 10.1093/ehjqcco/qcz019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/22/2019] [Accepted: 04/16/2019] [Indexed: 12/20/2022]
Abstract
AIMS As assessment of patients with suspected acute coronary syndromes (ACS) in emergency departments (EDs) represents a major workload because high-sensitivity troponin (HsTn) T and I levels are frequently measured, and a minority of patients have final diagnosis of myocardial infarction (MI). We determined the relative frequencies of three patients groups: Type-I MI, Type-II MI (including acute myocardial injury). METHODS AND RESULTS Among 2738 consecutive patients with suspected ACS presenting to ED at Liverpool Hospital, Australia, between March and June 2014. We studied the use of invasive and pharmacological therapies, and 4-year outcomes. Adjudication of MI was according to the 4th universal definition as follows: (i) Type-I MI; (ii) Type-II MI (including acute myocardial injury), and (iii) chronic myocardial injury. Of 995 patients (36%) [median age 76 years (interquartile range 65-83)] with ≥2 HsTnT measurements and one >14 ng/L, 727 (73%) had chronic myocardial injury, 171 (17%) had Type-II MI, and 97 (9.7%) had Type-I MI; respective late mortality rates to 48 months were 33%, 43%, and 14% (P < 0.001). In-hospital angiography rates were 95% for patients with Type-I MI, [62% had percutaneous coronary intervention (PCI)] 24% (7% PCI) for those with Type-II MI, and 3.4% for chronic myocardial injury. On Cox modelling for mortality relative to Type 1 MI, adjusted hazard ratios were 1.94 [95% confidence intervals (CIs) 1.06-3.57]; P = 0.032 for Type 2 MI, and for chronic myocardial injury 1.14 (95% CIs 0.64-2.02); P = 0.66. CONCLUSION Among unselected patients undergoing HsTnT testing in EDs, Type-II MI including acute myocardial injury was more common than Type-I MI. Chronic myocardial injury, which occurred in three of four patients. Whereas patients with Type-II MI had higher late mortality than those with Type-I MI, after multivariable analyses mortality rates were marginally different.
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Affiliation(s)
- Aisha Etaher
- Department of Cardiology, Liverpool Hospital, Sydney, Elizabeth Street, Locked Bag 7103T, Liverpool BC, New South Wales 1871, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Oliver J Gibbs
- Department of Cardiology, Liverpool Hospital, Sydney, Elizabeth Street, Locked Bag 7103T, Liverpool BC, New South Wales 1871, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Yousef M Saad
- Department of Cardiology, Liverpool Hospital, Sydney, Elizabeth Street, Locked Bag 7103T, Liverpool BC, New South Wales 1871, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Steven Frost
- Faculty of Nursing, Western Sydney University, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Tuan L Nguyen
- Department of Cardiology, Liverpool Hospital, Sydney, Elizabeth Street, Locked Bag 7103T, Liverpool BC, New South Wales 1871, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Ian Ferguson
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, Elizabeth Street, Locked Bag 7103T, Liverpool BC, New South Wales 1871, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Derek Chew
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, Elizabeth Street, Locked Bag 7103T, Liverpool BC, New South Wales 1871, Australia.,Faculty of Medicine, 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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23
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Redwood E, Hyun K, French JK, Kritharides L, Ryan M, Chew DP, D'Souza M, Brieger DB. The influence of travelling to hospital by ambulance on reperfusion time and outcomes for patients with STEMI. Med J Aust 2021; 214:377-378. [PMID: 33811331 DOI: 10.5694/mja2.51005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Eleanor Redwood
- Prince of Wales Hospital and Community Health Services, Sydney, NSW
| | - Karice Hyun
- Concord Repatriation General Hospital, Sydney, NSW.,University of Sydney, Sydney, NSW
| | | | - Leonard Kritharides
- Concord Repatriation General Hospital, Sydney, NSW.,ANZAC Research Institute, Sydney, NSW
| | - Mark Ryan
- Shoalhaven District Memorial Hospital, Nowra, NSW
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24
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Burgess SN, Juergens CP, Nguyen T, Leung M, Robledo KP, Thomas L, Mussap C, Lo ST, French JK. Diabetes and Incomplete Revascularisation in ST Elevation Myocardial Infarction. Heart Lung Circ 2021; 30:471-480. [DOI: 10.1016/j.hlc.2020.09.928] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 06/18/2020] [Accepted: 09/14/2020] [Indexed: 11/26/2022]
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Chuang A(MY, Nguyen MT, Khan E, Jones D, Horsfall M, Lehman S, Smilowitz NR, Lambrakis K, Than M, Vaile J, Sinhal A, French JK, Chew DP. Troponin elevation pattern and subsequent cardiac and non-cardiac outcomes: Implementing the Fourth Universal Definition of Myocardial Infarction and high-sensitivity troponin at a population level. PLoS One 2021; 16:e0248289. [PMID: 33711079 PMCID: PMC7954292 DOI: 10.1371/journal.pone.0248289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/23/2021] [Indexed: 01/19/2023] Open
Abstract
Background The Fourth Universal Definition of Myocardial Infarction (MI) differentiates MI from myocardial injury. We characterised the temporal course of cardiac and non-cardiac outcomes associated with MI, acute and chronic myocardial injury. Methods We included all patients presenting to public emergency departments in South Australia between June 2011–Sept 2019. Episodes of care (EOCs) were classified into 5 groups based on high-sensitivity troponin-T (hs-cTnT) and diagnostic codes: 1) Acute MI [rise/fall in hs-cTnT and primary diagnosis of acute coronary syndrome], 2) Acute myocardial injury with coronary artery disease (CAD) [rise/fall in hs-cTnT and diagnosis of CAD], 3) Acute myocardial injury without CAD [rise/fall in hs-cTnT without diagnosis of CAD], 4) Chronic myocardial injury [elevated hs-cTnT without rise/fall], and 5) No myocardial injury. Multivariable flexible parametric models were used to characterize the temporal hazard of death, MI, heart failure (HF), and ventricular arrhythmia. Results 372,310 EOCs (218,878 individuals) were included: acute MI (19,052 [5.12%]), acute myocardial injury with CAD (6,928 [1.86%]), acute myocardial injury without CAD (32,231 [8.66%]), chronic myocardial injury (55,056 [14.79%]), and no myocardial injury (259,043 [69.58%]). We observed an early hazard of MI and HF after acute MI and acute myocardial injury with CAD. In contrast, subsequent MI risk was lower and more constant in patients with acute injury without CAD or chronic injury. All patterns of myocardial injury were associated with significantly higher risk of all-cause mortality and ventricular arrhythmia. Conclusions Different patterns of myocardial injury were associated with divergent profiles of subsequent cardiac and non-cardiac risk. The therapeutic approach and modifiability of such excess risks require further research.
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Affiliation(s)
- Anthony (Ming-yu) Chuang
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
- * E-mail:
| | - Mau T. Nguyen
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Ehsan Khan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Dylan Jones
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Matthew Horsfall
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Sam Lehman
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Nathaniel R. Smilowitz
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York City, New York, United States of America
| | - Kristina Lambrakis
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Julian Vaile
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Ajay Sinhal
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - John K. French
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
- Western Sydney University, Sydney, Australia
| | - Derek P. Chew
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
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Femia G, Faour A, Assad J, Sharma L, Idris H, Gibbs O, Pender P, Leung D, Hopkins A, Rajaratnam R, P Juergens C, Mussap C, K French J, Lo S. Comparing the clinical and prognostic impact of proximal versus nonproximal lesions in dominant right coronary artery ST-elevation myocardial infarction. Catheter Cardiovasc Interv 2020; 97:E646-E652. [PMID: 32870605 DOI: 10.1002/ccd.29245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/22/2020] [Accepted: 08/17/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the prognostic significance of culprit lesion location in dominant right coronary artery (RCA) ST-elevation myocardial infarction (STEMI). BACKGROUND In RCA STEMI, proximal culprit lesions have been shown to have higher rates of acute complications such as bradycardia and cardiogenic shock (CS) but data on mortality is limited. METHODS We retrospectively identified and analyzed data from consecutive patients with a dominant RCA STEMI who underwent either primary or rescue percutaneous coronary intervention (PCI) between January 2003 and December 2016. We compared the rates of sustained ventricular tachycardia (VT), CS, intra-aortic balloon pump (IABP), temporary cardiac pacing (TCP) and death between culprit lesions located proximal and distal to the origin of the last right ventricular (RV) marginal artery >1 mm in diameter. RESULTS The 939 patients were included; 599 (63.7%) had a proximal lesion and 340 (36.3%) had a nonproximal lesion. The 801 (85.3%) underwent primary PCI and 138 (14.7%) underwent rescue PCI. There was no difference in first medical contact to balloon or fibrinolysis times between the groups; p = .98 and .71. There was no significant difference in the rate of sustained VT (3.0%vs. 3.2%, p = .85) but proximal lesions were more likely to develop CS (10.9%vs. 5.8%, p = .01), require IABP (7.3%vs.2.9%, p < .01) and TCP (6.3%vs. 2.6%, p = .01). Thirty-day mortality was higher for proximal lesions (5.0%vs. 0.9%, p < .01) particularly for those with CS (35.3%vs. 10.0%, p = .05). CONCLUSION Culprit lesions located proximal to the origin of the last RV marginal artery had a higher rate of acute complications such as CS and mortality.
