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Single Rural Referral Hospital Experience with Computed Tomography Coronary Angiogram for Evaluation of Low-to-Intermediate Risk Coronary Artery Disease
Abstracts
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119 Rural Inequity in STEMI Treatment Can Be Addressed by Implementation of the New Zealand National STEMI Pathway L. Thompson 2,∗ , K. Gagliardi 3 , T. Mowjood 1 , B. Rennie 3 , N. Fisher 1 , A. Kerr 4 , T. Smith 3 , T. Pegg 1 1 Nelson
Marlborough Health, Nelson, New
Zealand 2 University
of Auckland, Auckland, New Zealand 3 St. John, Mount Wellington Auckland, New Zealand 4 Middlemore Hospital, Auckland, New Zealand Background: Although timely reperfusion therapy is instrumental in determining treatment outcomes for STelevation myocardial infarction (STEMI) patients, the lack of a coordinated approach in regional Australasia leads to substantial delays in the delivery of time critical treatment. Methods: A collaborative treatment algorithm involving Emergency Medical Services (EMS) and secondary care aimed to deliver either primary percutaneous coronary intervention (PPCI) or pre-hospital thrombolysis with routine immediate transfer of eligible patients to a PCI centre was developed, trialled and evaluated in the predominantly rural Nelson and Marlborough region of New Zealand. Using data from ANZACS-QI and EMS; parameters including pre-hospital ECG transmission, fibrinolysis administration, device and transfer times were evaluated. Results: Sixty-seven of the 100 consecutive STEMI/presumed STEMI patients from February 2016 onwards met the eligibility criteria; the initial reperfusion strategy included PPCI (n = 36), fibrinolysis (n = 28), and medical treatment (n = 1). First medical contact (FMC) to device time for PPCI patients was 89 minutes (43-194, n = 36, 72.2% < 120 minutes), FMC to pre-hospital needle time was 44 minutes (16-78, n = 28, 23.8% < 30 minutes). FMC to arrival at a PCI centre was 75 minutes (27-278, n = 54, 66% < 90 minutes), however door-in-door-out time (DIDO) time for patients presenting to a non-PCI centre was 99 minutes (25-248, n = 9, 11.10% < 30 minutes). Conclusion: A coordinated STEMI pathway can lead to timely arrival at PCI centres and reperfusion therapy for patients that receive PPCI and reasonable FMC to pre-hospital fibrinolysis. However, poor DIDO from non-PCI centres times require further improvement to achieve equity. http://dx.doi.org/10.1016/j.hlc.2017.06.120
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120 Safety of Early Emergency Discharge in High-Sensitivity-Troponin-I (HsTnI) Negative Chest Pain Patients M. Salib 1,∗ , K. Madan 1 , P. Chandrala 2 , D. Coulshed 1 1 Nepean 2 Barts
Hospital, Sydney, Australia Heart Centre, London, United Kingdom
Background: Chest pain and suspected acute coronary syndrome (ACS) is a common presentation to the emergency department (ED) and often results in hospital admission or a prolonged ED stay, straining health resources. There is a need to achieve a balance between efficient utilisation of resources yet ensuring serious cardiac events are not missed. A significant body of evidence now exists to demonstrate that HsTn correlates with short and long-term mortality. Aim: We aim to show that discharge of patients deemed at either low or intermediate risk using HsTnI, with early assessment in an ambulatory Nepean Angina Assessment Clinic (NAAC), will improve resource utilisation whilst still providing a safe and effective service. Methods: This prospective cohort study included all patients referred to the NAAC from Nepean hospital ED. Patients were assessed by emergency medical staff employing the newly implemented chest pain pathway in conjunction with HsTnI testing (at 0 and 2 hours). A patient determined to be low or intermediate risk was subsequently referred to and re-assessed by a cardiology advanced trainee the next business day where the need for further investigations for ACS was discussed. Outcomes were measured 30 days postNAAC-enrolment via electronic medical records and a brief phone questionnaire. Results: 123 patients were included