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Incidence and Predictors of 30-Day Unplanned Cardiac Readmission Following Percutaneous Coronary Intervention: Insights from the Victorian Cardiac Outcomes Registry
Abstracts
S81
Clinical Outcomes
AT (n = 25)
AC(n = 25)
P
Death
1
0
1
Revascularisation
1
2
1
Symptomatic graft failure
2
2
1
Myocardial infarction
2
3
1
...........................................
Bleeding
6 (24%)
2 (8.0%)
0.25
CTCA Outcomes
AT (n = 21)
AC(n = 20)
P
Grafts assessed
58
73
Any graft occluded
8 (14%)
9 (12%)
0.80
Arterial graft occluded
3
1
0.34
Vein graft occluded
4
8
0.54
Conclusion: Preliminary results of IMPACT show DAPT to be safe in post ACS patients undergoing CABG. No difference is apparent in clinical outcomes or graft patency at 12 months. http://dx.doi.org/10.1016/j.hlc.2017.06.085 085 Incidence and Impact of Atrial Fibrillation Post Acute Coronary Syndrome A. Bhat ∗ , G. Gan, C. Ng, A. Drescher, F. Fernandez, D. Burgess, R. Denniss, T. Tan Department of Cardiology, Blacktown Hospital, Sydney, Australia Background: Atrial fibrillation (AF) is frequently encountered in the setting of acute coronary syndromes (ACS), which can potentially impact clinical course and prognosis. This study seeks to identify the incidence of AF in patients with an ST-elevation myocardial infarct (STEMI) and non-ST elevation myocardial infarct (NSTEMI) patients, and to identify differences in clinical factors and prognosis. Methods: Consecutive patients presenting to our institution with an ACS between 2013 to 2016 were assessed for new onset AF post myocardial infarction. Demographics, comorbidities and clinical course were examined and compared between patients with STEMIs and NSTEMI. Patients with no defined coronary artery disease i.e. Takotsubo cardiomyopathy, coronary dissections or coronary spasms were excluded. Results: A total of 921 patients with acute coronary syndrome were examined. 80 (8.7%) had a STEMI and 841 (91.3%) had a NSTEMI. A total of 49 (5.3%) developed AF post infarct (5% of STEMI and 5.4% of NSTEMI patients). Key clinical differences between the two groups included age, gender, peak troponin and hypercholesterolaemia. A total of 7 patients died with no statistical difference between groups. Conclusions: There was no difference in incidence of new onset AF in patients with NSTEMI or STEMI, despite larger myocardial damage as expressed by troponin in the STEMI population possibly indicating that development of AF may be independent of infarct burden.
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
STEMI
NSTEMI
Significance (p value)
........................................... Age Male
61.2 ± 13.0
66.6 ± 14.1
0.001
60 (75%)
527 (62.7%)
0.017
Peak troponin
15201.7 ± 16120.9 3831.8 ± 8343.5 <0.0001
Peak creatinine
98 ± 68
114 ± 112
0.20
Length of stay
6.8 ± 8.5
6.5 ± 5.4
0.65
Pre-existent cardiac failure
10 (12.5%)
162 (19%)
0.087
Diabetes
30 (37.5%)
329 (39.1%)
0.44
Hypertension
44 (55%)
596 (70.9%)
0.003
Previous AMI
27 (33.8%)
371 (44%)
0.077 0.008
Hypercholesterolaemia
52 (65%)
424 (50.4%)
Preexistent AF
5 (6.3%)
94 (11.2%)
0.254
New diagnosis of AF
4 (5%)
45 (5.4%)
0.58
Death
1 (1.3%)
6 (0.7%)
0.472
http://dx.doi.org/10.1016/j.hlc.2017.06.086 086 Incidence and Predictors of 30-Day Unplanned Cardiac Readmission Following Percutaneous Coronary Intervention: Insights from the Victorian Cardiac Outcomes Registry S. Biswas 1,2,∗ , D. Dinh 2 , A. Brennan 2 , M. Tacey 2 , N. Andrianopoulos 2 , R. Brien 2 , J. Gutman 3 , A. MacIsaac 4 , C. Hiew 5 , M. Rowe 6 , R. Dick 7 , J. Amerena 8 , N. Nadarajah 9 , D. Liew 2 , D. Stub 1,2 , J. Lefkovits 2,10 , C. Reid 2,11 1 The
Alfred Hospital, Melbourne, Australia University, Melbourne, Australia 3 St. Vincent’s Private Hospital, Melbourne, Australia 4 St. Vincent’s Hospital, Melbourne, Australia 5 University Hospital Geelong, Geelong, Australia 6 Knox Private Hospital, Melbourne, Australia 7 Epworth Hospital, Melbourne, Australia 8 Geelong Private Hospital, Geelong, Australia 9 St John of God Bendigo Hospital, Bendigo, Australia 10 Cabrini Hospital, Melbourne, Australia 11 Curtin University, Perth, Australia 2 Monash
Background: Unplanned readmission to hospital after percutaneous coronary intervention (PCI) is an important problem, which results in a significant burden to the healthcare system. We sought to determine the incidence and predictors of unplanned cardiac readmission within 30 days of PCI, in a large contemporary Australian cohort.