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Affiliation(s)
- Giuseppe Femia
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Amir Faour
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, Liverpool, New South Wales, Australia
| | - Joseph Assad
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, Liverpool, New South Wales, Australia
| | - Lokesh Sharma
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Hanan Idris
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Oliver Gibbs
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, Liverpool, New South Wales, Australia
| | - Patrick Pender
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Dominic Leung
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, Liverpool, New South Wales, Australia
| | - Andrew Hopkins
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Rohan Rajaratnam
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, Liverpool, New South Wales, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, Liverpool, New South Wales, Australia
| | - Christian Mussap
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, Liverpool, New South Wales, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, Liverpool, New South Wales, Australia
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Liverpool, New South Wales, Australia
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27
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Lo STH, Yong AS, Sinhal A, Shetty S, McCann A, Clark D, Galligan L, El-Jack S, Sader M, Tan R, Hallani H, Barlis P, Sechi R, Dictado E, Walton A, Starmer G, Bhagwandeen R, Leung DY, Juergens CP, Bhindi R, Muller DWM, Rajaratnum R, French JK, Kritharides L. Consensus guidelines for interventional cardiology services delivery during covid-19 pandemic in Australia and new Zealand. Heart Lung Circ 2020; 29:e69-e77. [PMID: 32471696 PMCID: PMC7202321 DOI: 10.1016/j.hlc.2020.04.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The global coronavirus disease (COVID-19) pandemic poses an unprecedented stress on healthcare systems internationally. These Health system-wide demands call for efficient utilisation of resources at this time in a fair, consistent, ethical and efficient manner would improve our ability to treat patients. Excellent co-operation between hospital units (especially intensive care unit [ICU], emergency department [ED] and cardiology) is critical in ensuring optimal patient outcomes. The purpose of this document is to provide practical guidelines for the effective use of interventional cardiology services in Australia and New Zealand. The document will be updated regularly as new evidence and knowledge is gained with time. Goals Considerations.
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Affiliation(s)
- S T H Lo
- Department of Cardiology, Liverpool Hospital, NSW, Australia.
| | - A S Yong
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia; University of Sydney, Australia
| | - A Sinhal
- Flinders Medical Centre, SA, Australia
| | - S Shetty
- Department of Cardiology, Fiona Stanley Hospital, WA, Australia
| | - A McCann
- Department of Cardiology, Princess Alexandra Hospital, QLD, Australia; University of Queensland, Australia
| | - D Clark
- Department of Cardiology, Austin Hospital, VIC, Australia
| | - L Galligan
- Department of Cardiology, Royal Hobart Hospital, TAS, Australia
| | - S El-Jack
- Department of Cardiology, North Shore Hospital, New Zealand
| | - M Sader
- University of Sydney, Australia; Department of Cardiology, St George Hospital, NSW, Australia
| | - R Tan
- Department of Cardiology, The Canberra Hospital, ACT, Australia
| | - H Hallani
- Department of Cardiology, The Canberra Hospital, ACT, Australia
| | - P Barlis
- Department of Cardiology, Nepean Hospital, NSW, Australia; Department of Cardiology, The Northern Hospital, VIC, Australia; Department of Cardiology, St Vincents' Hospital, VIC, Australia; University of Melbourne, VIC, Australia
| | - R Sechi
- Department of Nursing, Liverpool Hospital, NSW, Australia
| | - E Dictado
- Department of Nursing, Liverpool Hospital, NSW, Australia
| | - A Walton
- Department of Cardiology, Alfred Hospital, VIC, Australia; Monash University, VIC, Australia
| | - G Starmer
- Department of Cardiology, Cairns Hospital, QLD, Australia
| | - R Bhagwandeen
- Department of Cardiology, John Hunter Hospital, NSW, Australia; Lake Macquarie Private Hospital, NSW, Australia
| | - D Y Leung
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia
| | - C P Juergens
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia
| | - R Bhindi
- University of Sydney, Australia; Department of Cardiology, Royal North Shore Hospital, NSW, Australia
| | - D W M Muller
- University of New South Wales, NSW, Australia; St Vincent's Hospital, NSW, Australia
| | - R Rajaratnum
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia; Western Sydney University, NSW, Australia
| | - J K French
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia; Western Sydney University, NSW, Australia
| | - L Kritharides
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia; University of Sydney, Australia; ANZAC Medical Research Institute, Australia
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Etaher A, Nguyen TL, Saad YM, Frost S, Ferguson I, Juergens CP, Chew D, French JK. Mortality at 5 Years Among Very Elderly Patients Undergoing High Sensitivity Troponin T Testing for Suspected Acute Coronary Syndromes. Heart Lung Circ 2020; 29:1696-1703. [PMID: 32439246 DOI: 10.1016/j.hlc.2020.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/07/2020] [Accepted: 02/29/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients aged ≥80 years old often present to Emergency Departments (ED) with symptoms potentially due to an acute coronary syndrome (ACS). This study aimed to evaluate associations between baseline level(s) of high sensitivity troponin T (HsTnT), adjudicated diagnoses and outcomes. METHODS Consecutive patients aged ≥80 years were studied, who presented to the ED at Liverpool Hospital, NSW, Australia during the 4 months period March to June 2014 (inclusive) with symptoms suggestive of an ACS, and who had at least one HsTnT assay performed. Diagnoses were based on the fourth universal definition of MI (myocardial infarction) including type-1 MI, type-2 MI, acute myocardial injury, chronic myocardial injury; the rest were termed "other diagnoses". Patients were categorised by baseline HsTnT levels 1) ≤14 ng/L, 2) 15-29 ng/L, 3) 30-49 ng/L and 4) ≥50 ng/L. RESULTS Of 2,773 patients screened, 545 were aged ≥80 years (median age 85 [IQR 82-88]); median follow-up was 32 months (IQR 5-56). The respective rates of adjudicated diagnoses were type-I MI 3.1%, type-2 MI 13%, acute myocardial injury 9.5%, chronic myocardial injury 56% and 18.6% had other diagnoses. Mortality rates increased, irrespective of adjudicated diagnoses with increasing HsTnT levels (ng/L): 17% (16/96) for ≤14; 35% (67/194) for 15-29; 51% (65/127) for 30-49; and 64% (82/128) for ≥50 ng/L; log rank p≤0.001. On multi-variable analyses, after adjusting for potential confounding factors including age, hypertension, chronic kidney disease (CKD) and chronic obstructive pulmonary disease (COPD), MI type was not associated with late mortality. CONCLUSIONS Among patients aged ≥80 years higher HsTnT levels, irrespective of adjudicated diagnoses, were associated with increased mortality. Most very elderly patients presenting with symptoms suggestive of an ACS undergoing HsTnT testing in EDs had elevated levels most commonly due to chronic myocardial injury. Whether any interventions can modify outcomes require prospective evaluation.