in the study, of which 5 required admission, 4 underwent revascularisation, and 2 developed symptoms of cardiac failure. No patients died, developed myocardial infarction, ventricular fibrillation/tachycardia, or cardiac arrest. Discussion: Early ED discharge of low-to-intermediate risk HsTnI-negative chest pain patients is safe provided early ambulatory follow-up. http://dx.doi.org/10.1016/j.hlc.2017.06.121 121 Single Rural Referral Hospital Experience with Computed Tomography Coronary Angiogram for Evaluation of Low-to-Intermediate Risk Coronary Artery Disease S. Sugito ∗ , J. Deane, P. Diu, S. Mylabathula Hunter New England Local Health District, Newcastle, Australia Background: Low-to-intermediate risk acute coronary syndrome (ACS) is a common presentation to rural referral hospitals who do not have on site percutaneous coronary angiography capability. They present a complex management
Abstracts
problem, given issues with prolonged length of stay waiting for referral and transport to a coronary angiography capable centre. Computed tomography coronary angiogram (CTCA) is used in Australia under Medicare Benefits Schedule item No. 57360 for patients with stable symptoms consistent with coronary ischaemia, at low-to-intermediate risk of coronary artery disease (CAD) and would have been considered for coronary angiography. Methods: We analysed forty-four consecutive patients referred for CTCA from the Maitland Hospital between April 2015 and March 2016, who were admitted following initial assessment that determined them to be of low-tointermediate risk and requiring inpatient investigation for CAD. Primary endpoint was to identify safe reduction in coronary angiography by mortality and recurrent ACS in 12 months. Results: Thirty-seven patients (84.1%) safely avoided referral for coronary angiography following normal CTCA investigation. Seven patients (15.9%) required subsequent coronary angiography, with four of those patients (9.1%) requiring percutaneous coronary intervention. 12-month mortality was zero and recurrent admission for ACS occurred in 3 (6.8%) patients. Conclusion: At rural referral hospitals without onsite coronary angiography capability, selective use of CTCA for investigation of significant CAD in low-to-intermediate risk patients with chest pain may safely avoid percutaneous coronary angiography. http://dx.doi.org/10.1016/j.hlc.2017.06.122 122 Smoking is an Over-Represented Risk Factor in Younger Patients with STEMI A. May ∗ , J. Colgan, M. William Gosford Hospital, Gosford, Australia Background: Each year, smoking costs Australia over $30 billion in social, health and economic costs. National prevalence of smoking has decreased from 19% to 15% over the past 10 years, but our local health district had the highest rate of 21% in NSW in 2016. Previous studies have shown a pronounced disproportionate increase in risk of STEMI in younger smokers, and we sought to examine this in our local health district. Methods: Database of consecutive patients with STEMI in an outer metropolitan health district since mid-2014. We analysed the difference in smoking rates and in-hospital outcomes in patients aged <50, 50-65 and >65 years. Results: Over two years, there were 323 patients with STEMI. 17 were excluded with unknown smoking status. In patients <50 years (n = 43), the incidence of current smoking was 75%, past smoking 9% and never smoking 16%. In patients 50-65 years (n = 126), current smoking was 56%, past smoking 19% and never smoking 25%. In patients >65 years (n = 137), current smoking was 24%, past smoking 34% and never smoking 42%. Other risk factors were lower in the younger cohorts (44% vs 47% vs 65%), cholesterol (40% vs 38% vs 49%) and diabetes (16% vs 20% vs 24%). The rate of
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in-hospital death was 9% (<50 years), 2% (50-65 years), and 13% (>65 years). Conclusions: Despite the decreasing national prevalence of smoking, we found current smoking was a significant risk factor for STEMI and in-hospital death, and it was the leading risk factor in younger patients. http://dx.doi.org/10.1016/j.hlc.2017.06.123 123 ST-Elevation Myocardial Infarction in an Australian Migrant Population: a Registry Based Study of Patient Treatment and Outcomes E. Rye 1,∗ , A. Lee 1 , H. Mukhtar 1 , A. Narayan 2 , R. Denniss 2 , C. Chow 2 , P. Kovoor 2 , G. Sivagangabalan 1,2 1 School of Medicine, University of Notre Dame, Sydney, Australia 2 Department of Cardiology, Westmead Hospital, Sydney, Australia