Abstracts
S82
Methods: We prospectively collected data on 17,153 PCI cases between January 2014 and December 2015 in the multicentre Victorian Cardiac Outcomes Registry (VCOR). We identified patients with an unplanned cardiac readmission within 30 days of PCI, and determined demographic, clinical and procedural characteristics. Results: 644 (3.8%) patients had an unplanned cardiac readmission of which 94.7% had only 1 readmission. The 30-day unplanned readmission rate was higher in patients with acute coronary syndrome (ACS) compared to non-ACS patients (5.1% vs. 2.3%, p < 0.01), but similar in ST-elevation and non-ST-elevation ACS patients (5.0% vs. 5.1%, p = NS). Independent predictors of unplanned readmission included female gender, ACS presentation, severe left-ventricular systolic dysfunction, chronic kidney disease and being on chronic oral anticoagulant therapy (all p < 0.02). Patient age, low socioeconomic status and diabetes status were not associated with increased unplanned readmission (p = NS). There was also no difference in the readmission rate between public and private hospitals (3.8% vs. 3.6%, p = NS). Conclusion: While local unplanned readmission rates following PCI compare favourably with international data, over 300 patients per annum are still being unexpectedly readmitted in the first 30 days following PCI in Victoria. Targeted strategies for high-risk patients are needed to reduce this burden on both patients and the health system. http://dx.doi.org/10.1016/j.hlc.2017.06.087 087 This abstract has been withdrawn
http://dx.doi.org/10.1016/j.hlc.2017.06.088 088 Initial Single Centre Experience Implementing a Rapid Access Chest Pain Clinic B. Nkoane-Kelaeng 1,∗ , R. Lembo 2 , G. Figtree 1,2 , G. Nelson 1 , R. Kozor 1,2 1 Cardiology,
Royal North Shore Hospital, Sydney, Australia 2 Sydney Medical School, University of Sydney, Sydney, Australia Cardiac chest pain accounts for 8335 presentations to the Emergency Department at Royal North Shore Hospital (RNSH) annually and of these more than 700 are hospitalised because of intermediate risk and discharged within 1.2 days without a need for invasive investigation–a cost burden exceeding $1.5 million. A Rapid Access Chest Pain Clinic (RACPC) affords a potential mechanism of cost saving without compromise of patient safety. Aim: We report initial experiences in clinic processes, case selection, patient safety, cost analysis, outcome measures and research potential.