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Affiliation(s)
- Aisha Etaher
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; The University of New South Wales, Faculty of Medicine, Sydney, NSW, Australia
| | - Tuan L Nguyen
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; The University of New South Wales, Faculty of Medicine, Sydney, NSW, Australia; Department of Emergency, Liverpool Hospital, Sydney, NSW, Australia
| | - Yousef M Saad
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; The University of New South Wales, Faculty of Medicine, Sydney, NSW, Australia
| | - Steven Frost
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Sydney, NSW, Australia; Western Sydney University, Sydney, NSW, Australia
| | - Ian Ferguson
- The University of New South Wales, Faculty of Medicine, Sydney, NSW, Australia; Department of Emergency, Liverpool Hospital, Sydney, NSW, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; The University of New South Wales, Faculty of Medicine, Sydney, NSW, Australia
| | - Derek Chew
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; The University of New South Wales, Faculty of Medicine, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.
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29
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Femia G, Kim S, Burgess S, Eftal M, Ullah I, Dignan R, Mussap C, French JK. P187 Late outcomes of all patients at a single center with diabetes mellitus undergoing SYNTAX scoring after angiographic screening for the FREEDOM trial. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehz872.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multi-Vessel Disease (FREEDOM) trial randomized only a minority of screened patients with diabetes mellitus (DM) and 2-3 vessel disease (MVD), representing an high risk diabetic MVD cohort.
Methods
Consecutive patients with DM underwent angiographic screening from June 2006 to March 2010 at Liverpool Hospital, Sydney, Australia, for the FREEDOM trial; SYNTAX Scores (SS) were subsequently performed. Patients had late follow-up to determine late rates of death, non-fatal MI and stroke.
Results
Among 1263 patients with DM 833 (66%) had 0-1 vessel disease and 430 (34%) had MVD of whom 139 had prior coronary artery bypass grafting (CABG), and SS were 0 in 272, 1-9 in 336, 10-22 in 264, 23-32 in 109, and 271 patients had SS ≥33. Revascularisation was performed by coronary artery bypass grafting (CABG) in 139 (11%), 486 (38%) underwent PCI, and 638 (51%) did not undergo a revascularization procedure; respective mean ages were 63.5, 64.2 and 64.7 years; p = 0.39, and presentation rates with an ACS were 52%, 57% and 37%; p < 0.05. Amongst patients with MVD, those undergoing CABG had lower rates of MACE than either PCI or medical therapy (22%, 40%, and 51% respectively; p < 0.001). Kaplan-Meier curves (Figure) with respect to SS and late events are shown for: A) Death; B) Non-fatal MI; C) Death/MI/Stroke; D) Late Revascularization. Multi-variable analyses found independent predictors of late mortality were age >75 (HR 6.2), prior MI (HR 1.1), prior CABG (HR 1.6); and LVEF <40% (all p < 0.05). Predictors of late MI were older age, ACS presentation at screening, LVEF < 40% and insulin use.
Conclusions
Among diabetic patients who screened for the FREEDOM Trial, among 34% with MVD CABG was associated with lower rates of non-fatal MI and MACE compared to PCI and medical therapy. The poorest outcomes were observed in DM patients with MVD managed with medical therapy alone.
Abstract P187 Figure. SYNTAX scores &late events in diabetics
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Affiliation(s)
- G Femia
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - S Kim
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - S Burgess
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - M Eftal
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - I Ullah
- Liverpool Hospital, Sydney, Australia
| | - R Dignan
- Liverpool Hospital, Cardiothoracic, Liverpool, Australia
| | - C Mussap
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - J K French
- Liverpool Hospital, Cardiology, Sydney, Australia
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Abstract
Abstract
Background
Worldwide, and in Australia, a large proportion of patients with ST-segment elevation myocardial infarction (STEMI) are unable to undergo timely primary percutaneous coronary intervention (PCI), and so are transferred for PCI after receiving fibrinolytic therapy (so-called pharmaco-invasive PCI).
Methods
Our Hospital, the primary PCI centre for Southwest Sydney, Australia receives patients for both primary PCI and transferred post- fibrinolytic therapy for rescue or prognostic PCI. Associations were determined between late outcomes (bleeding according to Bleeding Academic Research Consortium (BARC) criteria and mortality) and reperfusion strategy, either primary PCI, or pharmaco-invasive PCI, in patients undergoing PCI for STEMI during hospitalization.
Results
Among 2083 consecutive patients (80% male) with STEMI who underwent PCI (1076 [52%] primary PCI and 1007 [48%] pharmaco-invasive PCI), mortality at 3 years was 8.7%,11.1% after primary PCI and 6.2% after pharmaco-invasive PCI (9.4% after rescue PCI and 4.6% after prognostic PCI); p<0.001 (Figure). Rates of type 2–5 BARC bleeding post-PCI were 35% after primary PCI and 24% after pharmaco-invasive PCI (42% after rescue PCI and 15% after prognostic PCI); p<0.001. while the rate of major bleeding type 3b-5 were 5% after primary PCI and 3% after pharmaco-invasive PCI (8% after rescue PCI and 1% after prognostic PCI); p=0.112.The independent predictors of 3 year mortality were, pre-PCI cardiogenic shock HR=0.25 [95% CI: 0.16–0.39], p<0.001), age (HR=1.05 [95% CI: 1.03–1.06], p<0.001), TIMI 3 flow post-PCI (HR=5.25 [95% CI: 2.51–11.00], p≤0.001), eGFR<60mL/min/1.73m2 (HR=2.90 [95% CI: 1.93–4.34], p≤0.001), post PCI bleeding (HR=2.17 [95% CI: 1.53–3.08], p≤0.001), anterior infarction (HR=1.76 [95% CI: 1.23–2.51], p=0.002), and female gender (HR=1.56 [95% CI: 1.07–2.27], p=0.022); and primary PCI (HR=1.6 [95% CI: 1.18–2.19; p=0.003]. On multi-variable analysis, age, cardiogenic shock presentation, rescue PCI, intra-aortic balloon pump, Pre-procedural anaemia, (all p<0.001) and eGFR<60mL/min/1.73m2 (p=0.006) were associated with bleeding.
Figure 1. Late survival after primary & PI PCI
Conclusion
Among patients with STEMI who underwent pharmaco-invasive PCI had lower mortality rates than to those who had primary PCI, though procedural selection criteria may have been different; bleeding rates were similar. Among suitable patients pharmaco-invasive PCI should be evaluated in large clinical trials.
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Affiliation(s)
- H Idris
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - W Yang
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - S Burgess
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - A Faour
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - A McLean
- Liverpool Hospital, Liverpool, Australia
| | - S Sidney Lo
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - C J Mussap
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - C P Juergens
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - J K French
- Liverpool Hospital, Cardiology, Sydney, Australia
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Etaher A, Gibbs O, Saad YM, Frost S, Nguyen T, Ferguson I, Juergens C, Chew D, French JK. P2717Type-II MI and chronic myocardial injury rates, invasive management and 4 year mortality among consecutive patients undergoing high sensitivity troponin T testing in the emergency department. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.1034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In emergency departments (EDs), assessment of patients with suspected acute coronary syndromes (ACS) represents a major workload and high sensitivity troponin (HsTn) T and I levels are frequently measured. A minority of patients have final diagnosis of myocardial infarction (MI).
Methods and results
Among 2738 consecutive patients with suspected ACS presenting to ED at Liverpool Hospital, Australia, between March and June 2014, we determined the relative frequencies of 3 patient groups: type-I MI, type-II MI including chronic myocardial injury (CMI), and assessed the use of invasive and pharmacological therapies and 4-year outcomes. Adjudication of MI was according to the 4th universal definition of MI as follows: 1) type-I MI; 2) type-II MI (including acute myocardial injury), and 3) CMI. Of 995 patients (36%) median age 76 years [IQR 65–83]), with at least 2 HsTnT measurements and one >14ng/l, 727 (73%) had chronic myocardial injury, 171 (17%) had type-II MI; and 97 (9.7%) had type-I MI. Patients with type-I MI (mean age 63 years) were younger than those with type-II MI or chronic myocardial injury by 12 and 14 years respectively. The main triggering factors for type-II MI/acute injury included: sepsis (21.1%), acute heart failure (18.3%), tachyarrhythmia (16.9%), anaemia (8.6%) and a combination of factors (16%). In-hospital angiography (62% had PCI) rates were 95% for patients with type-I MI, 24% (7% PCI) for those with type-II MI and 3.4% for CMI. Mortality at 4 years was 55% for type-II MI, 44% for CMI and 18% for type-1 MI (P<0.001; Figure), though after Cox modelling adjusting for age, gender, renal function and COPD, compared to type 1 MI, type-II MI (hazard ratio 1.61 [95% CIs 0.90–2.86]; p=0.106) and CMI (hazard ratio 1.01 [95% CIs 0.59–1.74]; p=0.963) were not independently associated with increased late mortality, largely because patients with type 1 MI were a decade younger.
