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- 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
Correspondence: david.brieger@sswahs.nsw.gov.au
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.
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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.