Background: Internationally a growing number of studies have identified race-related disparities in the presentation, treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI). With a diverse ethnic makeup and large migrant population Australia presents a unique microcosm in which to study the impact of migrant status and ethnicity in STEMI patients. Methods: We conducted a retrospective observational study utilising data from a clinician-initiated registry to investigate if first-generation migrants differed in presentation, treatment or outcomes following STEMI compared with the Australian-born population. The study involved 2,154 patients who presented to 12 hospitals between 2004–2012. Our main outcome measures included time to reperfusion, 30-day mortality and complications. Results: Migrants (n = 1035, 48.8%) were more likely to be older (61 vs 58yr, p < 0.001), diabetic (29.3 vs. 21.5%, p < 0.001) and have a prolonged symptom to door time (102 vs 91 min, p = 0.04). Despite lower rates of previous ischaemic heart disease (22.5 vs 26.6%, p = 0.03) migrants had more diffuse disease (3VD/LM: 29.8 vs. 22.0%, p < 0.001) and higher troponin values (3.77 vs 3.22 g/L, p = 0.01) at time of presentation. We found no significant differences in hospital treatment times, intervention types or rates. Multivariate regression identified age, diabetes, female gender and multi-vessel disease as predictors of complications and death at 30 days. Conclusion: Migrants had longer pre-hospital delays and exhibited different cardiovascular risk profiles to Australianborn patients but received comparable treatment in the acute hospital setting. Higher rates of diabetes and multi-vessel coronary artery disease were seen amongst migrant patients indicating a relatively higher risk population. http://dx.doi.org/10.1016/j.hlc.2017.06.124
S96
119 Rural Inequity in STEMI Treatment Can Be Addressed by Implementation of the New Zealand National STEMI Pathway L. Thompson 2,∗ , K. Gagliardi 3 , T. Mowjood 1 , B. Rennie 3 , N. Fisher 1 , A. Kerr 4 , T. Smith 3 , T. Pegg 1 1 Nelson
Marlborough Health, Nelson, New
Zealand 2 University
of Auckland, Auckland, New Zealand 3 St. John, Mount Wellington Auckland, New Zealand 4 Middlemore Hospital, Auckland, New Zealand Background: Although timely reperfusion therapy is instrumental in determining treatment outcomes for STelevation myocardial infarction (STEMI) patients, the lack of a coordinated approach in regional Australasia leads to substantial delays in the delivery of time critical treatment. Methods: A collaborative treatment algorithm involving Emergency Medical Services (EMS) and secondary care aimed to deliver either primary percutaneous coronary intervention (PPCI) or pre-hospital thrombolysis with routine immediate transfer of eligible patients to a PCI centre was developed, trialled and evaluated in the predominantly rural Nelson and Marlborough region of New Zealand. Using data from ANZACS-QI and EMS; parameters including pre-hospital ECG transmission, fibrinolysis administration, device and transfer times were evaluated. Results: Sixty-seven of the 100 consecutive STEMI/presumed STEMI patients from February 2016 onwards met the eligibility criteria; the initial reperfusion strategy included PPCI (n = 36), fibrinolysis (n = 28), and medical treatment (n = 1). First medical contact (FMC) to device time for PPCI patients was 89 minutes (43-194, n = 36, 72.2% < 120 minutes), FMC to pre-hospital needle time was 44 minutes (16-78, n = 28, 23.8% < 30 minutes). FMC to arrival at a PCI centre was 75 minutes (27-278, n = 54, 66% < 90 minutes), however door-in-door-out time (DIDO) time for patients presenting to a non-PCI centre was 99 minutes (25-248, n = 9, 11.10% < 30 minutes). Conclusion: A coordinated STEMI pathway can lead to timely arrival at PCI centres and reperfusion therapy for patients that receive PPCI and reasonable FMC to pre-hospital fibrinolysis. However, poor DIDO from non-PCI centres times require further improvement to achieve equity. http://dx.doi.org/10.1016/j.hlc.2017.06.120
