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Gender Differences in Survival and Readmission Following Acute Coronary Syndrome in China
Abstracts
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750 Delays in Treatment of Rural STEMI: Stoic Patients or System Delays? A. Elder 1,2,∗ , S. Dunkerton 2 , R. Arnold 2 , D. Amos 2 , A. French 2 , E. Ryan 2 , S. Faddy 3 , M. McMullen 3 1 Royal
Prince Alfred Hospital, Sydney, Australia Hospital, Orange, Australia 3 NSW Ambulance, Sydney, Australia 2 Orange
Background: Rural STEMI patients have lower rates of reperfusion and higher mortality compared to their metropolitan counterparts, in part due to the large distances and resource limitations of rural NSW. We aimed to review the contribution of patient delays in accessing timely reperfusion. Methods: A retrospective audit of STEMI patients within Western NSW LHD in 2015 was undertaken. Comparisons were made with NSW ambulance data on metropolitan STEMI patients from a single month in 2012. Results: 150 patients were diagnosed with STEMI in 2015. Of these, 49% called an ambulance and 51% presented directly to ED. For patients calling an ambulance, the median symptom-onset-to-call time was 34 min, compared to 66 min for metropolitan patients. Symptom onset to first clinical contact (FCC) was significantly longer for rural patients presenting direct to ED (median 110min) compared to those presenting via ambulance (median 72min)(p=0.037). Mean FCC time to lysis for rural ambulance was 44+/-26 min versus 60+/-33 min for ED (p=0.02). FCC was outside the thrombolysis window (12hrs) in 9% of rural patients, compared to 4% in metro patients. Table 1. Table: Symptom onset to FCC according to mode of presentation and location Symptom onset to FCC
0-30min
30-60min
60-90min
>90min
Metro Ambulance(%)
25
16
13
46
Rural Ambulance(%)
31
17
17
35
Rural ED(%)
21
13
9
56
.............................................
Conclusion: The majority of rural STEMI patients do not call an ambulance, delaying care and preventing access to pre-hospital thrombolysis. Strategies to reduce these delays are vital to address disparities in clinical outcomes for rural patients. http://dx.doi.org/10.1016/j.hlc.2016.06.753
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751 Does a Relationship Between Ankle Brachial Index and Health Status in Patients With Peripheral Artery Disease Exist? A Pilot Study C. Labrosciano ∗ , P. Cowled, R. Fitridge, J. Beltrame The University of Adelaide, Adelaide, Australia Background: Peripheral Arterial Disease (PAD) produces impaired blood flow in the peripheral circulation, which manifests as intermittent claudication and is diagnosed by Ankle Brachial Index (ABI)<0.9. ABI<0.9 is a determinant of subsequent major adverse cardiac events but its value in determining health status (HS) is unclear. HS evaluates the burden of disease reflected by patient symptoms, physical limitation and quality of life. Validated HS instruments include the Peripheral Artery Questionnaire (PAQ) and Euroqol Quality of Life Questionnaire (EQ-5D). The study’s objective was to determine whether ABI measured at diagnosis correlated with initial HS and subsequently at 3 months. Methods: Newly diagnosed PAD patients were recruited from vascular outpatients. The PAQ and EQ-5D were administered at recruitment and 3 months. Potential relationships between initial ABI and each HS score were assessed. Results: The 68 patients recruited (67(54-74) years, 66% males) had low PAQ scores initially (43.1±23.2) and at 3 months (50.9±25.9). Similarly, initial EQ-5D (68.9±18.4) and 3-month (64.0±24.2) scores were low. Moreover, no significant improvement in scores occurred over 