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Effectiveness of Utilising Aortic Regurgitation (AR) Index to Define Peri-Prosthetic Aortic Regurgitation (periAR) Severity in Transcatheter Aortic Valve Implantation (TAVI) Patients
Abstracts
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[STEMI]) treated by PCI. Prior studies have documented high rates of optimal medical therapy following PCI. Methods: 2270 (14.6% of cohort) patients with UA treated with PCI were compared to 6,279 (40.5%) patients with NSTEMI and 6,970 (44.9%) STEMI patients enrolled in the Melbourne Interventional Group (MIG) Registry from 2005-2014. Long-term all-cause mortality was obtained with National Death Index (NDI) linkage. Results: Patients with STEMI were younger (63±13 years vs 65±13 NSTEMI and 66±12 UA) with fewer baseline comorbidities such as heart failure, diabetes and hypertension (all p<0.0001). There was an increase in in-hospital, 30-day and 1 year all-cause mortality from UA to NSTEMI to STEMI (2.5% all-cause mortality at 1 year vs 4.5% vs 8.7% respectively p=<0.0001). Kaplan-Meier survival estimates showed earlier increased mortality in the STEMI and NSTEMI groups however, after approximately 6.9 years survival was similar across all 3 groups (p=0.001). Subtype of ACS was not an independent predictor of increased hazard using multivariate Cox-Proportional Hazards modelling (HR 1.1, 95% CI 0.98-1.14, p=0.19).
Conclusions: Despite disparate baseline characteristics and differences in short-term mortality, long-term mortality was not different across the spectrum of ACS. http://dx.doi.org/10.1016/j.hlc.2016.06.405 404 Efax STEMI Study. Accuracy of Interpreting Fax to Email ST-elevation Myocardial Infarction Electrocardiograms Viewed on Smartphones E. Nehme 1,∗ , J. Riskallah 1 , R. Rehan 1 , P. Fahmy 1 , D. Burgess 1,2 , A. Kanthan 1,2 1 Blacktown 2 Western
Hospital, Sydney, Australia Sydney University, Sydney, Australia
We aimed to compare the accuracy of reviewing electronically faxed STEMI ECG’s on smart phones with viewing of printed ECG’s that are transmitted via traditional fax service. 120 STEMI ECG’s, which were confirmed as true STEMIs from coronary angiography and 200 consecutive NSTEMI ECG’s of patients who underwent coronary angiography at a major teaching hospital were sent in a randomised fashion
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via a fax to email service (eFax) in PDF to be viewed directly on a smartphone with 5’+ HD screen. The transmitted ECG’s were interpreted by two independent and blinded cardiologists and classified as STEMI, including infarct territory, NSTEMI or LBBB. Four weeks later, the same cardiologists interpreted the paper ECG’s. The results were compared and correlated with cardiac catheterisation findings. Of the 120 STEMI ECG’s, the two cardiologists were able to correctly identify all 120 ECGs as STEMIs both when viewed as PDF on a smartphone and when viewing the printed ECG. The overall agreement between smartphone viewed ECGs and the printed ECGs was 100%. Localisation of infarct territory was then correlated with cardiac catheterisation findings and showed a 79% correlation on smartphone viewed ECG’s compared to 80% with printed ECG’s. ECG’s transmitted via eFax compared to traditional fax can be viewed in a more timely fashion. Coupled with the fact that the STEMI pick up rate is equivalent, and the localisation of STEMI was equivalent, we postulate that this may lead to improved clinical outcomes in patients presenting with STEMI to emergency. http://dx.doi.org/10.1016/j.hlc.2016.06.406 405 Effectiveness of Utilising Aortic Regurgitation (AR) Index to Define Peri-Prosthetic Aortic Regurgitation (periAR) Severity in Transcatheter Aortic