Conclusion
Among unselected patients undergoing HsTnT testing in EDs, type-II MI including acute myocardial injury was more common than type-I MI. Chronic myocardial injury, which occurred in 3 of 4 patients. While patients with type-II MI acute myocardial injury had higher late mortality rates than type-I MI, though after multivariable analyses mortality rates were not different.
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Affiliation(s)
- A Etaher
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - O Gibbs
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - Y M Saad
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - S Frost
- University of Western Sydney, Sydney, Australia
| | - T Nguyen
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - I Ferguson
- Liverpool Hospital, Liverpool, Australia
| | - C Juergens
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - D Chew
- Flinders Medical Centre and Flinders University, Cardiology, Adelaide, Australia
| | - J K French
- Liverpool Hospital, Liverpool, Australia
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Burgess S, Juergens C, Nguyen T, Leung M, Thomas L, Mussap C, Lo S, French JK. P6443Late outcomes in patients undergoing PCI for ST elevation myocardial infarction with respect to diabetic status and completeness of revascularisation. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.1037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
This paper examines the degree to which the poor prognosis of ST elevation myocardial infarction (STEMI) patients with diabetes mellitus (DM) can be attributed to incomplete revascularization (ICR).
Background
Cardiovascular disease is the most common cause of death for patients with DM; patients with DM often have complex coronary disease and ICR. In STEMI the relative impact of DM and ICR is uncertain as these two factors frequently co-exist, the potential for confounding is high.
Methods and results
Of 589 consecutive STEMI patients, 22% had DM, who compared to patients without DM were of similar age (59 years), were more often female, had more hypertension and dyslipidaemia, but less often were smokers. A residual SYNTAX Score (rSS) >8, which defined ICR, occurred in 33%. Late cardiac death [median 3.5 years] was 4% among those without DM and 12% in those with DM (p=0.002) (p<0.001), and was 3% among 396 with rSS≤8 and 12% in 193 patients with rSS>8 (p<0.001). Patients with both ICR and DM accounted for only 8% of the STEMI population but 30% of all cardiac deaths. At final follow up (3.5 years) cardiac death rates (see Figure) were 22% in patients with both DM and ICR; these were significantly higher than rates in patients with ICR but no-DM (9%, p=0.034), and those with DM and rSS≤8 (6%, p<0.019). Multivariable analysis for cardiac death found a HR for ICR of 2.89 (95% CI 1.31–6.37; p=0.009) and a HR for DM of 5.18 (95% CI 2.45–10.97, p<0.001).
Diabetes, cardiac death & rSS
Conclusions
While ICR in DM patients with STEMI predicts a significantly poorer outcome, the poor prognosis seen in patients with DM is not explained by the degree of ICR alone. Both ICR and DM contribute independently to the risk of cardiac death in STEMI patients.
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Affiliation(s)
- S Burgess
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - C Juergens
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - T Nguyen
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - M Leung
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - L Thomas
- Westmead Hospital, Cardiology, Sydney, Australia
| | - C Mussap
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - S Lo
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - J K French
- Liverpool Hospital, Cardiology, Sydney, Australia
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33
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Chew DP, Lambrakis K, Blyth A, Seshadri A, Edmonds MJR, Briffa T, Cullen LA, Quinn S, Karnon J, Chuang A, Nelson AJ, Wright D, Horsfall M, Morton E, French JK, Papendick C. A Randomized Trial of a 1-Hour Troponin T Protocol in Suspected Acute Coronary Syndromes: The Rapid Assessment of Possible Acute Coronary Syndrome in the Emergency Department With High-Sensitivity Troponin T Study (RAPID-TnT). Circulation 2019; 140:1543-1556. [PMID: 31478763 DOI: 10.1161/circulationaha.119.042891] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High-sensitivity troponin assays promise earlier discrimination of myocardial infarction. Yet, the benefits and harms of this improved discriminatory performance when incorporated within rapid testing protocols, with respect to subsequent testing and clinical events, has not been evaluated in an in-practice patient-level randomized study. This multicenter study evaluated the noninferiority of a 0/1-hour high-sensitivity cardiac troponin T (hs-cTnT) protocol in comparison with a 0/3-hour masked hs-cTnT protocol in patients with suspected acute coronary syndrome presenting to the emergency department (ED). METHODS Patients were randomly assigned to either a 0/1-hour hs-cTnT protocol (reported to the limit of detection [<5 ng/L]) or masked hs-cTnT reported to ≤29 ng/L evaluated at 0/3-hours (standard arm). The 30-day primary end point was all-cause death and myocardial infarction. Noninferiority was defined as an absolute margin of 0.5% determined by Poisson regression. RESULTS In total, 3378 participants with an emergency presentation were randomly assigned between August 2015 and April 2019. Ninety participants were deemed ineligible or withdrew consent. The remaining participants received care guided either by the 0/1-hour hs-cTnT protocol (n=1646) or the 0/3-hour standard masked hs-cTnT protocol (n=1642) and were followed for 30 days. Median age was 59 (49-70) years, and 47% were female. Participants in the 0/1-hour arm were more likely to be discharged from the ED (0/1-hour arm: 45.1% versus standard arm: 32.3%, P<0.001) and median ED length of stay was shorter (0/1-hour arm: 4.6 [interquartile range, 3.4-6.4] hours versus standard arm: 5.6 (interquartile range, 4.0-7.1) hours, P<0.001). Those randomly assigned to the 0/1-hour protocol were less likely to undergo functional cardiac testing (0/1-hour arm: 7.5% versus standard arm: 11.0%, P<0.001). The 0/1-hour hs-cTnT protocol was not inferior to standard care (0/1-hour arm: 17/1646 [1.0%] versus 16/1642 [1.0%]; incidence rate ratio, 1.06 [ 0.53-2.11], noninferiority P value=0.006, superiority P value=0.867), although an increase in myocardial injury was observed. Among patients discharged from ED, the 0/1-hour protocol had a negative predictive value of 99.6% (95% CI, 99.0-99.9%) for 30-day death or myocardial infarction. CONCLUSIONS This in-practice evaluation of a 0/1-hour hs-cTnT protocol embedded in ED care enabled more rapid discharge of patients with suspected acute coronary syndrome. Improving short-term outcomes among patients with newly recognized troponin T elevation will require an evolution in management strategies for these patients. CLINICAL TRIAL REGISTRATION URL: https://www.anzctr.org.au. Unique identifier: ACTRN12615001379505.
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Affiliation(s)
- Derek P Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Health and Medical Research Institute, Adelaide (D.P.C., A.J.C.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Kristina Lambrakis
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Andrew Blyth
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Anil Seshadri
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Michael J R Edmonds
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth (T.B.)
| | - Louise A Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Australia (L.A.C.).,School of Public Health, Queensland University of Technology, Brisbane, Australia (L.A.C.).,School of Medicine, University of Queensland, Brisbane, Australia (L.A.C.)
| | - Stephen Quinn
- Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Australia (S.Q.)
| | - Jonathan Karnon
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.)
| | - Anthony Chuang
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.).,South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Adam J Nelson
- South Australian Health and Medical Research Institute, Adelaide (D.P.C., A.J.C.).,School of Medicine, University of Adelaide, Australia (A.J.C.)
| | - Deborah Wright
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Matthew Horsfall
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
| | - Erin Morton
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide (D.P.C., A.B., A.S., J.K., A.C., E.M.)
| | - John K French
- Department of Cardiology, University of New South Wales, Sydney, Australia (J.K.F.)
| | - Cynthia Papendick
- South Australian Department of Health, Adelaide (D.P.C., K.L., A.B., A.S., M.J.R.E., A.C., D.W., M.H., C.P.)
