- Email: [email protected]
2011 Addendum to the Guidelines for the Management of Acute Coronary Syndromes 2006
remain off Warfarin (low CHAD score) in sinus rhythm or DDDR A pace V pace mode with no recurrence of AF from one year to the next, including three patients off beta blocker therapy (no strokes or TIAs). doi:10.1016/j.hlc.2011.05.274 272 Transseptal Puncture and Thrombotic Risk C. Schultz 1,∗ , S. Willoughby 1 , H. Lim 1 , B. John 2 , S. Chandy 2 , D. Lau 1 , K. Roberts-Thomson 1 , G. Young 1 , P. Sanders 1 1 Centre
for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Australia 2 Department of Cardiology, Christian Medical College, Vellore, India Introduction: Left atrial (LA) procedures are associated with a short term increase in thromboembolic events. The mechanisms underlying this phenomenon are unclear. It is plausible that transseptal puncture acts as a precipitating event inducing thrombus formation. Therefore this study investigated whether transseptal puncture acutely increases markers of thrombogenesis, endothelial function and inflammation. Methods: Patients undergoing radiofrequency ablation (n = 16, 41 ± 14 years) for left sided accessory pathway disease were studies. Blood samples were taken from the right atrium (RA) prior to transseptal puncture and the LA 10 minute after transseptal puncture, and before the administration of heparin. Platelet activation was assessed using whole blood flow cytometry (P-selectin [CD62P]) and ADP (5 m) induced impedance aggregometry. Markers of thrombin generation (thrombin/anti-thrombin [TAT]), endothelial function (asymmetric dimethylarginine [ADMA]) and inflammation (intracellular adhesion molecule [ICAM-1] and vascular adhesion molecule [VCAM-1]), were measured by ELISA. Results: Following transseptal puncture there was no difference between the RA and LA for any measured variables (see table). Conclusion: This study shows that atrial platelet reactivity, thrombin generation, endothelial function and inflammation are not altered acutely by transseptal puncture alone. This data suggests that transseptal puncture its self does not contribute to the increased thrombotic risk. Further evaluation of primary disease process and theatre
Abstracts CSANZ Abstracts 2011
S111
management need to be considered in the risk of thrombus formation. Right atria CD62P (%) Aggregation (Ohms) TAT (g/L) ADMA (mol/L) I CAM-1 (mg/mL VCAM1 (mg/mL)
20.2 5.3 22.5 0.4 130 389
± ± ± ± ± ±
10 2.0 10.7 0.9 80 150
Left atria 27.5 5.1 23 0.4 121 386
± ± ± ± ± ±
13 0.5 10.5 0.05 76 190
P value 0.19 0.88 0.79 0.56 0.79 0.96
doi:10.1016/j.hlc.2011.05.275 Interventional Cardiology 273 2011 Addendum to the Guidelines for the Management of Acute Coronary Syndromes 2006 D. Chew 1,∗ , C. Aroney 2 , P. Aylward 1 , H. White 3 , P. Tideman 1 , A. Kelly 4 , J. Waddell 5 , L. Azadi 5 , A. Wilson 5 , L. Ruta 5 1 Flinders
Medical Centre, Australia Spirit Northside Hospital, Australia 3 Auckland City Hospital, New Zealand 4 Joseph Epstein Centre for Emergency Medicine Research, Australia 5 National Heart Foundation of Australia, Australia 2 Holy
Introduction: The Heart Foundation and Cardiac Society of Australia and New Zealand (CSANZ) have released an addendum to their Guidelines for the management of acute coronary syndromes 2006 and 2007 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006. Methods: An evidence-based update of the 2006 guidelines and 2007 addendum was undertaken by the Guideline Executive Writing Group to include this information. All key stakeholders organisations who endorsed the 2006 guidelines were consulted; this included the Australasian College for Emergency Medicine and the Internal Medicine Society of Australia and New Zealand. Results: Published in Heart, Lung and Circulation, the 2011 addendum considers evidence published since 2007 and gives updated recommendations for serum troponin testing using the newer high-sensitivity assays, choice of reperfusion therapy for STEMI, antithrombotic therapy for STEMI and NSTEACS, the modification of pharmacologic therapies in response to bleeding risk in ACS, oxygen therapy for patients with ACS and system factors. The addendum presents this new information relevant to both the 2006 guidelines and 2007 addendum, in order to provide up to date advice to clinicians managing patients with ACS. Conclusion: The 2011 addendum is intended to complement the Guidelines for the management of acute coronary syndromes 2006 and corresponding 2007 adden-