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120 Safety of Early Emergency Discharge in High-Sensitivity-Troponin-I (HsTnI) Negative Chest Pain Patients M. Salib 1,∗ , K. Madan 1 , P. Chandrala 2 , D. Coulshed 1 1 Nepean 2 Barts
Hospital, Sydney, Australia Heart Centre, London, United Kingdom
Background: Chest pain and suspected acute coronary syndrome (ACS) is a common presentation to the emergency department (ED) and often results in hospital admission or a prolonged ED stay, straining health resources. There is a need to achieve a balance between efficient utilisation of resources yet ensuring serious cardiac events are not missed. A significant body of evidence now exists to demonstrate that HsTn correlates with short and long-term mortality. Aim: We aim to show that discharge of patients deemed at either low or intermediate risk using HsTnI, with early assessment in an ambulatory Nepean Angina Assessment Clinic (NAAC), will improve resource utilisation whilst still providing a safe and effective service. Methods: This prospective cohort study included all patients referred to the NAAC from Nepean hospital ED. Patients were assessed by emergency medical staff employing the newly implemented chest pain pathway in conjunction with HsTnI testing (at 0 and 2 hours). A patient determined to be low or intermediate risk was subsequently referred to and re-assessed by a cardiology advanced trainee the next business day where the need for further investigations for ACS was discussed. Outcomes were measured 30 days postNAAC-enrolment via electronic medical records and a brief phone questionnaire. Results: 123 patients were included in the study, of which 5 required admission, 4 underwent revascularisation, and 2 developed symptoms of cardiac failure. No patients died, developed myocardial infarction, ventricular fibrillation/tachycardia, or cardiac arrest. Discussion: Early ED discharge of low-to-intermediate risk HsTnI-negative chest pain patients is safe provided early ambulatory follow-up. http://dx.doi.org/10.1016/j.hlc.2017.06.121 121 Single Rural Referral Hospital Experience with Computed Tomography Coronary Angiogram for Evaluation of Low-to-Intermediate Risk Coronary Artery Disease S. Sugito ∗ , J. Deane, P. Diu, S. Mylabathula Hunter New England Local Health District, Newcastle, Australia Background: Low-to-intermediate risk acute coronary syndrome (ACS) is a common presentation to rural referral hospitals who do not have on site percutaneous coronary angiography capability. They present a complex management
Abstracts
problem, given issues with prolonged length of stay waiting for referral and transport to a coronary angiography capable centre. Computed tomography coronary angiogram (CTCA) is used in Australia under Medicare Benefits Schedule item No. 57360 for patients with stable symptoms consistent with coronary ischaemia, at low-to-intermediate risk of coronary artery disease (CAD) and would have been considered for coronary angiography. Methods: We analysed forty-four consecutive patients referred for CTCA from the Maitland Hospital between April 2015 and March 2016, who were admitted following initial assessment that determined them to be of low-tointermediate risk and requiring inpatient investigation for CAD. Primary endpoint was to identify safe reduction in coronary angiography by mortality and recurrent ACS in 12 months. Results: Thirty-seven patients (84.1%) safely avoided referral for coronary angiography following normal CTCA investigation. Seven patients (15.9%) required subsequent coronary angiography, with four of those patients (9.1%) requiring percutaneous coronary intervention. 