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Methods: Staff costs included 0.5 FTE advanced trainee and 0.5 FTE senior medical staff for a daily morning clinic. The Heart Score and standard NSW Chest Pain pathway were utilised to risk stratify patients. Results: 15 patients were seen in the first 4 weeks. All patients had clinical assessment. Functional tests were performed in 14 and CT coronary angiogram in 6. Four proceeded to elective angiography and 2 had culprit vessel stenting. No patient had acute myocardial infarction or urgent readmission. 1 stented patient stayed overnight in RNSH, therefore admission was avoided in 14 patients with a potential annual saving of $68,996. Conclusion: Initial experience of managing intermediate risk patients in a RACPC shows a reduction in admitted patients, without undermining patient safety and quality of care, plus potential cost-benefit to the healthcare system with this model of care. Exploring robust methods of identifying the appropriate cohort of patients and evaluating the impact of the clinic are potential research opportunities aiming to improve on current evidence. http://dx.doi.org/10.1016/j.hlc.2017.06.089 089 Intracoronary Thrombolysis in Patient with Large Thrombus Burden and Coronary Artery Ectasia–Case Report A. Saraswat ∗ , A. Rahman Gold Coast University Hospital, Gold Coast, Australia Coronary artery ectasia (CAE) is an uncommon but well recognised condition of abnormally dilated coronary arteries. It often causes angina and increases the risk of myocardial infarction and sudden cardiac death due to slow-flow, vasospasm, dissection and thrombosis. Currently the optimal treatment options for this condition remain undefined, although anti-platelets, anti-coagulation and calcium channel blocker use has been suggested. We present a noteworthy case of an acute inferior ST elevation myocardial infarction in a 75-year-old male with severe CAE and large thrombus burden in the right coronary artery (RCA). Primary percutaneous coronary intervention (PPCI) with balloon angioplasty restored coronary blood flow to a degree but the large thrombus burden remained. Despite attempts of manual aspiration and intracoronary administration of Glycoprotein IIb/IIIa inhibitor, there was very limited improvement in the thrombus burden. Therefore, we administered intracoronary tenecteplase at a low dose to further decrease the thrombus burden. On repeat angiography after 48 hours, the thrombus burden had significantly reduced with marked improvement in coronary blood flow. The patient experienced no major bleeding complications during his hospital stay and remains stable and asymptomatic at 30-day follow-up. In cases of myocardial infarction with large thrombus burden and failure of manual aspiration, intracoronary thrombolysis at a lower dose has been well documented in multiple studies, demonstrating safety of use in an acute set-
S81
Clinical Outcomes
AT (n = 25)
AC(n = 25)
P
Death
1
0
1
Revascularisation
1
2
1
Symptomatic graft failure
2
2
1
Myocardial infarction
2
3
1
...........................................
Bleeding
6 (24%)
2 (8.0%)
0.25
CTCA Outcomes
AT (n = 21)
AC(n = 20)
P
Grafts assessed
58
73
Any graft occluded
8 (14%)
9 (12%)
0.80
Arterial graft occluded
3
1
0.34
Vein graft occluded
4
8
0.54
Conclusion: Preliminary results of IMPACT show DAPT to be safe in post ACS patients undergoing CABG. No difference is apparent in clinical outcomes or graft patency at 12 months. http://dx.doi.org/10.1016/j.hlc.2017.06.085 085 Incidence and Impact of Atrial Fibrillation Post Acute Coronary Syndrome A. Bhat ∗ , G. Gan, C. Ng, A. Drescher, F. Fernandez, D. Burgess, R. Denniss, T. Tan Department of Cardiology, Blacktown Hospital, Sydney, Australia Background: Atrial fibrillation (AF) is frequently encountered in the setting of acute coronary syndromes (ACS), which can potentially impact clinical course and prognosis. This study seeks to identify the incidence of AF in patients with an ST-elevation myocardial infarct (STEMI) and non-ST elevation myocardial infarct (NSTEMI) patients, and to identify differences in clinical factors and prognosis. Methods: Consecutive patients presenting to our institution with an ACS between 2013 to 2016 were assessed for new onset AF post myocardial infarction. Demographics, comorbidities and clinical course were examined and compared between patients with STEMIs and NSTEMI. Patients with no defined coronary artery disease i.e. Takotsubo cardiomyopathy, coronary dissections or coronary spasms were excluded. Results: A total of 921 patients with acute coronary syndrome were examined. 80 (8.7%) had a STEMI and 841 (91.3%) had a NSTEMI. A total of 49 (5.3%) developed AF post infarct (5% of STEMI and 5.4% of NSTEMI patients). Key clinical differences between the two groups included age, gender, peak troponin and hypercholesterolaemia. A total of 7 patients died with no statistical difference between groups. Conclusions: There was no difference in incidence of new onset AF in patients with NSTEMI or STEMI, despite larger myocardial damage as expressed by troponin in the STEMI population possibly indicating that development of AF may be independent of infarct burden.