ABSTRACTS
Heart, Lung and Circulation 2011;20S:S1–S155
S112
Abstracts CSANZ Abstracts 2011
ABSTRACTS
dum with updated recommendations based on the latest available evidence. doi:10.1016/j.hlc.2011.05.276
Heart, Lung and Circulation 2011;20S:S1–S155
275 A Bayesian Risk Index for Predicting Risk of Major Adverse Cardiac Events at 12 Months Post Angioplasty and Its Application to Clinical Service Quality Improvement
274 Sixty-four Cases of Stent Thrombosis: A Seven Year Experience from the Australian Capital Territory
J. Cameron 1,2,∗ , J. Rivers 1,2 , P. Mengersen 3 , I. Smith 2
A. Mishra ∗ , A. Farshid, R. Tan, S. O’ Connor, M. Rahman, C. Allada, D. McGill, P. Marley, L. Arnolda
2 St
The Canberra Hospital, Australia Background: Stent thrombosis (ST) is a feared complication of percutaneous coronary intervention due to its adverse consequences. Methods: We analysed records of 4226 consecutive patients from January 2004 to October 2010 who underwent successful stenting. Baseline clinical characteristics, angiographic features and outcomes were compared in patients with and without ST. Results: A total of 64 cases of angiographic ST were recorded including six patients who had more than one episode of ST. Fifty-six percent of ST cases occurred in the first 30 days, 31% in days 30–365 and 13% after 365 days. Patients undergoing primary PCI (PPCI) had the highest risk of ST (3.1% vs 1.1% in all others, p = 0.0001). There was no difference in ST rate between patients treated with DES and BMS (1.4% vs 1.6%, p = ns). Incidence of ST beyond one year was 0.2% for BMS and 0.3% for DES (p = ns). There was a trend towards higher ST rate in patients who had a 2.25 mm diameter stent compared to larger stents (3.8% vs 1.5%, p = 0.06). Age, sex, diabetes and smoking status were not predictive of ST. Early experience with 20 primary PCI patients treated with Prasugrel was associated with no stent thrombosis. Patients with ST had a mortality rate of 10.9% compared with 2.7% in those without ST (p < 0.01). Conclusions: The risk of ST is higher in the first 30 days post procedure. PPCI patients had the highest risk of ST. There was no significant difference in ST rate between DES and BMS. ST was associated with significantly higher mortality during follow-up. doi:10.1016/j.hlc.2011.05.277
Hadjipetrou 1,2 , K.
1 Queensland
Cardiovascular Group, Australia Andrew’s Medical Institute, Australia 3 Queensland University of Technology, Australia Background: Clinical application of statistical process control (SPC) to monitoring of procedural outcomes improves when risk adjustment (RA) is incorporated to account for common cause variation. This project describes the development of a RA model for estimating the risk of major adverse cardiac events (MACE) at 12 months following a percutaneous coronary intervention (PCI). Application of the RA model to SPC based monitoring was evaluated. Methods and results: Prospectively collected data for 2330 index PCI procedures were analysed to identify factors predictive of 12 month MACE. A Bayesian RA model was built using these factors. Model performance was evaluated for discrimination and calibration using the area under the receiver operating characteristic curve (AUC) and the Hosmer–Lemeshow “C”-statistic. CUmulative SUM, Exponentially Weighted Moving Average and Funnel Plots were constructed using the RA model and subjectively evaluated. Factors included in the RA model included: left ventricular function (p < 0.001), acute or rescue MI (p = 0.065), age (p < 0.001), use of bare metal stents (p < 0.001), hypertension (p = 0.004), diabetes (p = 0.016), number of vessels (p = 0.004) and number of lesions (p < 0.001). Cross validation analysis confirmed acceptable performance of the model (AUC: 0.74, H–L p-value: 0.2). Retrospective application of the RA significantly modified “alarm signals” during SPC monitoring. Conclusion: A RA model was developed and applied to SPC monitoring for 12 month MACE in a PCI database and resulted in a reinterpretation of “alarm signals” based on unadjusted data. If linked to appropriate quality improvement governance response protocols, SPC using this RA tool might improve quality control and risk management. doi:10.1016/j.hlc.2011.05.278
