Editorials
Cardiovascular diseases
Volume 205 - Issue 3

Improving outcomes in coronary artery disease

Author:  Andrew I MacIsaac

Med J Aust 2016; 205 (3): 111-112. || doi: 10.5694/mja16.00656
Published online: 1 August 2016
Systems, procedures and policies are needed to further reduce the toll of cardiovascular disease
Download PDF (133 KB)
Share: Share on Blue Sky Share on Facebook Share on LinkedIn Share by email

Systems, procedures and policies are needed to further reduce the toll of cardiovascular disease

Although major advances have been made in many aspects of the treatment of heart disease, rates of mortality and morbidity from acute coronary syndromes (ACS) in Australia and New Zealand remain significant. The SNAPSHOT ACS study reported outcomes of patients presenting with ACS.1 The 18-month mortality for patients presenting with an ST-elevation myocardial infarction was 16.2%, 16.3% for those presenting with a non-ST-elevation myocardial infarction, and 6.8% for those with unstable angina. Although these outcomes are a substantial advance on historical data, there is still much room for improvement.2 It is therefore timely that the National Heart Foundation (NHF) and the Cardiac Society of Australia and New Zealand (CSANZ) have revised the Australian guidelines for the management of ACS (summarised in this issue of the MJA).3 The NHF, CSANZ and all involved should be congratulated on the development of these guidelines.

The revised ACS guidelines simplify the target time for myocardial reperfusion in patients presenting with an ST-elevation myocardial infarction. Primary percutaneous coronary intervention (PCI) should be performed within 120 minutes of first medical contact or within 90 minutes of presentation to a PCI-enabled hospital. Otherwise thrombolysis should be administered unless there are contraindications. Patients’ outcomes are maximised when the duration of myocardial ischaemia (ie, time from symptom onset to reperfusion) is minimised, with optimal outcomes occurring when this time is less than 120 minutes.4 Protocols to expedite thrombolysis or PCI are required to minimise treatment delays.5 Continuing public education programs are needed to raise awareness of the symptoms of a heart attack. Such campaigns have been shown to reduce Australian patients’ time to presentation.6 Pre-hospital electrocardiograms recorded by the ambulance service further reduce delays, and pre-hospital thrombolysis programs, especially for patients in remote locations, can significantly reduce ischaemia times, as reported by Khan and colleagues in this issue of the Journal.7 Additionally, the revised guidelines provide clinical assessment protocols to expedite troponin testing using highly sensitive assays to rule out myocardial infarction within 2 hours of presentation. This will particularly benefit compliance with the 4-hour National Emergency Access Target for presentations to emergency departments.8

In this issue of the Journal, May and colleagues indirectly address the appropriate use of coronary stenting (PCI) in patients with stable coronary artery disease.9 The DEFER study confirmed that subjective operator assessment of the severity of intermediate coronary artery lesions is a poor predictor of myocardial ischaemia as assessed by fractional flow reserve (FFR), an index of reduced myocardial perfusion.10 The FAME 2 trial demonstrated that the benefit of PCI in stable patients is confined to stenting lesions with an FFR < 0.80.11 FFR was used in 4.8% of coronary angiograms funded by Medicare in 2015. It is not known how many of these patients were investigated for stable coronary disease or whether these patients underwent pre-procedural stress testing as an alternative to FFR. PCI should be carefully targeted in stable coronary artery disease; it is of benefit when there is limiting angina due to a proximal coronary artery stenosis > 50%, a positive stress test demonstrating ischaemia in at least 10% of the myocardium, or an FFR < 0.80.12

Following a cardiac event, secondary prevention strategies improve outcomes.13 Secondary prevention is traditionally overseen in a cardiac rehabilitation program. Only a minority of patients attend such programs, and a significant number do not continue with guideline-recommended therapy and lifestyle modifications.14 New technologies including video conferencing and various apps may provide a mechanism to extend the reach of cardiac rehabilitation, as Gallagher and Neubeck note in this issue of the Journal.15 These technologies may enhance or replace traditional services. It is yet to be demonstrated that they will deliver on their promise. Strategies that enhance compliance with the Australian Commission on Safety and Quality in Health Care ACS standard are required.16

There is a need to enhance quality assurance by establishing registries to assess patient outcomes. The SNAPSHOT ACS study provided valuable insights into the nationwide treatment of ACS patients, and allowed the identification of treatment gaps and compliance with guidelines and standards. Such information is required to assess the impact of various treatment strategies and health care policies. The CSANZ has established the Australasian Cardiac Outcomes Registry (http://www.acor.net.au). Sustainable funding models need to be established to support the collection of risk-adjusted patient, procedural and device outcomes. It is incumbent on the cardiac community to ensure that systems, procedures and policies are developed to further reduce the toll of cardiovascular disease in an environment where outcomes are monitored and continuously assessed.

Author

  • Andrew I MacIsaac1,2
  • 1. Department of Cardiology, St Vincent's Hospital Melbourne, Melbourne, VIC
  • 2. Guest Editor, MJA Cardiology issue

Correspondence: andrew.macisaac@svha.org.au

Competing interests

No relevant disclosures.

References

Linked content

  • Podcast with A/Prof Andrew MacIsaac

  • Video with A/Prof Andrew MacIsaac

Provenance: Commissioned; externally peer reviewed.

View this article on Wiley Online Library