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Lambrakis K, French JK, Scott IA, Briffa T, Brieger D, Farkouh ME, White H, Chuang AMY, Tiver K, Quinn S, Kaambwa B, Horsfall M, Morton E, Chew DP. The appropriateness of coronary investigation in myocardial injury and type 2 myocardial infarction (ACT-2): A randomized trial design. Am Heart J 2019; 208:11-20. [PMID: 30522086 DOI: 10.1016/j.ahj.2018.09.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 09/30/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Elevated troponin level findings among patients presenting with suspected acute coronary syndrome (ACS) or another intercurrent illness undeniably identifies patients at increased risk of mortality. Whilst enhancing our capacity to discriminate risk, the use of high-sensitivity troponin assays frequently identifies patients with myocardial injury (i.e. troponin rise without acute signs of myocardial ischemia) or type 2 myocardial infarction (T2MI; oxygen supply-demand imbalance). This leads to the clinically challenging task of distinguishing type 1 myocardial infarction (T1MI; coronary plaque rupture) from myocardial injury and T2MI in the context of concurrent acute illness. Diagnostic discernment in this context is crucial because MI classification has implications for further investigation and care. Early invasive management is of well-established benefit among patients with T1MI. However, the appropriateness of this investigation in the heterogeneous context of T2MI, where there is high competing mortality risk, remains unknown. Although coronary angiography in T2MI is advocated by some, there is insufficient evidence in existing literature to support this opinion as highlighted by current national guidelines. OBJECTIVE The objective is to evaluate the clinical and economic impact of early invasive management with coronary angiography in T2MI in terms of all-cause mortality and cost effectiveness. DESIGN This prospective, pragmatic, multicenter, randomized trial among patients with suspected supply demand ischemia leading to troponin elevation (n=1,800; T2MI [1,500], chronic myocardial injury [300]) compares the impact of invasive angiography (or computed tomography angiography as per local preference) within 5 days of randomization versus conservative management (with or without functional testing at clinician discretion) on all-cause mortality by 2 years. Randomized treatment allocation will be stratified by baseline estimated risk of mortality using the Acute Physiology, Age, and Chronic Health Evaluation (APACHE) III risk score. Cost-effectiveness will be evaluated by follow-up on clinical events, quality of life, and resource utilization over 24 months. SUMMARY Ascertaining the most appropriate first-line investigative strategy for these commonly encountered high-risk T2MI patients in a randomized comparative study will be pivotal in informing evidence-based guidelines that lead to better patient and health care outcomes.
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Affiliation(s)
| | - John K French
- School of Medicine, University of New South Wales, Sydney, Australia
| | - Ian A Scott
- School of Clinical Medicine, University of Queensland, Brisbane, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - David Brieger
- Department of Cardiology, Concord Hospital, Sydney, Australia
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Canada
| | - Harvey White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | | | - Kathryn Tiver
- Department of Cardiology, Flinders Medical Centre, Adelaide, Australia
| | - Stephen Quinn
- Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Australia
| | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Matthew Horsfall
- Department of Cardiology, Flinders Medical Centre, Adelaide, Australia
| | - Erin Morton
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Derek P Chew
- Department of Cardiology, Flinders Medical Centre, Adelaide, Australia; College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia.
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35
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Ellis CJ, Gamble GD, Williams MJ, Matsis P, Elliott JM, Devlin G, Mann S, French JK, White HD. All-Cause Mortality Following an Acute Coronary Syndrome: 12-Year Follow-Up of the Comprehensive 2002 New Zealand Acute Coronary Syndrome Audit. Heart Lung Circ 2019; 28:245-256. [DOI: 10.1016/j.hlc.2017.10.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 09/04/2017] [Accepted: 10/18/2017] [Indexed: 12/22/2022]
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36
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Song N, French JK. Aspirin for primary cardiovascular disease prevention: what we know and what we don't know. Intern Med J 2019; 49:12-14. [PMID: 30680899 DOI: 10.1111/imj.14190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/05/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Ning Song
- Department of Cardiology, St Vincent's Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - John K French
- School of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
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37
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Burgess SN, French JK, Nguyen TL, Leung M, Richards DAB, Thomas L, Mussap C, Lo S, Juergens CP. The impact of incomplete revascularization on early and late outcomes in ST-elevation myocardial infarction. Am Heart J 2018; 205:31-41. [PMID: 30153623 DOI: 10.1016/j.ahj.2018.07.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 07/24/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND In ST-elevation myocardial infarction (STEMI) in patients with multivessel disease, there is a lack of consensus regarding the importance of complete revascularization and the timing of treatment of nonculprit stenoses. Our objective was to investigate the impact of incomplete revascularization in STEMI patients using the residual Synergy Between PCI with TAXUS and Cardiac Surgery score (rSS) to define completeness of revascularization. METHODS This study examined associations between incomplete revascularization, determined by the rSS, and the combined outcome of cardiac death and myocardial infarction (MI). Patients were divided into groups: rSS = 0 (complete revascularization), rSS = 1-8 (incomplete revascularization with a low burden of residual disease), or rSS >8 (incomplete revascularization with a high burden of residual disease). RESULTS The rSS score was calculated in 589 consecutive patients; 25% had an rSS of 0, 42% rSS 1-8, and 33% rSS >8. At median follow-up of 3.5 years, cardiac death and MI occurred in 5% of rSS = 0 patients, 15% rSS = 1-8, and 26% with rSS >8 (P < .001). The rSS was powerful independent predictor of cardiac death and MI (hazard ratio 5.05, CI 2.89-12.00, rSS >8 vs rSS 0, P < .001 and hazard ratio 2.96, CI 1.31-6.69, rSS = 1-8 vs rSS = 0, P = .009), respectively, and an independent predictor of mortality, MI, unplanned revascularization, and major adverse cardiovascular events. CONCLUSIONS In patients with STEMI, the rSS independently predicts cardiac death and MI. Patients with an rSS >8 had substantially higher rates of cardiac death or MI. The rSS can be used to define incomplete revascularization in STEMI and predict adverse outcomes.
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Affiliation(s)
- Sonya N Burgess
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia; The University of New South Wales, Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia; The University of New South Wales, Sydney, New South Wales, Australia.
| | - Tuan L Nguyen
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia; The University of New South Wales, Sydney, New South Wales, Australia
| | - Melissa Leung
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia; The University of New South Wales, Sydney, New South Wales, Australia
| | - David A B Richards
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia; The University of New South Wales, Sydney, New South Wales, Australia
| | - Liza Thomas
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia; The University of New South Wales, Sydney, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Christian Mussap
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia; The University of New South Wales, Sydney, New South Wales, Australia
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia; The University of New South Wales, Sydney, New South Wales, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia; The University of New South Wales, Sydney, New South Wales, Australia
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38
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Mueller-Hennessen M, Lindahl B, Giannitsis E, Vafaie M, Biener M, Haushofer AC, Seier J, Christ M, Alquézar-Arbé A, deFilippi CR, McCord J, Body R, Panteghini M, Jernberg T, Plebani M, Verschuren F, French JK, Christenson RH, Dinkel C, Katus HA, Mueller C. Combined testing of copeptin and high-sensitivity cardiac troponin T at presentation in comparison to other algorithms for rapid rule-out of acute myocardial infarction. Int J Cardiol 2018; 276:261-267. [PMID: 30404726 DOI: 10.1016/j.ijcard.2018.10.084] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/04/2018] [Accepted: 10/23/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND We aimed to directly compare the diagnostic and prognostic performance of a dual maker strategy (DMS) with combined testing of copeptin and high-sensitivity (hs) cardiac troponin T (cTnT) at time of presentation with other algorithms for rapid rule-out of acute myocardial infarction (AMI). METHODS 922 patients presenting to the emergency department with suspected AMI and available baseline copeptin measurements qualified for the present TRAPID-AMI substudy. Diagnostic measures using the DMS (copeptin <10, <14 or < 20 pmol/L and hs-cTnT≤14 ng/L), the 1 h-algorithm (hs-cTnT<12 ng/L and change <3 ng/L at 1 h), as well as the hs-cTnT limit-of-blank (LoB, <3 ng/L) and -detection (LoD, <5 ng/L) were compared. Outcomes were assessed as combined end-points of death and myocardial re-infarction. RESULTS True-negative rule-out using the DMS could be achieved in 50.9%-62.3% of all patients compared to 35.0%, 45.3% and 64.5% using LoB, LoD or the 1 h-algorithm, respectively. The DMS showed NPVs of 98.1%-98.3% compared to 99.2% for the 1 h-algorithm, 99.4% for the LoB and 99.3% for the LoD. Sensitivities were 93.5%-94.8%, as well as 96.8%, 98.7% and 98.1%, respectively. Addition of clinical low-risk criteria such as a HEART-score ≤ 3 to the DMS resulted in NPVs and sensitivities of 100% with a true-negative rule-out to 33.8%-41.6%. Rates of the combined end-point of death/MI within 30 days ranged between 0.2% and 0.3% for all fast-rule-out protocols. CONCLUSION Depending on the applied copeptin cut-off and addition of clinical low-risk criteria, the DMS might be an alternative to the hs-cTn-only-based algorithms for rapid AMI rule-out with comparable diagnostic measures and outcomes.