for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, Australia 2 Department of Cardiology, Christian Medical College, Vellore, India Introduction: Left atrial (LA) procedures are associated with a short term increase in thromboembolic events. The mechanisms underlying this phenomenon are unclear. It is plausible that transseptal puncture acts as a precipitating event inducing thrombus formation. Therefore this study investigated whether transseptal puncture acutely increases markers of thrombogenesis, endothelial function and inflammation. Methods: Patients undergoing radiofrequency ablation (n = 16, 41 ± 14 years) for left sided accessory pathway disease were studies. Blood samples were taken from the right atrium (RA) prior to transseptal puncture and the LA 10 minute after transseptal puncture, and before the administration of heparin. Platelet activation was assessed using whole blood flow cytometry (P-selectin [CD62P]) and ADP (5 m) induced impedance aggregometry. Markers of thrombin generation (thrombin/anti-thrombin [TAT]), endothelial function (asymmetric dimethylarginine [ADMA]) and inflammation (intracellular adhesion molecule [ICAM-1] and vascular adhesion molecule [VCAM-1]), were measured by ELISA. Results: Following transseptal puncture there was no difference between the RA and LA for any measured variables (see table). Conclusion: This study shows that atrial platelet reactivity, thrombin generation, endothelial function and inflammation are not altered acutely by transseptal puncture alone. This data suggests that transseptal puncture its self does not contribute to the increased thrombotic risk. Further evaluation of primary disease process and theatre
Abstracts CSANZ Abstracts 2011
S111
management need to be considered in the risk of thrombus formation. Right atria CD62P (%) Aggregation (Ohms) TAT (g/L) ADMA (mol/L) I CAM-1 (mg/mL VCAM1 (mg/mL)
20.2 5.3 22.5 0.4 130 389
± ± ± ± ± ±
10 2.0 10.7 0.9 80 150
Left atria 27.5 5.1 23 0.4 121 386
± ± ± ± ± ±
13 0.5 10.5 0.05 76 190
P value 0.19 0.88 0.79 0.56 0.79 0.96
doi:10.1016/j.hlc.2011.05.275 Interventional Cardiology 273 2011 Addendum to the Guidelines for the Management of Acute Coronary Syndromes 2006 D. Chew 1,∗ , C. Aroney 2 , P. Aylward 1 , H. White 3 , P. Tideman 1 , A. Kelly 4 , J. Waddell 5 , L. Azadi 5 , A. Wilson 5 , L. Ruta 5 1 Flinders
Medical Centre, Australia Spirit Northside Hospital, Australia 3 Auckland City Hospital, New Zealand 4 Joseph Epstein Centre for Emergency Medicine Research, Australia 5 National Heart Foundation of Australia, Australia 2 Holy
Introduction: The Heart Foundation and Cardiac Society of Australia and New Zealand (CSANZ) have released an addendum to their Guidelines for the management of acute coronary syndromes 2006 and 2007 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006. Methods: An evidence-based update of the 2006 guidelines and 2007 addendum was undertaken by the Guideline Executive Writing Group to include this information. All key stakeholders organisations who endorsed the 2006 guidelines were consulted; this included the Australasian College for Emergency Medicine and the Internal Medicine Society of Australia and New Zealand. Results: Published in Heart, Lung and Circulation, the 2011 addendum considers evidence published since 2007 and gives updated recommendations for serum troponin testing using the newer high-sensitivity assays, choice of reperfusion therapy for STEMI, antithrombotic therapy for STEMI and NSTEACS, the modification of pharmacologic therapies in response to bleeding risk in ACS, oxygen therapy for patients with ACS and system factors. The addendum presents this new information relevant to both the 2006 guidelines and 2007 addendum, in order to provide up to date advice to clinicians managing patients with ACS. Conclusion: The 2011 addendum is intended to complement the Guidelines for the management of acute coronary syndromes 2006 and corresponding 2007 adden-
ABSTRACTS
