Connect
MJA
MJA

Survival after an acute coronary syndrome: 18-month outcomes from the Australian and New Zealand SNAPSHOT ACS study

David B Brieger, Derek PB Chew, Julie Redfern, Chris Ellis, Tom G Briffa, Tegwen E Howell, Bernadette Aliprandi-Costa, Carolyn M Astley, Greg Gamble, Bridie Carr, Christopher JK Hammett, Neville Board and John K French
Med J Aust 2015; 203 (9): 368. || doi: 10.5694/mja15.00504

Summary

Objectives: To assess the impact of the availability of a catheterisation laboratory and evidence-based care on the 18-month mortality rate in patients with suspected acute coronary syndromes (ACS).

Design, setting and participants: Management and outcomes are described for patients enrolled in the 2012 Australian and New Zealand SNAPSHOT ACS audit. Patients were stratified according to their presentation to hospitals with or without cardiac catheterisation facilities. Data linkage ascertained patient vital status 18 months after admission. Descriptive and Cox proportional hazards analyses determined predictors of outcomes, and were used to estimate the numbers of deaths that could be averted by improved application of evidence-based care.

Main outcome measures: Mortality for ACS patients from admission to 18 months after admission.

Results: Definite ACS patients presenting to catheterisation-capable (CC) hospitals (n = 1326) were more likely to undergo coronary angiography than those presenting to non-CC hospitals (n = 1031) (61.5% v 50.8%; P = 0.0001), receive timely reperfusion (for ST elevation myocardial infarction (STEMI) patients: 45.2% v 19.2%; P < 0.001), and be referred for cardiac rehabilitation (57% v 53%; P = 0.05). All-cause mortality over 18 months was highest for STEMI (16.2%) and non-STEMI (16.3%) patients, and lowest for those presenting with unstable angina (6.8%) and non-cardiac chest pain (4.8%; P < 0.0001 for trend). After adjustment for patient propensity to present to a CC hospital and patient risk, presentation to a CC hospital was associated with 21% (95% CI, 2%–37%) lower mortality than presentation to a non-CC hospital. This mortality difference was attenuated after adjusting for delivery of evidence-based care.

Conclusion: In Australia and New Zealand, the availability of a catheterisation laboratory appears to have a significant impact on long-term mortality in ACS patients, which is still substantial. This mortality may be reduced by improvements in evidence-based care in both CC and non-CC hospitals.

Please login with your free MJA account to view this article in full

  • David B Brieger1
  • Derek PB Chew2
  • Julie Redfern3
  • Chris Ellis4
  • Tom G Briffa5
  • Tegwen E Howell3
  • Bernadette Aliprandi-Costa6
  • Carolyn M Astley2
  • Greg Gamble8
  • Bridie Carr9
  • Christopher JK Hammett10
  • Neville Board11,12
  • John K French12,13

  • 1 Concord Repatriation General Hospital, Sydney, NSW
  • 2 Flinders Medical Centre, Adelaide, SA
  • 3 The George Institute for Global Health, University of Sydney, Sydney, NSW
  • 4 Auckland City Hospital, Auckland, New Zealand
  • 5 The University of Western Australia, Perth, WA
  • 6 University of Sydney, Sydney, NSW
  • 7 Flinders University, Adelaide, SA
  • 8 University of Auckland, Auckland, New Zealand
  • 9 Cardiac Network Agency for Clinical Innovation, Sydney, NSW
  • 10 Royal Brisbane and Women's Hospital, Brisbane, QLD
  • 11 Australian Commission on Safety and Quality in Health Care, Sydney, NSW
  • 12 Liverpool Hospital, Sydney, NSW
  • 13 University of New South Wales, Sydney, NSW


Acknowledgements: 

We acknowledge the contributions of all the SNAPSHOT investigators, listed in the online to this article.

Competing interests:

David Brieger sits on the advisory boards of AstraZeneca Australia, Boehringer Ingelheim Australia, Bayer Australia, Pfizer, and BMS Australia; he has received research funding from AstraZeneca Australia, Sanofi Aventis Australia, Merck Schering Plough Australia, and Boehringer Ingelheim Australia; lecturing fees from AstraZeneca Australia and Bayer Australia; and travel assistance from Bayer Australia and Boehringer Ingelheim Australia. Derek P. Chew has received lecturing fees from AstraZeneca Australia and the educational program Heart.org. Tom Briffa has received a grant-in-aid and travel support from the Western Australia Department of Health. Tegwen Howell has received travel assistance from Heart Foundation Australia. Greg Gamble has received a grant from the Auckland Greenlane Fund. Chris Hammett is a consultant to Bayer Australia and Eli Lilly Australia, and has received lecturing fees from Boehringer Ingelheim and Eli Lilly Australia, and travel assistance from AstraZeneca Australia, Bayer Australia, Boehringer Ingelheim Australia, Eli Lilly Australia, Schering Plough Australia, and Abbott Medical Australia. John French sits on the advisory boards of Sanofi Aventis Australia, AstraZeneca Australia, Eli Lilly Australia and Boehringer Ingelheim Australia, and holds a grant-in-aid from The Medicines Company.