3 months. ABI correlated weakly with the PAQ summary score (r=0.254, P=0.037) and symptoms domain (r=0.302, P=0.012) at recruitment. ABI was inversely correlated (r=-0.338, P=0.005) with the EQ-5D usual activities domain. No correlations between initial ABI and 3-month HS scores existed. Conclusion: ABI has previously been associated with major adverse cardiac events and appears to be weakly correlated with HS at diagnosis. Moreover, ABI does not appear to predict 3-month HS. Accordingly, ABI cannot be used as a surrogate for HS assessment. http://dx.doi.org/10.1016/j.hlc.2016.06.754 752 Gender Differences in Survival and Readmission Following Acute Coronary Syndrome in China E. Atkins 1,2,∗ , X. Du 3 , A. Patel 1,2,4 , C. Chow 1,2,5 , On behalf of the CPACS investigators 1 The
George Institute for Global Health, University of Sydney, Sydney, Australia 2 Sydney Medical School,University of Sydney, Sydney, Australia 3 The George Institute for Global Health, China 4 Royal Prince Alfred Hospital, Sydney, Australia 5 Westmead Hospital, Sydney, Australia
Abstracts
Introduction: Accessible evidence-based healthcare for women is an important equity issue. Differences in care following ACS admission may result in gender differences in survival and readmission. The second phase Clinical Pathways in ACS study provides an opportunity to investigate these differences in China. Methods: Patients with ACS enrolled in a clusterrandomised trial of clinical pathways for ACS management in China October 2007 to August 2010. Chi-square was used to hospital admissions at 12 months follow-up by gender. Poisson regression with log-link was used to compare in-hospital mortality by gender. The effect of gender on survival over 12 months using multivariate Cox regression adjusting for baseline characteristics. Results: Of 15140 patients, 30.6% were female. Initial admission was unstable angina for 57.0% of women (42.4% men), STEMI for 28.5% (44.3%) and non-STEMI 14.4% (13.3%). Men experienced higher rates of thrombolysis and PCI in hospital, and preventive therapy at discharge. After adjustment for age, hospital type, and diagnosis, women experienced a higher risk of death in hospital (relative risk 1.62; 95%CI 1.35-1.95). At 12 months follow-up there was a higher proportion of admissions for congestive heart failure (2.5% vs 1.5%; p<0.001) and angina (6.1% vs. 4.9%) in women. Survival analysis shows increased hazard of death at 12 months in women aged 65-74 years (HR 1.41; 95%CI 1.01-1.97), but no difference in other age groups. Conclusion: Women experience poorer in-hospital survival, and for women aged 65-74 years, poorer survival 12 months later. This highlights the importance of clinical pathways and accessible healthcare for women. http://dx.doi.org/10.1016/j.hlc.2016.06.755 753 Gender Inequalities in Cardiovascular Disease Prevention and Management in Australian Primary Health Care: Results from the TORPEDO Study K. Hyun 1,∗ , J. Redfern 1 , D. Peiris 1 , A. Patel 1 , D. Brieger 2 , D. Sullivan 3 , M. Harris 4 , M. Woodward 1 1 The
George Institute for Global Health, University of Sydney, Sydney, Australia 2 Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia 3 Department of Chemical Pathology, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia 4 Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia Background/Objectives: Previously, cardiovascular disease (CVD) was portrayed as a men’s disease. Lately, considerable effort has been made to increase awareness of women’s CVD risk. Our aim was to determine whether there is currently a gap in CVD risk factor assessment and management between women and men in Australian primary healthcare services.