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
STEMI
NSTEMI
Significance (p value)
........................................... Age Male
61.2 ± 13.0
66.6 ± 14.1
0.001
60 (75%)
527 (62.7%)
0.017
Peak troponin
15201.7 ± 16120.9 3831.8 ± 8343.5 <0.0001
Peak creatinine
98 ± 68
114 ± 112
0.20
Length of stay
6.8 ± 8.5
6.5 ± 5.4
0.65
Pre-existent cardiac failure
10 (12.5%)
162 (19%)
0.087
Diabetes
30 (37.5%)
329 (39.1%)
0.44
Hypertension
44 (55%)
596 (70.9%)
0.003
Previous AMI
27 (33.8%)
371 (44%)
0.077 0.008
Hypercholesterolaemia
52 (65%)
424 (50.4%)
Preexistent AF
5 (6.3%)
94 (11.2%)
0.254
New diagnosis of AF
4 (5%)
45 (5.4%)
0.58
Death
1 (1.3%)
6 (0.7%)
0.472
http://dx.doi.org/10.1016/j.hlc.2017.06.086 086 Incidence and Predictors of 30-Day Unplanned Cardiac Readmission Following Percutaneous Coronary Intervention: Insights from the Victorian Cardiac Outcomes Registry S. Biswas 1,2,∗ , D. Dinh 2 , A. Brennan 2 , M. Tacey 2 , N. Andrianopoulos 2 , R. Brien 2 , J. Gutman 3 , A. MacIsaac 4 , C. Hiew 5 , M. Rowe 6 , R. Dick 7 , J. Amerena 8 , N. Nadarajah 9 , D. Liew 2 , D. Stub 1,2 , J. Lefkovits 2,10 , C. Reid 2,11 1 The
Alfred Hospital, Melbourne, Australia University, Melbourne, Australia 3 St. Vincent’s Private Hospital, Melbourne, Australia 4 St. Vincent’s Hospital, Melbourne, Australia 5 University Hospital Geelong, Geelong, Australia 6 Knox Private Hospital, Melbourne, Australia 7 Epworth Hospital, Melbourne, Australia 8 Geelong Private Hospital, Geelong, Australia 9 St John of God Bendigo Hospital, Bendigo, Australia 10 Cabrini Hospital, Melbourne, Australia 11 Curtin University, Perth, Australia 2 Monash
Background: Unplanned readmission to hospital after percutaneous coronary intervention (PCI) is an important problem, which results in a significant burden to the healthcare system. We sought to determine the incidence and predictors of unplanned cardiac readmission within 30 days of PCI, in a large contemporary Australian cohort.