  • 1. Australian Institute of Health and Welfare. Cardiovascular disease: Australian facts 2011. Canberra: AIHW, 2011. (AIHW Cat. No. CVD 53). http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737418530 (accessed Aug 2015).
  • 2. Brieger DB, Redfern J. Contemporary themes in acute coronary syndrome management: from acute illness to secondary prevention. Med J Aust 2013; 199: 174-178. <MJA full text>
  • 3. Peterson ED, Ohman EM, Brindis RG, et al. Development of systems of care for ST-elevation myocardial infarction patients: evaluation and outcomes. Circulation 2007; 116: e64-e67.
  • 4. Walters DL, Aroney CN, Chew DP, et al. Variations in the application of cardiac care in Australia. Med J Aust 2008; 188: 218-223. <MJA full text>
  • 5. Alter DA, Naylor CD, Austin PC, Tu JV. Long-term MI outcomes at hospitals with or without on-site revascularization. JAMA 2001; 285: 2101-2108.
  • 6. Halabi AR, Beck CA, Eisenberg MJ, et al. Impact of on-site cardiac catheterization on resource utilization and fatal and non-fatal outcomes after acute myocardial infarction. BMC Health Serv Res 2006; 6: 148.
  • 7. Wright SM, Daley J, Peterson ED, Thibault GE. Outcomes of acute myocardial infarction in the Department of Veterans Affairs: does regionalization of health care work? Med Care 1997; 35: 128-141.
  • 8. Chen J, Krumholz HM, Wang Y, et al. Differences in patient survival after acute myocardial infarction by hospital capability of performing percutaneous coronary intervention: implications for regionalization. Arch Internal Med 2010; 170: 433-439.
  • 9. Selby JV, Fireman BH, Lundstrom RJ, et al. Variation among hospitals in coronary-angiography practices and outcomes after myocardial infarction in a large health maintenance organization. N Engl J Med 1996; 335: 1888-1896.
  • 10. Pilote L, Califf RM, Sapp S, et al. Regional variation across the United States in the management of acute myocardial infarction. N Engl J Med 1995; 333: 565-572.
  • 11. Every NR, Parsons LS, Fihn SD, et al. Long-term outcome in acute myocardial infarction patients admitted to hospitals with and without on-site cardiac catheterization facilities. Circulation 1997; 96: 1770-1775.
  • 12. Krumholz HM, Chen J, Murillo JE, et al. Admission to hospitals with on-site cardiac catheterization facilities: impact on long-term costs and outcomes. Circulation 1998; 98: 2010-2016.
  • 13. Australian Commission on Safety and Quality in Health Care. Acute coronary syndromes clinical care standard. Sydney: ACSQHC, 2014. http://www.safetyandquality.gov.au/wp-content/uploads/2014/12/Acute-Coronary-Syndromes-Clinical-Care-Standard.pdf (accessed Aug 2015).
  • 14. New Zealand Ministry of Health. Diabetes and cardiovascular disease quality improvement plan. Wellington: Ministry of Health, 2007. https://www.health.govt.nz/system/files/documents/publications/diabetes-cardio-quality-improvement-plan-feb08-v2.pdf (accessed Aug 2015).
  • 15. Ellis C, Gamble G, French J, et al. Management of patients admitted with an acute coronary syndrome in New Zealand: results of a comprehensive nationwide audit. N Z Med J 2004; 117: 953.
  • 16. Ellis C, Gamble G, Hamer A, et al. Patients admitted with an acute coronary syndrome (ACS) in New Zealand in 2007: results of a second comprehensive nationwide audit and a comparison with the first audit from 2002. N Z Med J 2010; 123: 25-43.
  • 17. Chew DP, French J, Briffa TG, et al. Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study. Med J Aust 2013; 199: 185-191. <MJA full text>
  • 18. Fox KAA, Dabbous OH, Goldberg RJ, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ 2006; 333: 1091.
  • 19. Aroney CN, Aylward P, Kelly AM, et al. National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184 (8 Suppl): S1-S30. <MJA full text>
  • 20. Fox KAA, Anderson FA, Goodman SG, et al. Time course of events in acute coronary syndromes: implications for clinical practice from the GRACE registry. Nat Clin Pract Cardiovasc Med 2008; 5: 580-589.
  • 21. Armstrong PW, Fu Y, Chang WC, et al. Acute coronary syndromes in the GUSTO-IIb trial: prognostic insights and impact of recurrent ischemia. Circulation 1998; 98: 1860-1868.
  • 22. Fox KAA, Carruthers KF, Dunbar DR, et al. Underestimated and under-recognized: the late consequences of acute coronary syndrome (GRACE UK-Belgian Study). Eur Heart J 2010; 31: 2755-2764.
  • 23. Cullen L, French JK, Briffa TG, et al. Availability of highly sensitive troponin assays and acute coronary syndrome care: insights from the SNAPSHOT registry. Med J Aust 2015; 202: 36-39. <MJA full text>
  • 24. Every NR, Larson EB, Litwin PE, et al. The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. N Engl J Med 1993; 329: 546-551.
  • 25. Brieger D, Aliprandi-Costa B. Developments in procedural and disease registries: a focus on coronary artery disease. Curr Opin Cardiol 2013; 28: 405-410.
  • 26. Hutchison AW, Malaiapan Y, Jarvie I, et al. Prehospital 12-lead ECG to triage ST-elevation myocardial infarction and emergency department activation of the infarct team significantly improves door-to-balloon times: ambulance Victoria and MonashHEART Acute Myocardial Infarction (MonAMI) 12-lead ECG project. Circ Cardiovasc Interv 2009; 2: 528-534.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Responses are now closed for this article.