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Methods: The records of 53085 routinely attending patients were extracted from 60 Australian primary healthcare services in 2012. Multivariable logistic regression models, were used to compare the rate of CVD risk factor assessment and recommended medication prescriptions between women and men. Results: Of 53085 (58% female patients), women were less often measured for the national guideline-recommended CVD risk factors than men (41% vs 46%, p<0.001). After adjusting for demographic and clinical characteristics, women were less likely to have CVD risk factors measured (odds ratio (95% confidence interval): 0.88 (0.81, 0.96)). Amongst 13294 (47% female patients) at high CVD risk, women were prescribed guideline-recommended medications at a similar rate to men (47% vs. 48%, p=0.20). Once adjusted, the odds of prescription were greater for women than men: 1.12 (1.01, 1.23). However, subgroup analyses by age (p for heterogeneity <0.001) showed that high risk women aged 35-54 years had 37% lower odds of being appropriately treated compared to the men of the same age: 0.63 (0.52, 0.77). Conclusions: Women attending primary healthcare services in Australia are less likely to have CVD risk factors assessed. Despite considerable improvements in recent years, there remain inequalities between the sexes in CVD health care in Australia. http://dx.doi.org/10.1016/j.hlc.2016.06.756 754 High Rates of Self-Reported Depression in a Rapid Access Chest Pain Clinic (RACPC) Population From a Tertiary Metropolitan Hospital S. Fathieh ∗ , J. Sheriff, A. Ng, S. Brazete, J. Gullick, D. Brieger, L. Kritharides, H. Lowe Concord Hospital, Sydney, Australia Background: High rates of depression are noted in a number of cardiovascular conditions. Local data, particularly relating to acute chest pain presentations to emergency departments, is sparse. Aims: To examine levels of depression in patients presenting to a RACPC Methods: All patients presenting to CRGH RACPC between 2008-2015 were reviewed from a dedicated database. These patients are referred following presentation to the ED with chest pain, and assessed as low risk for coronary artery disease. Patients attending the RACPC were given 1 of 2 self-reporting established depression questionnaires: from 2008-2014, the DS-SF tool, from 2015 the PHQ9 questionnaire. Results: 988 patients were referred and attended the RACPC. The mean age was 52±15 years. 58% were male. Cardiovascular risk factors included hypertension (36%), obesity (28%), current or past smoking (29%), family history of ischaemic heart disease (45%), dyslipidaemia (37%), and diabetes (12%). Out of 858 patients assessed with DS-SF tool, 152 (18%) were positive for depression. In 124 (14%) the questionnaire was not completed. Of 128 PHQ9 patients assessed with
S318
750 Delays in Treatment of Rural STEMI: Stoic Patients or System Delays? A. Elder 1,2,∗ , S. Dunkerton 2 , R. Arnold 2 , D. Amos 2 , A. French 2 , E. Ryan 2 , S. Faddy 3 , M. McMullen 3 1 Royal
Prince Alfred Hospital, Sydney, Australia Hospital, Orange, Australia 3 NSW Ambulance, Sydney, Australia 2 Orange
Background: Rural STEMI patients have lower rates of reperfusion and higher mortality compared to their metropolitan counterparts, in part due to the large distances and resource limitations of rural NSW. We aimed to review the contribution of patient delays in accessing timely reperfusion. Methods: A retrospective audit of STEMI patients within Western NSW LHD in 2015 was undertaken. Comparisons were made with NSW ambulance data on metropolitan STEMI patients from a single month in 2012. Results: 150 patients were diagnosed with STEMI in 2015. Of these, 49% called an ambulance and 51% presented directly to ED. For patients calling an ambulance, the median symptom-onset-to-call time was 34 min, compared to 66 min for metropolitan patients. Symptom onset to first clinical contact (FCC) was significantly longer for rural patients presenting direct to ED (median 110min) compared to those presenting via ambulance (median 72min)(p=0.037). Mean FCC time to lysis for rural ambulance was 44+/-26 min versus 60+/-33 min for ED (p=0.02). FCC was outside the thrombolysis window (12hrs) in 9% of rural patients, compared to 4% in metro patients. Table 1. Table: Symptom onset to FCC according to mode of presentation and location Symptom onset to FCC
0-30min
30-60min
60-90min
>90min
Metro Ambulance(%)
25
16
13
46
Rural Ambulance(%)
31
17
17
35
Rural ED(%)
21
13
9
56
.............................................