Valve Implantation (TAVI) Patients P. Black, M. Savage, D. Murdoch, C. Raffel, D. Walters ∗ The Prince Charles Hospital, Queensland Health, Brisbane, Australia Introduction: Transcatheter aortic valve implantation (TAVI) provides a non-surgical alternative to aortic valve replacement in high risk patients with severe symptomatic aortic stenosis. Post procedural peri-prosthetic aortic regurgitation (periAR) is a known complication of TAVI and can predict mortality risk. Aortic regurgitation (AR) index ([(DBPLVEDP)/SBP] x 100) evaluates periAR grade and we sought to establish the incidence and degree of periAR severity during TAVI and 1 year outcomes. Methods: PeriAR was assessed in 172 patients undergoing TAVI with the Corevalve or Sapien prosthesis. AR index and post procedural transthoracic echocardiography (TTE) was used to analyse periAR. Results: TTE revealed 32 patients (18.6%) exhibited no periAR, 93 patients (54.1%) mild, 42 patients (24.4%) moderate and 5 patients (2.9%) had severe periAR. The Corevalve cohort demonstrated a significant association between AR index and periAR (r = -0.391 p = <0.001) (Figure 1). Patients receiving Sapien demonstrated no significant correlation (r = 0.1184 p=0.289). (Figure 2). Patients with AR index <25 had no significant increase in 1 year mortality compared with patients with AR index ≥25 (8.0% vs 9.72% p = 0.786). This was consistent on subgroup analysis: Corevalve (8.8% vs 10.71% p = 1.0) and Sapien (4.5% vs 10.53% p = 0.408). AR index
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<25 had 72% sensitivity and 47% specificity for moderate or severe periAR. Conclusions: AR index was correlated with periAR severity in patients receiving Corevalve, but not Sapien TAVI. In this cohort, assessment of AR index did not predict 1 year mortality after TAVI, possibly related to low rates of moderate and severe periAR.
http://dx.doi.org/10.1016/j.hlc.2016.06.407 406 Effects of Invasive Management and Recurrent Cardiac Events on Survival in Troponin-Negative NSTEACS (TN-NSTEACS) S. Vogrin 1,3,∗ , R. Harper 2 , A. MacIsaac 1,3 , J. Burchell 3 , B. Smith 1 , A. Scott 4 , J. Yong 4 , V. Sundararajan 1,3 1 St
Vincent’s Hospital, Melbourne, Australia Heart, Melbourne, Australia 3 The Department of Medicine, The University of Melbourne, Australia 4 Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, Australia 2 Monash
Background: In TN-NSTEACS there are no clear recommendations regarding the use of invasive coronary angiograms (ICA) to initiate the invasive management pathway. Results of most RCTs show no survival benefit in patients with invasive management, however they demonstrate high crossover rates from control to treatment groups. Objective: To assess the impact of early ICA and subsequent cardiac events on 12-month mortality after TNNSTEACS. Methods: Longitudinal study using hospital data from Victoria, 2001–2011. Discrete time survival analysis on propensity score matched samples. Results: Patients without an acute cardiac hospitalisation in the year prior to presenting emergently to a hospital with ICA facilities and surviving ≥ 48 hours were included (n=37,394). Matched sample (n=16,916) balanced on 45 factors except receipt of ICA. Risk of dying was the highest in the first month after discharge (0.0048, CI:0.0043, 0.0054) and halved by 12 months (0.002, CI:0.0016, 0.0023). Receipt of ICA was associated with 50% decreased mortality (HR 0.45, CI:0.29, 0.69); revascularisation did not show survival benefit (HR 0.97, CI:0.75, 1.25). Other factors associated with decreased survival were readmissions for AMI (HR 6.53, CI:4.54, 9.41), emergent 2nd TN-NSTEACS (HR 1.65, CI:1.29, 2.13) and emergent stable coronary artery disease (HR 1.50, CI:1.14, 1.97).