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Affiliation(s)
- Matthias Mueller-Hennessen
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Mehrshad Vafaie
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz Biener
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Josef Seier
- Central Laboratory, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Community Hospital and Paracelsus Medical University, Nuremberg, Germany
| | | | - Christopher R deFilippi
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - James McCord
- Henry Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, MI, United States of America
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, and Manchester University NHS Foundation Trust, United Kingdom
| | - Mauro Panteghini
- Department of Biomedical and Clinical Sciences 'Luigi Sacco', University of Milan Medical School, Milano, Italy
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University, Karolinska Institutet, Stockholm, Sweden
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padua, Italy
| | - Franck Verschuren
- Department of Acute Medicine, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - John K French
- Liverpool Hospital and University of New South Wales, Sydney, Australia
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | | | - Hugo A Katus
- Department of Internal Medicine III, Cardiology, Angiology & Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Mueller
- Cardiology & Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland
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39
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Boeddinghaus J, Nestelberger T, Twerenbold R, Neumann JT, Lindahl B, Giannitsis E, Sörensen NA, Badertscher P, Jann JE, Wussler D, Puelacher C, Rubini Giménez M, Wildi K, Strebel I, Du Fay de Lavallaz J, Selman F, Sabti Z, Kozhuharov N, Potlukova E, Rentsch K, Miró Ò, Martin-Sanchez FJ, Morawiec B, Parenica J, Lohrmann J, Kloos W, Buser A, Geigy N, Keller DI, Osswald S, Reichlin T, Westermann D, Blankenberg S, Mueller C, Klimmeck I, Chiaverio F, Garrido E, Gea J, Cruz HM, Inostroza CIF, Briñón MAG, Shrestha S, Flores D, Freese M, Stelzig C, Kulangara C, Meissner K, Schaerli N, Mueller D, Sazgary L, Marbot S, López B, Calderón S, Adrada ER, Kawecki D, Nowalany-Kozielska E, Ganovská E, von Eckardstein A, Campodarve I, Christ M, Ordóñez-Llanos J, de Filippi CR, McCord J, Body R, Panteghini M, Jernberg T, Plebani M, Verschuren F, French JK, Christenson R, Weiser S, Bendig G, Dilba P. Impact of age on the performance of the ESC 0/1h-algorithms for early diagnosis of myocardial infarction. Eur Heart J 2018; 39:3780-3794. [DOI: 10.1093/eurheartj/ehy514] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 08/05/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Raphael Twerenbold
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Martinistraße 52, Hamburg, Germany
| | - Johannes Tobias Neumann
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Martinistraße 52, Hamburg, Germany
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Centre, Uppsala University, Akademiska sjukhuset, Ing. 40, 5 tr, Uppsala, Sweden
| | - Evangelos Giannitsis
- Medizinische Klinik III, University Heidelberg, Im Neuenheimer Feld 410, Heidelberg, Germany
| | - Nils Arne Sörensen
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Martinistraße 52, Hamburg, Germany
| | - Patrick Badertscher
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Janina E Jann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Desiree Wussler
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Christian Puelacher
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Maria Rubini Giménez
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Karin Wildi
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Ivo Strebel
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Jeanne Du Fay de Lavallaz
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Farah Selman
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Zaid Sabti
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Nikola Kozhuharov
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Eliska Potlukova
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Katharina Rentsch
- Laboratory Medicine, University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Òscar Miró
- GREAT Network, Via Antonio Serra 54, Rome, Italy
- Emergency Department, Hospital Clinic, Calle Villarroel, Barcelona, Catalonia, Spain
| | - F Javier Martin-Sanchez
- GREAT Network, Via Antonio Serra 54, Rome, Italy
- Servicio de Urgencias, Hospital Clínico San Carlos, Profesor Martín Lagos, S/N, Madrid, Spain
| | - Beata Morawiec
- GREAT Network, Via Antonio Serra 54, Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, ul. M. Curie-Sklodowskiej 9, Zabrze, Poland
| | - Jiri Parenica
- GREAT Network, Via Antonio Serra 54, Rome, Italy
- Department of Cardiology, University Hospital Brno, Jihlavská 20, CZ, Brno, Czech Republic
- Medical Faculty, Masaryk University, Kamenice 5, Brno-Bohunice, Czech Republic
| | - Jens Lohrmann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Wanda Kloos
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Hebelstrasse 10, Basel, Switzerland
- Department of Hematology, University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Liestal, Rheinstrasse 26, Liestal, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Rämistrasse 100, Zürich, Switzerland
| | - Stefan Osswald
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
| | - Dirk Westermann
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Martinistraße 52, Hamburg, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, Hamburg University Heart Center, Martinistraße 52, Hamburg, Germany
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, Basel, Switzerland
- GREAT Network, Via Antonio Serra 54, Rome, Italy
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French JK, Etaher A, Frost S, Saad Y, Nguyen T, Juergens CP, Ferguson I. P3480High sensitivity Troponin T and late survival of patients at least 80 years with suspected ACS. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J K French
- University of New South Wales, Sydney, Australia
| | - A Etaher
- University of New South Wales, Sydney, Australia
| | - S Frost
- University of Western Sydney, Sydney, Australia
| | - Y Saad
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - T Nguyen
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - C P Juergens
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - I Ferguson
- Liverpool Hospital, Cardiology, Sydney, Australia
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French JK, Etaher A, Gibbs O, Frost S, Saad Y, Ferguson I, Juergens CP. P6428Late mortality rates of patients with type 2 MI compared to type 1 MI and stable high sensitivity troponin T elevations. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J K French
- University of New South Wales, Sydney, Australia
| | - A Etaher
- University of New South Wales, Sydney, Australia
| | - O Gibbs
- University of New South Wales, Sydney, Australia
| | - S Frost
- University of Western Sydney, Sydney, Australia
| | - Y Saad
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - I Ferguson
- Liverpool Hospital, Cardiology, Sydney, Australia
| | - C P Juergens
- Liverpool Hospital, Cardiology, Sydney, Australia
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Burgess SN, Juergens CP, Nguyen TL, Leung M, Richards DAB, Thomas L, Mussap CJ, Lo STH, French JK. P1642The impact of residual non-culprit stenoses in diabetic and non-diabetic patients with ST elevation myocardial infarction. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- S N Burgess
- University of New South Wales, Liverpool hospital, Cardiology department, & Nepean Hospital, Cardiology department, Sydney, Australia
| | - C P Juergens
- University of New South Wales, Liverpool Hospital, Cardiology department, Sydney, Australia
| | - T L Nguyen
- University of New South Wales, Liverpool Hospital, Cardiology department, Sydney, Australia
| | - M Leung
- University of New South Wales, Liverpool Hospital, Cardiology department, Sydney, Australia
| | - D A B Richards
- University of New South Wales, Liverpool Hospital, Cardiology department, Sydney, Australia
| | - L Thomas
- University of New South Wales, & Westmead hospital, Cardiology department, Sydney, Australia
| | - C J Mussap
- University of New South Wales, Liverpool Hospital, Cardiology department, Sydney, Australia
| | - S T H Lo
- University of New South Wales, Liverpool Hospital, Cardiology department, Sydney, Australia
| | - J K French
- University of New South Wales, Liverpool Hospital, Cardiology department, Sydney, Australia
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Xu J, Hee L, Hopkins A, Juergens CP, Lo S, French JK, Mussap CJ. Clinical and Angiographic Predictors of Mortality in Sudden Cardiac Arrest Patients Having Cardiac Catheterisation: A Single Centre Registry. Heart Lung Circ 2018; 28:370-378. [PMID: 29459218 DOI: 10.1016/j.hlc.2018.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 12/21/2017] [Accepted: 01/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Immediate cardiac catheterisation (CC) is recommended in ST-elevation myocardial infarction (STEMI) following sudden cardiac arrest (SCA). Guidelines advise urgent CC for SCA patients without-STEMI, at clinician discretion. We examined the clinical and angiographic factors predicting mortality in SCA patients having CC. METHODS Consecutive SCA patients having CC at Liverpool Hospital, Sydney (January 2011-September 2015) were retrospectively analysed. Patient data were retrieved from hospital records, and angiographic SYNTAX scores (SS) were quantified online. Independent predictors of mortality were derived using multivariate logistic analysis. RESULTS The study cohort comprised 104 SCA patients; mean age 61±12years, and 79% male. Immediate CC (<2hours post-SCA) was performed in 35% overall. Compared to the without-STEMI subgroup, STEMI patients had more ventricular fibrillation (91 vs 50%; p<0.0001), and higher mean peak serum high-sensitivity troponin-T (8.25±14.7 vs 1.97±6.13 ug/L; p=0.006); in the context of higher median SS (18 vs 6.5; p=0.002) and target-lesion SS (tSS, 10 vs 0; p<0.001). Percutaneous coronary intervention (PCI; 75 vs 23%; p<0.0001) and target vessel revascularisation (11 vs 0%; p=0.005) were more frequent for STEMI. All-cause mortality was 39%, at 1.3±1.5years follow-up. Independent mortality predictors were: delayed CC (HR 4.08), serum lactate >7mmol/L (HR 3.47), and tSS (HR 1.05). CONCLUSIONS Elevated serum lactate, tSS, and delayed CC, were predictive of longer-term mortality in SCA patients having CC. Late CC in patients without-STEMI suggest scope for improvement in real-world systems of care. Closer scrutiny of target lesion complexity may aid prognostication in SCA survivors.