Conclusion: The majority of rural STEMI patients do not call an ambulance, delaying care and preventing access to pre-hospital thrombolysis. Strategies to reduce these delays are vital to address disparities in clinical outcomes for rural patients. http://dx.doi.org/10.1016/j.hlc.2016.06.753
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
751 Does a Relationship Between Ankle Brachial Index and Health Status in Patients With Peripheral Artery Disease Exist? A Pilot Study C. Labrosciano ∗ , P. Cowled, R. Fitridge, J. Beltrame The University of Adelaide, Adelaide, Australia Background: Peripheral Arterial Disease (PAD) produces impaired blood flow in the peripheral circulation, which manifests as intermittent claudication and is diagnosed by Ankle Brachial Index (ABI)<0.9. ABI<0.9 is a determinant of subsequent major adverse cardiac events but its value in determining health status (HS) is unclear. HS evaluates the burden of disease reflected by patient symptoms, physical limitation and quality of life. Validated HS instruments include the Peripheral Artery Questionnaire (PAQ) and Euroqol Quality of Life Questionnaire (EQ-5D). The study’s objective was to determine whether ABI measured at diagnosis correlated with initial HS and subsequently at 3 months. Methods: Newly diagnosed PAD patients were recruited from vascular outpatients. The PAQ and EQ-5D were administered at recruitment and 3 months. Potential relationships between initial ABI and each HS score were assessed. Results: The 68 patients recruited (67(54-74) years, 66% males) had low PAQ scores initially (43.1±23.2) and at 3 months (50.9±25.9). Similarly, initial EQ-5D (68.9±18.4) and 3-month (64.0±24.2) scores were low. Moreover, no significant improvement in scores occurred over 3 months. ABI correlated weakly with the PAQ summary score (r=0.254, P=0.037) and symptoms domain (r=0.302, P=0.012) at recruitment. ABI was inversely correlated (r=-0.338, P=0.005) with the EQ-5D usual activities domain. No correlations between initial ABI and 3-month HS scores existed. Conclusion: ABI has previously been associated with major adverse cardiac events and appears to be weakly correlated with HS at diagnosis. Moreover, ABI does not appear to predict 3-month HS. Accordingly, ABI cannot be used as a surrogate for HS assessment. http://dx.doi.org/10.1016/j.hlc.2016.06.754 752 Gender Differences in Survival and Readmission Following Acute Coronary Syndrome in China E. Atkins 1,2,∗ , X. Du 3 , A. Patel 1,2,4 , C. Chow 1,2,5 , On behalf of the CPACS investigators 1 The
George Institute for Global Health, University of Sydney, Sydney, Australia 2 Sydney Medical School,University of Sydney, Sydney, Australia 3 The George Institute for Global Health, China 4 Royal Prince Alfred Hospital, Sydney, Australia 5 Westmead Hospital, Sydney, Australia
Abstracts
Introduction: Accessible evidence-based healthcare for women is an important equity issue. Differences in care following ACS admission may result in gender differences in survival and readmission. The second phase Clinical Pathways in ACS study provides an opportunity to investigate these differences in China. Methods: Patients with ACS enrolled in a clusterrandomised trial of clinical pathways for ACS management in China October 2007 to August 2010. Chi-square was used to hospital admissions at 12 months follow-up by gender. Poisson regression with log-link was used to compare in-hospital mortality by gender. The effect of gender on survival over 12 months using multivariate Cox regression adjusting for baseline characteristics. Results: Of 15140 patients, 30.6% were female. Initial admission was unstable angina for 57.0% of women (42.4% men), STEMI for 28.5% (44.3%) and non-STEMI 14.4% (13.3%). Men experienced higher rates of thrombolysis and PCI in hospital, and preventive therapy at discharge. After adjustment for age, hospital type, and diagnosis, women experienced a higher risk of death in hospital (relative risk 1.62; 95%CI 1.35-1.95). At 12 months follow-up there was a higher proportion of admissions for congestive heart failure (2.5% vs 1.5%; p<0.001) and angina (6.1% vs. 4.9%) in women. Survival