Abstracts
S82
Methods: We prospectively collected data on 17,153 PCI cases between January 2014 and December 2015 in the multicentre Victorian Cardiac Outcomes Registry (VCOR). We identified patients with an unplanned cardiac readmission within 30 days of PCI, and determined demographic, clinical and procedural characteristics. Results: 644 (3.8%) patients had an unplanned cardiac readmission of which 94.7% had only 1 readmission. The 30-day unplanned readmission rate was higher in patients with acute coronary syndrome (ACS) compared to non-ACS patients (5.1% vs. 2.3%, p < 0.01), but similar in ST-elevation and non-ST-elevation ACS patients (5.0% vs. 5.1%, p = NS). Independent predictors of unplanned readmission included female gender, ACS presentation, severe left-ventricular systolic dysfunction, chronic kidney disease and being on chronic oral anticoagulant therapy (all p < 0.02). Patient age, low socioeconomic status and diabetes status were not associated with increased unplanned readmission (p = NS). There was also no difference in the readmission rate between public and private hospitals (3.8% vs. 3.6%, p = NS). Conclusion: While local unplanned readmission rates following PCI compare favourably with international data, over 300 patients per annum are still being unexpectedly readmitted in the first 30 days following PCI in Victoria. Targeted strategies for high-risk patients are needed to reduce this burden on both patients and the health system. http://dx.doi.org/10.1016/j.hlc.2017.06.087 087 This abstract has been withdrawn
http://dx.doi.org/10.1016/j.hlc.2017.06.088 088 Initial Single Centre Experience Implementing a Rapid Access Chest Pain Clinic B. Nkoane-Kelaeng 1,∗ , R. Lembo 2 , G. Figtree 1,2 , G. Nelson 1 , R. Kozor 1,2 1 Cardiology,
Royal North Shore Hospital, Sydney, Australia 2 Sydney Medical School, University of Sydney, Sydney, Australia Cardiac chest pain accounts for 8335 presentations to the Emergency Department at Royal North Shore Hospital (RNSH) annually and of these more than 700 are hospitalised because of intermediate risk and discharged within 1.2 days without a need for invasive investigation–a cost burden exceeding $1.5 million. A Rapid Access Chest Pain Clinic (RACPC) affords a potential mechanism of cost saving without compromise of patient safety. Aim: We report initial experiences in clinic processes, case selection, patient safety, cost analysis, outcome measures and research potential.
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Methods: Staff costs included 0.5 FTE advanced trainee and 0.5 FTE senior medical staff for a daily morning clinic. The Heart Score and standard NSW Chest Pain pathway were utilised to risk stratify patients. Results: 15 patients were seen in the first 4 weeks. All patients had clinical assessment. Functional tests were performed in 14 and CT coronary angiogram in 6. Four proceeded to elective angiography and 2 had culprit vessel stenting. No patient had acute myocardial infarction or urgent readmission. 1 stented patient stayed overnight in RNSH, therefore admission was avoided in 14 patients with a potential annual saving of $68,996. Conclusion: Initial experience of managing intermediate risk patients in a RACPC shows a reduction in admitted patients, without undermining patient safety and quality of care, plus potential cost-benefit to the healthcare system with this model of care. Exploring robust methods of identifying the appropriate cohort of patients and evaluating the impact of the clinic are potential research opportunities aiming to improve on current evidence. http://dx.doi.org/10.1016/j.hlc.2017.06.089 089 Intracoronary Thrombolysis in Patient with Large Thrombus Burden and Coronary Artery Ectasia–Case Report A. Saraswat ∗ , A. Rahman Gold Coast University Hospital, Gold Coast, Australia Coronary artery ectasia (CAE) is an uncommon but well recognised condition of abnormally dilated coronary arteries. It often causes angina and increases the risk of myocardial infarction and sudden cardiac death due to slow-flow, vasospasm, dissection and thrombosis. Currently the optimal treatment options for this condition remain undefined, although anti-platelets, anti-coagulation and calcium channel blocker use has been suggested. We present a noteworthy case of an acute inferior ST elevation myocardial infarction in a 75-year-old male with severe CAE and large thrombus burden in the right coronary artery (RCA). Primary percutaneous coronary intervention (PPCI) with balloon angioplasty restored coronary blood flow to a degree but the large thrombus burden remained. Despite attempts of manual aspiration and intracoronary administration of Glycoprotein IIb/IIIa inhibitor, there was very limited improvement in the thrombus burden. Therefore, we administered intracoronary tenecteplase at a low dose to further decrease the thrombus burden. On repeat angiography after 48 hours, the thrombus burden had significantly reduced with marked improvement in coronary blood flow. The patient experienced no major bleeding complications during his hospital stay and remains stable and asymptomatic at 30-day follow-up. In cases of myocardial infarction with large thrombus burden and failure of manual aspiration, intracoronary thrombolysis at a lower dose has been well documented in multiple studies, demonstrating safety of use in an acute set-