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Survival at 12 months for patients receiving ICA within 3 months after the first TN-NSTEACS (96.8%, CI: 96.3%, 97.4%) did not differ from patients who had received ICA at index (97.7%, CI:97.3%, 98.1%). Conclusions: Patients with TN-NSTEACS benefit from ICA if it is performed within the 3 months from hospital discharge. http://dx.doi.org/10.1016/j.hlc.2016.06.408 407 Ensuring the Quality in Clinical Quality Registries – Design and Implementation of Rigorous Audit Activities in the Victorian Cardiac Outcomes Registry (VCOR) A. Brennan 1,∗ , D. Dinh 1 , J. Lefkovits 1,2 , D. Stub 1,3 , R. Brien 1 , H. Carruthers 1 , N. Andrianopoulos 1 , S. Duffy 3 , R. Dick 4 , D. Clark 5 , C. Hiew 6 , G. New 7 , R. Warren 8 , J. McNeil 1 , C. Reid 1,9 1 Monash
University, Melbourne, Australia Melbourne Hospital, Melbourne, Australia 3 Alfred Hospital, Melbourne, Australia 4 Epworth Health Care, Richmond, Australia 5 The Austin Hospital, Heidelberg, Australia 6 University Hospital, Geelong, Australia 7 Box Hill Hospital, Box Hill, Australia 8 Melbourne Private Hospital, Melbourne, Australia 9 Curtin University, Perth, Australia 2 Royal
Background: In 2010 the Australian Health Ministers’ Conference endorsed the Strategic & Operating Principles for Australian Clinical Quality Registries. Encompassed within this is several key principles related to ensuring data quality, including audit activities. We report on VCOR’s methods for ensuring accurate and high quality data acquisition. Methods and Results: VCOR undertakes audit at all sites to ensure data accuracy as well as correct case ascertainment (i.e. all relevant cases entered). Case ascertainment audit occurs annually with 21 hospitals having been audited once and 5 audited twice. Overall, the missing case rate was 3.3%, ranging from 0% to 14.8%. In sites audited twice, the missing case rate dropped from 4.7% to 1.1% between audits. Overall, sites subsequently entered the identified missing cases. Data accuracy audits are undertaken in approx. 5% of cases entered once sites have been active >1 year, with plans to repeat every 3 years. Data are extracted from the VCOR online system and comprises review of 26 entered fields compared to the medical records at hospitals. Fields audited include procedural information and outcome measures, e.g. bleeding, stroke and stent thrombosis. 21 sites have been audited for data accuracy, with an overall agreement rate of 97.3%. Individualised reports outlining the results are delivered to hospitals including comparison of results between audited hospitals. Conclusion: A rigorous audit regimen adopted by VCOR has not identified any systematic omission of cases across participating hospitals in VCOR. Data accuracy is high,
S173
[STEMI]) treated by PCI. Prior studies have documented high rates of optimal medical therapy following PCI. Methods: 2270 (14.6% of cohort) patients with UA treated with PCI were compared to 6,279 (40.5%) patients with NSTEMI and 6,970 (44.9%) STEMI patients enrolled in the Melbourne Interventional Group (MIG) Registry from 2005-2014. Long-term all-cause mortality was obtained with National Death Index (NDI) linkage. Results: Patients with STEMI were younger (63±13 years vs 65±13 NSTEMI and 66±12 UA) with fewer baseline comorbidities such as heart failure, diabetes and hypertension (all p<0.0001). There was an increase in in-hospital, 30-day and 1 year all-cause mortality from UA to NSTEMI to STEMI (2.5% all-cause mortality at 1 year vs 4.5% vs 8.7% respectively p=<0.0001). Kaplan-Meier survival estimates showed earlier increased mortality in the STEMI and NSTEMI groups however, after approximately 6.9 years survival was similar across all 3 groups (p=0.001). Subtype of ACS was not an independent predictor of increased hazard using multivariate Cox-Proportional Hazards modelling (HR 1.1, 95% CI 0.98-1.14, p=0.19).