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Affiliation(s)
- James Xu
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia
| | - Leia Hee
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia
| | - Andrew Hopkins
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia
| | - Craig P Juergens
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia
| | - Sidney Lo
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia
| | - John K French
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia
| | - Christian J Mussap
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia.
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Chew DP, Scott IA, Cullen L, French JK, Briffa TG, Tideman PA, Woodruffe S, Kerr A, Branagan M, Aylward PE. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2017; 205:128-33. [PMID: 27465769 DOI: 10.5694/mja16.00368] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/10/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points. MAIN RECOMMENDATIONS This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the: diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation. Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.
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Affiliation(s)
- Derek P Chew
- Department of Cardiology, Flinders University, Adelaide, SA
| | - Ian A Scott
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, QLD
| | - Louise Cullen
- Australian Centre for Health Services Innovation, Brisbane, QLD
| | - John K French
- Coronary Care and Cardiovascular Research, Liverpool Hospital, Sydney, NSW
| | - Tom G Briffa
- School of Population Health, University of Western Australia, Perth, WA
| | - Philip A Tideman
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA
| | - Stephen Woodruffe
- Ipswich Cardiac Rehabilitation and Heart Failure Service, Ipswich Hospital, Ipswich, QLD
| | - Alistair Kerr
- Cardiomyopathy Association of Australia, Melbourne, VIC
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Chew DP, Scott IA, Cullen L, French JK, Briffa TG, Tideman PA, Woodruffe S, Kerr A, Branagan M, Aylward PE. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2017; 25:895-951. [PMID: 27465769 DOI: 10.1016/j.hlc.2016.06.789] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points. MAIN RECOMMENDATIONS This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the: diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation. Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.
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Affiliation(s)
- Derek P Chew
- Department of Cardiology, Flinders University, Adelaide, SA
| | - Ian A Scott
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, QLD
| | - Louise Cullen
- Australian Centre for Health Services Innovation, Brisbane, QLD
| | - John K French
- Coronary Care and Cardiovascular Research, Liverpool Hospital, Sydney, NSW
| | - Tom G Briffa
- School of Population Health, University of Western Australia, Perth, WA
| | - Philip A Tideman
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA
| | - Stephen Woodruffe
- Ipswich Cardiac Rehabilitation and Heart Failure Service, Ipswich Hospital, Ipswich, QLD
| | - Alistair Kerr
- Cardiomyopathy Association of Australia, Melbourne, VIC
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Nowak R, Mueller C, Giannitsis E, Christ M, Ordonez-Llanos J, DeFilippi C, McCord J, Body R, Panteghini M, Jernberg T, Plebani M, Verschuren F, French JK, Christenson R, Jacobsen G, Dinkel C, Lindahl B. High sensitivity cardiac troponin T in patients not having an acute coronary syndrome: results from the TRAPID-AMI study. Biomarkers 2017; 22:709-714. [PMID: 28532247 DOI: 10.1080/1354750x.2017.1334154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To describe the baseline, 1 hr and delta high sensitivity cardiac troponin (hs-cTnT) values in patients with suspected acute myocardial infarction (AMI) but without a final acute coronary syndrome (ACS) diagnosis. MATERIALS AND METHODS hs-cTnT assay for RAPID rule out of acute myocardial infarction (TRAPID-AMI) was a prospective diagnostic trial that enrolled emergency department (ED) patients with suspected AMI. Final patient diagnoses were adjudicated by a clinical events committee and subjects placed in different clinical groups: AMI, unstable angina, non-ACS cardiac, non-cardiac and unknown origin. The baseline, 1 hr and delta hs-cTnT values were analysed in the 902 non-ACS patients. RESULTS Amongst the 1282 studied the patient groups were 213 (17%) AMI, 167 (13%) unstable angina, 113 (9%) non-ACS cardiac, 288 (22%) non-cardiac and 501 (39%) unknown origin. The hs-cTnT values in the non-cardiac and unknown origin groups were combined. The median hs-cTnT values (ng/L) were higher (p < 0.001) in the non-ACS cardiac compared to the non-cardiac/unknown origin group at baseline (11.8, <5) and 1 hr (12.3, <5). Their negative predictive values were 0.955 (baseline) and 0.954 (1 hr) for predicting non-ACS cardiac versus non-cardiac/unknown origin diagnoses. CONCLUSIONS Hs-cTnT may help predict whether non-ACS ED patients have a final non-ACS cardiac or non-cardiac/unknown origin diagnoses.