12-month mortality was zero and recurrent admission for ACS occurred in 3 (6.8%) patients. Conclusion: At rural referral hospitals without onsite coronary angiography capability, selective use of CTCA for investigation of significant CAD in low-to-intermediate risk patients with chest pain may safely avoid percutaneous coronary angiography. http://dx.doi.org/10.1016/j.hlc.2017.06.122 122 Smoking is an Over-Represented Risk Factor in Younger Patients with STEMI A. May ∗ , J. Colgan, M. William Gosford Hospital, Gosford, Australia Background: Each year, smoking costs Australia over $30 billion in social, health and economic costs. National prevalence of smoking has decreased from 19% to 15% over the past 10 years, but our local health district had the highest rate of 21% in NSW in 2016. Previous studies have shown a pronounced disproportionate increase in risk of STEMI in younger smokers, and we sought to examine this in our local health district. Methods: Database of consecutive patients with STEMI in an outer metropolitan health district since mid-2014. We analysed the difference in smoking rates and in-hospital outcomes in patients aged <50, 50-65 and >65 years. Results: Over two years, there were 323 patients with STEMI. 17 were excluded with unknown smoking status. In patients <50 years (n = 43), the incidence of current smoking was 75%, past smoking 9% and never smoking 16%. In patients 50-65 years (n = 126), current smoking was 56%, past smoking 19% and never smoking 25%. In patients >65 years (n = 137), current smoking was 24%, past smoking 34% and never smoking 42%. Other risk factors were lower in the younger cohorts (44% vs 47% vs 65%), cholesterol (40% vs 38% vs 49%) and diabetes (16% vs 20% vs 24%). The rate of
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in-hospital death was 9% (<50 years), 2% (50-65 years), and 13% (>65 years). Conclusions: Despite the decreasing national prevalence of smoking, we found current smoking was a significant risk factor for STEMI and in-hospital death, and it was the leading risk factor in younger patients. http://dx.doi.org/10.1016/j.hlc.2017.06.123 123 ST-Elevation Myocardial Infarction in an Australian Migrant Population: a Registry Based Study of Patient Treatment and Outcomes E. Rye 1,∗ , A. Lee 1 , H. Mukhtar 1 , A. Narayan 2 , R. Denniss 2 , C. Chow 2 , P. Kovoor 2 , G. Sivagangabalan 1,2 1 School of Medicine, University of Notre Dame, Sydney, Australia 2 Department of Cardiology, Westmead Hospital, Sydney, Australia
Background: Internationally a growing number of studies have identified race-related disparities in the presentation, treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI). With a diverse ethnic makeup and large migrant population Australia presents a unique microcosm in which to study the impact of migrant status and ethnicity in STEMI patients. Methods: We conducted a retrospective observational study utilising data from a clinician-initiated registry to investigate if first-generation migrants differed in presentation, treatment or outcomes following STEMI compared with the Australian-born population. The study involved 2,154 patients who presented to 12 hospitals between 2004–2012. Our main outcome measures included time to reperfusion, 30-day mortality and complications. Results: Migrants (n = 1035, 48.8%) were more likely to be older (61 vs 58yr, p < 0.001), diabetic (29.3 vs. 21.5%, p < 0.001) and have a prolonged symptom to door time (102 vs 91 min, p = 0.04). Despite lower rates of previous ischaemic heart disease (22.5 vs 26.6%, p = 0.03) migrants had more diffuse disease (3VD/LM: 29.8 vs. 22.0%, p < 0.001) and higher troponin values (3.77 vs 3.22 g/L, p = 0.01) at time of presentation. We found no significant differences in hospital treatment times, intervention types or rates. Multivariate regression identified age, diabetes, female gender and multi-vessel disease as predictors of complications and death at 30 days. Conclusion: Migrants had longer pre-hospital delays and exhibited different cardiovascular risk profiles to Australianborn patients but received comparable treatment in the acute hospital setting. Higher rates of diabetes and multi-vessel coronary artery disease were seen amongst migrant patients indicating a relatively higher risk population. http://dx.doi.org/10.1016/j.hlc.2017.06.124