Conclusions: Despite disparate baseline characteristics and differences in short-term mortality, long-term mortality was not different across the spectrum of ACS. http://dx.doi.org/10.1016/j.hlc.2016.06.405 404 Efax STEMI Study. Accuracy of Interpreting Fax to Email ST-elevation Myocardial Infarction Electrocardiograms Viewed on Smartphones E. Nehme 1,∗ , J. Riskallah 1 , R. Rehan 1 , P. Fahmy 1 , D. Burgess 1,2 , A. Kanthan 1,2 1 Blacktown 2 Western
Hospital, Sydney, Australia Sydney University, Sydney, Australia
We aimed to compare the accuracy of reviewing electronically faxed STEMI ECG’s on smart phones with viewing of printed ECG’s that are transmitted via traditional fax service. 120 STEMI ECG’s, which were confirmed as true STEMIs from coronary angiography and 200 consecutive NSTEMI ECG’s of patients who underwent coronary angiography at a major teaching hospital were sent in a randomised fashion
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
via a fax to email service (eFax) in PDF to be viewed directly on a smartphone with 5’+ HD screen. The transmitted ECG’s were interpreted by two independent and blinded cardiologists and classified as STEMI, including infarct territory, NSTEMI or LBBB. Four weeks later, the same cardiologists interpreted the paper ECG’s. The results were compared and correlated with cardiac catheterisation findings. Of the 120 STEMI ECG’s, the two cardiologists were able to correctly identify all 120 ECGs as STEMIs both when viewed as PDF on a smartphone and when viewing the printed ECG. The overall agreement between smartphone viewed ECGs and the printed ECGs was 100%. Localisation of infarct territory was then correlated with cardiac catheterisation findings and showed a 79% correlation on smartphone viewed ECG’s compared to 80% with printed ECG’s. ECG’s transmitted via eFax compared to traditional fax can be viewed in a more timely fashion. Coupled with the fact that the STEMI pick up rate is equivalent, and the localisation of STEMI was equivalent, we postulate that this may lead to improved clinical outcomes in patients presenting with STEMI to emergency. http://dx.doi.org/10.1016/j.hlc.2016.06.406 405 Effectiveness of Utilising Aortic Regurgitation (AR) Index to Define Peri-Prosthetic Aortic Regurgitation (periAR) Severity in Transcatheter Aortic Valve Implantation (TAVI) Patients P. Black, M. Savage, D. Murdoch, C. Raffel, D. Walters ∗ The Prince Charles Hospital, Queensland Health, Brisbane, Australia Introduction: Transcatheter aortic valve implantation (TAVI) provides a non-surgical alternative to aortic valve replacement in high risk patients with severe symptomatic aortic stenosis. Post procedural peri-prosthetic aortic regurgitation (periAR) is a known complication of TAVI and can predict mortality risk. Aortic regurgitation (AR) index ([(DBPLVEDP)/SBP] x 100) evaluates periAR grade and we sought to establish the incidence and degree of periAR severity during TAVI and 1 year outcomes. Methods: PeriAR was assessed in 172 patients undergoing TAVI with the Corevalve or Sapien prosthesis. AR index and post procedural transthoracic echocardiography (TTE) was used to analyse periAR. Results: TTE revealed 32 patients (18.6%) exhibited no periAR, 93 patients (54.1%) mild, 42 patients (24.4%) moderate and 5 patients (2.9%) had severe periAR. The Corevalve cohort demonstrated a significant association between AR index and periAR (r = -0.391 p = <0.001) (Figure 1). Patients receiving Sapien demonstrated no significant correlation (r = 0.1184 p=0.289). (Figure 2). Patients with AR index <25 had no significant increase in 1 year mortality compared with patients with AR index ≥25 (8.0% vs 9.72% p = 0.786). This was consistent on subgroup analysis: Corevalve (8.8% vs 10.71% p = 1.0) and Sapien (4.5% vs 10.53% p = 0.408). AR index
Abstracts
S174
<25 had 72% sensitivity and 47% specificity for moderate or severe periAR. Conclusions: AR index was correlated with periAR severity in patients receiving Corevalve, but not Sapien TAVI. In this cohort, assessment of AR index did not predict 1 year mortality after TAVI, possibly related to low rates of moderate and severe periAR.