analysis shows increased hazard of death at 12 months in women aged 65-74 years (HR 1.41; 95%CI 1.01-1.97), but no difference in other age groups. Conclusion: Women experience poorer in-hospital survival, and for women aged 65-74 years, poorer survival 12 months later. This highlights the importance of clinical pathways and accessible healthcare for women. http://dx.doi.org/10.1016/j.hlc.2016.06.755 753 Gender Inequalities in Cardiovascular Disease Prevention and Management in Australian Primary Health Care: Results from the TORPEDO Study K. Hyun 1,∗ , J. Redfern 1 , D. Peiris 1 , A. Patel 1 , D. Brieger 2 , D. Sullivan 3 , M. Harris 4 , M. Woodward 1 1 The
George Institute for Global Health, University of Sydney, Sydney, Australia 2 Department of Cardiology, Concord Hospital, University of Sydney, Sydney, Australia 3 Department of Chemical Pathology, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia 4 Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia Background/Objectives: Previously, cardiovascular disease (CVD) was portrayed as a men’s disease. Lately, considerable effort has been made to increase awareness of women’s CVD risk. Our aim was to determine whether there is currently a gap in CVD risk factor assessment and management between women and men in Australian primary healthcare services.
S319
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Methods: The records of 53085 routinely attending patients were extracted from 60 Australian primary healthcare services in 2012. Multivariable logistic regression models, were used to compare the rate of CVD risk factor assessment and recommended medication prescriptions between women and men. Results: Of 53085 (58% female patients), women were less often measured for the national guideline-recommended CVD risk factors than men (41% vs 46%, p<0.001). After adjusting for demographic and clinical characteristics, women were less likely to have CVD risk factors measured (odds ratio (95% confidence interval): 0.88 (0.81, 0.96)). Amongst 13294 (47% female patients) at high CVD risk, women were prescribed guideline-recommended medications at a similar rate to men (47% vs. 48%, p=0.20). Once adjusted, the odds of prescription were greater for women than men: 1.12 (1.01, 1.23). However, subgroup analyses by age (p for heterogeneity <0.001) showed that high risk women aged 35-54 years had 37% lower odds of being appropriately treated compared to the men of the same age: 0.63 (0.52, 0.77). Conclusions: Women attending primary healthcare services in Australia are less likely to have CVD risk factors assessed. Despite considerable improvements in recent years, there remain inequalities between the sexes in CVD health care in Australia. http://dx.doi.org/10.1016/j.hlc.2016.06.756 754 High Rates of Self-Reported Depression in a Rapid Access Chest Pain Clinic (RACPC) Population From a Tertiary Metropolitan Hospital S. Fathieh ∗ , J. Sheriff, A. Ng, S. Brazete, J. Gullick, D. Brieger, L. Kritharides, H. Lowe Concord Hospital, Sydney, Australia Background: High rates of depression are noted in a number of cardiovascular conditions. Local data, particularly relating to acute chest pain presentations to emergency departments, is sparse. Aims: To examine levels of depression in patients presenting to a RACPC Methods: All patients presenting to CRGH RACPC between 2008-2015 were reviewed from a dedicated database. These patients are referred following presentation to the ED with chest pain, and assessed as low risk for coronary artery disease. Patients attending the RACPC were given 1 of 2 self-reporting established depression questionnaires: from 2008-2014, the DS-SF tool, from 2015 the PHQ9 questionnaire. Results: 988 patients were referred and attended the RACPC. The mean age was 52±15 years. 58% were male. Cardiovascular risk factors included hypertension (36%), obesity (28%), current or past smoking (29%), family history of ischaemic heart disease (45%), dyslipidaemia (37%), and diabetes (12%). Out of 858 patients assessed with DS-SF tool, 152 (18%) were positive for depression. In 124 (14%) the questionnaire was not completed. Of 128 PHQ9 patients assessed with