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Affiliation(s)
- Richard Nowak
- a Emergency Medicine , Henry Ford Hospital , Detroit , MI , USA
| | - Christian Mueller
- b Department of Cardiology & Cardiovascular Research Institute Basel , University Hospital Base , Basel , Switzerland
| | - Evangelos Giannitsis
- c Department of Internal Medicine, Cardiology, Angiology & Pulmonary , University Hospital Heidelberg , Heidelberg , Germany
| | - Michael Christ
- d Department of Emergency and Critical Care Medicine , Paracelsus Medical University , Germany , Nuernberg
| | | | | | - James McCord
- g Cardiology , Henry Ford Hospital , Detroit , MI , USA
| | - Richard Body
- h Emergency Medicine , Central Manchester University NHS Foundation Trust , Manchester , UK
| | - Mauro Panteghini
- i Laboratorio Analisi Chimico Cliniche , Azienda Ospedaliera Luigi Sacco , Milan , Italy
| | - Tomas Jernberg
- j Cardiology , Karolinska University Hospital , Stockholm , Sweden
| | - Mario Plebani
- k Servizio Medicina di Laboratorio Azienda Ospedaliera , Universita di Padova Via Giustinianeo , Padova , Italy
| | - Franck Verschuren
- l Department of Acute Medicine , Cliniques Universitaires St-Luc Universite Catholiques de Louvain , Brussels , Belgium
| | - John K French
- m Cardiology , Liverpool Hospital , Liverpool , NSW , Australia
| | - Robert Christenson
- n Department of Pathology , University of Maryland , Baltimore , MD , USA
| | - Gordon Jacobsen
- o Department of Public Health Sciences , Henry Ford Hospital , Detroit , MI , USA
| | - Carina Dinkel
- p Department of Statistics , Roche Diagnostics , Penzberg , Germany
| | - Bertil Lindahl
- q Uppsala Clinical Research Center , Uppsala University , Uppsala , Sweden
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French JK, Chew DP, Harper RW, Aylward PEG. Pre‐hospital thrombolysis in ST‐segment elevation myocardial infarction: a regional Australian experience. Med J Aust 2017; 206:369. [DOI: 10.5694/mja16.01199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 11/02/2016] [Indexed: 11/17/2022]
Affiliation(s)
| | - Derek P Chew
- Flinders University, Adelaide, SA
- MonashHeart, Monash Health, Melbourne, VIC
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Elliott JM, Wang TKM, Gamble GD, Williams MJ, Matsis P, Troughton R, Hamer A, Devlin G, Mann S, Richards M, French JK, White HD, Ellis CJ. A decade of improvement in the management of New Zealand ST-elevation myocardial infarction (STEMI) patients: results from the New Zealand Acute Coronary Syndrome (ACS) Audit Group national audits of 2002, 2007 and 2012. N Z Med J 2017; 130:17-28. [PMID: 28384143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
AIMS To audit the management of ST-segment elevation myocardial infarction (STEMI) patients admitted to a New Zealand Hospital over three 14-day periods to review their number, characteristics, management and outcome changes over a decade. METHODS The acute coronary syndrome (ACS) audits were conducted over 14 days in May of 2002, 2007 and 2012 at New Zealand Hospitals admitting patients with a suspected or definite ACS. Longitudinal analyses of the STEMI subgroup are reported. RESULTS From 2002 to 2012, the largest change in management was the proportion of patients undergoing reperfusion by primary PCI from 3% to 15% and 41%; P<0.001, and the rates of second antiplatelet agent use in addition to aspirin from 14% to 62% and 98%; P<0.001. The use of proven secondary prevention medications at discharge also increased during the decade. There were also significant increases in cardiac investigations for patients, especially echocardiograms (35%, 62% and 70%, P<0.001) and invasive coronary angiograms (31%, 58% and 87%, P<0.001). Notably even in 2012, one in four patients presenting with STEMI did not receive any reperfusion therapy. CONCLUSIONS Substantial improvements have been seen in the management of STEMI patients in New Zealand over the last decade, in accordance with evidenced-based guideline recommendations. However, there appears to be considerable room to optimise management, particularly with the use of timely reperfusion therapy for more patients.
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Affiliation(s)
| | - Tom Kai Ming Wang
- Cardiology Registrar, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland
| | | | | | | | | | | | | | | | | | - John K French
- Cardiologist, Liverpool Hospital, SW Sydney Clinical School (UNSW) Sydney, Australia
| | - Harvey D White
- Cardiologist, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland
| | - Chris J Ellis
- Cardiologist, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland. For the NZ Regional Cardiac Society ACS Audit Group
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Holmes LE, Gupta R, Rajendran S, Luu J, French JK, Juergens CP. A randomized trial assessing the impact of three different glycoprotein IIb/IIIa antagonists on glycoprotein IIb/IIIa platelet receptor inhibition and clinical endpoints in patients with acute coronary syndromes. Cardiovasc Ther 2017; 34:330-6. [PMID: 27327862 DOI: 10.1111/1755-5922.12203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS To compare three glycoprotein IIb/IIIa receptor antagonists (GPIs) in terms of platelet inhibition and major adverse cardiac events (MACEs), and assess the rate of bleeding and MACEs between GPIs and coadministered P2Y12 agents. METHODS Eighty-three acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) with planned GPI use were randomized to receive high-dose bolus tirofiban, double-bolus eptifibatide, or abciximab followed by a 12-hour infusion. Glycoprotein IIb/IIIa platelet receptor inhibition was measured at baseline and at 10 minutes, 1 hour, and 24 hours postbolus dose. Major adverse cardiac events and bleeding complications at 30 days were documented. The incidence of MACEs and bleeding in patients receiving ticagrelor or prasugrel were compared to those given clopidogrel. RESULTS There were no statistically significant differences in platelet inhibition between GPIs at 10 minutes (P=.085) and 1 hour (P=.337). At 24 hours, abciximab achieved statistically significantly higher median [interquartile range] platelet inhibition (75 [65-88]%) compared to tirofiban (28 [3-56]%; P<.0001) and eptifibatide (44 [31-63]%; P=.007). There were no differences in bleeding or MACEs depending on GPI or P2Y12 inhibitor administered. CONCLUSIONS Glycoprotein receptor inhibitors achieve similar levels of platelet inhibition at 10 minutes and 1 hour; however, abciximab maintains this benefit 24 hours after bolus dose. We did not witness an increased rate of bleeding in patients given new potent P2Y12 inhibitors and a GPI in the modern era.
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Affiliation(s)
- Lewis E Holmes
- South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia.,Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia
| | - Rohan Gupta
- South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia.,Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia
| | - Saissan Rajendran
- South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia.,Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia
| | - John Luu
- South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia.,Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia
| | - John K French
- South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia.,Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia
| | - Craig P Juergens
- South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia. .,Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia.
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50
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Etaher A, Chew D, Redfern J, Briffa T, Ellis C, Hammett C, Lefkovits J, Elliott J, Cullen L, Brieger D, French JK. Suspected ACS Patients Presenting With Myocardial Damage or a Type 2 Myocardial Infarction Have a Similar Late Mortality to Patients With a Type 1 Myocardial Infarction: A Report From the Australian and New Zealand 2012 SNAPSHOT ACS Study. Heart Lung Circ 2017; 26:1051-1058. [PMID: 28139353 DOI: 10.1016/j.hlc.2016.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/29/2016] [Accepted: 11/20/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cardiac troponin (T and I) are considered the standard markers for detection of myocardial damage and the diagnosis of acute coronary syndrome (ACS) among patients who present to an emergency department with chest pain. However, these markers can be released in other situations and may be associated with short- and long-term clinical outcomes. In this study, we examine late mortality rates among patients presenting with a suspected ACS due to an unstable coronary plaque and those patients having a non-ACS. METHODS 4388 patients were hospitalised with suspected ACS, between 14 and 27 May 2012 in the Australia and New Zealand SNAPSHOT ACS study. Those patients were categorised in five diagnostic groups: 1) ST elevation MI (n=419); 2) non-ST elevation MI (n=1012); 3) unstable angina (n=925); 4) non-ACS diagnoses (n=837); and 5) chest pain considered unlikely ischaemic (not otherwise specified, n=1195). RESULT The respective mortality rates at 18 months in these groups were 16.2%, 16.3%, 6.8%, 12.8%, and 4.8%; Pearson χ2=110 p<0.001. Among non-ACS diagnoses patients (group 4) those with the highest mortality rates (cardiac (14.4%), respiratory (18.2%), sepsis (15.4%) and neoplastic (67%) diagnoses) had the highest rates of elevated troponin levels (48%, 31%, 38% and 67% respectively). By contrast, those with the lowest mortality rates (musculoskeletal (2.9%), gastrointestinal disorders (3.9%) and non-specific chest pain (7.4%)) had the lowest rate of elevated troponin levels (9%, 18% and 15.8% respectively). However, after adjusting for baseline clinical and demographic characteristics, the mortality rate at 18 months for patients with elevated troponin was similar for ACS or non-ACS diagnoses (Hazard Ratio, 95% C.I.0.98-1.07, p=0.333). CONCLUSIONS Among patients in the 2012 SNAPSHOT ACS study, non-ACS diagnoses characterised by high rates of elevated troponin levels had high mortality rates similar to those diagnosed with ACS. Therapies known to be effective in ACS patients, including early invasive management, should be examined in these non-ACS patients with troponin elevations within adequately powered randomised trials.
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Affiliation(s)
- Aisha Etaher
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, the University of New South Wales, Sydney, NSW, Australia
| | - Derek Chew
- Flinders University of South Australia, Adelaide, SA, Australia
| | - Julie Redfern
- The George Institute, University of Sydney, Sydney, NSW, Australia
| | - Tom Briffa
- University of Western Australia, Perth, WA, Australia
| | | | | | | | - John Elliott
- Christchurch Hospital, Christchurch, New Zealand
| | | | | | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, the University of New South Wales, Sydney, NSW, Australia.
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