http://dx.doi.org/10.1016/j.hlc.2016.06.407 406 Effects of Invasive Management and Recurrent Cardiac Events on Survival in Troponin-Negative NSTEACS (TN-NSTEACS) S. Vogrin 1,3,∗ , R. Harper 2 , A. MacIsaac 1,3 , J. Burchell 3 , B. Smith 1 , A. Scott 4 , J. Yong 4 , V. Sundararajan 1,3 1 St
Vincent’s Hospital, Melbourne, Australia Heart, Melbourne, Australia 3 The Department of Medicine, The University of Melbourne, Australia 4 Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, Australia 2 Monash
Background: In TN-NSTEACS there are no clear recommendations regarding the use of invasive coronary angiograms (ICA) to initiate the invasive management pathway. Results of most RCTs show no survival benefit in patients with invasive management, however they demonstrate high crossover rates from control to treatment groups. Objective: To assess the impact of early ICA and subsequent cardiac events on 12-month mortality after TNNSTEACS. Methods: Longitudinal study using hospital data from Victoria, 2001–2011. Discrete time survival analysis on propensity score matched samples. Results: Patients without an acute cardiac hospitalisation in the year prior to presenting emergently to a hospital with ICA facilities and surviving ≥ 48 hours were included (n=37,394). Matched sample (n=16,916) balanced on 45 factors except receipt of ICA. Risk of dying was the highest in the first month after discharge (0.0048, CI:0.0043, 0.0054) and halved by 12 months (0.002, CI:0.0016, 0.0023). Receipt of ICA was associated with 50% decreased mortality (HR 0.45, CI:0.29, 0.69); revascularisation did not show survival benefit (HR 0.97, CI:0.75, 1.25). Other factors associated with decreased survival were readmissions for AMI (HR 6.53, CI:4.54, 9.41), emergent 2nd TN-NSTEACS (HR 1.65, CI:1.29, 2.13) and emergent stable coronary artery disease (HR 1.50, CI:1.14, 1.97).
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Survival at 12 months for patients receiving ICA within 3 months after the first TN-NSTEACS (96.8%, CI: 96.3%, 97.4%) did not differ from patients who had received ICA at index (97.7%, CI:97.3%, 98.1%). Conclusions: Patients with TN-NSTEACS benefit from ICA if it is performed within the 3 months from hospital discharge. http://dx.doi.org/10.1016/j.hlc.2016.06.408 407 Ensuring the Quality in Clinical Quality Registries – Design and Implementation of Rigorous Audit Activities in the Victorian Cardiac Outcomes Registry (VCOR) A. Brennan 1,∗ , D. Dinh 1 , J. Lefkovits 1,2 , D. Stub 1,3 , R. Brien 1 , H. Carruthers 1 , N. Andrianopoulos 1 , S. Duffy 3 , R. Dick 4 , D. Clark 5 , C. Hiew 6 , G. New 7 , R. Warren 8 , J. McNeil 1 , C. Reid 1,9 1 Monash
University, Melbourne, Australia Melbourne Hospital, Melbourne, Australia 3 Alfred Hospital, Melbourne, Australia 4 Epworth Health Care, Richmond, Australia 5 The Austin Hospital, Heidelberg, Australia 6 University Hospital, Geelong, Australia 7 Box Hill Hospital, Box Hill, Australia 8 Melbourne Private Hospital, Melbourne, Australia 9 Curtin University, Perth, Australia 2 Royal
Background: In 2010 the Australian Health Ministers’ Conference endorsed the Strategic & Operating Principles for Australian Clinical Quality Registries. Encompassed within this is several key principles related to ensuring data quality, including audit activities. We report on VCOR’s methods for ensuring accurate and high quality data acquisition. Methods and Results: VCOR undertakes audit at all sites to ensure data accuracy as well as correct case ascertainment (i.e. all relevant cases entered). Case ascertainment audit occurs annually with 21 hospitals having been audited once and 5 audited twice. Overall, the missing case rate was 3.3%, ranging from 0% to 14.8%. In sites audited twice, the missing case rate dropped from 4.7% to 1.1% between audits. Overall, sites subsequently entered the identified missing cases. Data accuracy audits are undertaken in approx. 5% of cases entered once sites have been active >1 year, with plans to repeat every 3 years. Data are extracted from the VCOR online system and comprises review of 26 entered fields compared to the medical records at hospitals. Fields audited include procedural information and outcome measures, e.g. bleeding, stroke and stent thrombosis. 21 sites have been audited for data accuracy, with an overall agreement rate of 97.3%. Individualised reports outlining the results are delivered to hospitals including comparison of results between audited hospitals. Conclusion: A rigorous audit regimen adopted by VCOR has not identified any systematic omission of cases across participating hospitals in VCOR. Data accuracy is high,