Heart, Lung and Circulation 2011;20S:S1–S155
S112
Abstracts CSANZ Abstracts 2011
ABSTRACTS
dum with updated recommendations based on the latest available evidence. doi:10.1016/j.hlc.2011.05.276
Heart, Lung and Circulation 2011;20S:S1–S155
275 A Bayesian Risk Index for Predicting Risk of Major Adverse Cardiac Events at 12 Months Post Angioplasty and Its Application to Clinical Service Quality Improvement
274 Sixty-four Cases of Stent Thrombosis: A Seven Year Experience from the Australian Capital Territory
J. Cameron 1,2,∗ , J. Rivers 1,2 , P. Mengersen 3 , I. Smith 2
A. Mishra ∗ , A. Farshid, R. Tan, S. O’ Connor, M. Rahman, C. Allada, D. McGill, P. Marley, L. Arnolda
2 St
The Canberra Hospital, Australia Background: Stent thrombosis (ST) is a feared complication of percutaneous coronary intervention due to its adverse consequences. Methods: We analysed records of 4226 consecutive patients from January 2004 to October 2010 who underwent successful stenting. Baseline clinical characteristics, angiographic features and outcomes were compared in patients with and without ST. Results: A total of 64 cases of angiographic ST were recorded including six patients who had more than one episode of ST. Fifty-six percent of ST cases occurred in the first 30 days, 31% in days 30–365 and 13% after 365 days. Patients undergoing primary PCI (PPCI) had the highest risk of ST (3.1% vs 1.1% in all others, p = 0.0001). There was no difference in ST rate between patients treated with DES and BMS (1.4% vs 1.6%, p = ns). Incidence of ST beyond one year was 0.2% for BMS and 0.3% for DES (p = ns). There was a trend towards higher ST rate in patients who had a 2.25 mm diameter stent compared to larger stents (3.8% vs 1.5%, p = 0.06). Age, sex, diabetes and smoking status were not predictive of ST. Early experience with 20 primary PCI patients treated with Prasugrel was associated with no stent thrombosis. Patients with ST had a mortality rate of 10.9% compared with 2.7% in those without ST (p < 0.01). Conclusions: The risk of ST is higher in the first 30 days post procedure. PPCI patients had the highest risk of ST. There was no significant difference in ST rate between DES and BMS. ST was associated with significantly higher mortality during follow-up. doi:10.1016/j.hlc.2011.05.277
Hadjipetrou 1,2 , K.
1 Queensland
Cardiovascular Group, Australia Andrew’s Medical Institute, Australia 3 Queensland University of Technology, Australia Background: Clinical application of statistical process control (SPC) to monitoring of procedural outcomes improves when risk adjustment (RA) is incorporated to account for common cause variation. This project describes the development of a RA model for estimating the risk of major adverse cardiac events (MACE) at 12 months following a percutaneous coronary intervention (PCI). Application of the RA model to SPC based monitoring was evaluated. Methods and results: Prospectively collected data for 2330 index PCI procedures were analysed to identify factors predictive of 12 month MACE. A Bayesian RA model was built using these factors. Model performance was evaluated for discrimination and calibration using the area under the receiver operating characteristic curve (AUC) and the Hosmer–Lemeshow “C”-statistic. CUmulative SUM, Exponentially Weighted Moving Average and Funnel Plots were constructed using the RA model and subjectively evaluated. Factors included in the RA model included: left ventricular function (p < 0.001), acute or rescue MI (p = 0.065), age (p < 0.001), use of bare metal stents (p < 0.001), hypertension (p = 0.004), diabetes (p = 0.016), number of vessels (p = 0.004) and number of lesions (p < 0.001). Cross validation analysis confirmed acceptable performance of the model (AUC: 0.74, H–L p-value: 0.2). Retrospective application of the RA significantly modified “alarm signals” during SPC monitoring. Conclusion: A RA model was developed and applied to SPC monitoring for 12 month MACE in a PCI database and resulted in a reinterpretation of “alarm signals” based on unadjusted data. If linked to appropriate quality improvement governance response protocols, SPC using this RA tool might improve quality control and risk management. doi:10.1016/j.hlc.2011.05.278