Showing papers by "Derek P. Chew published in 2015"
TL;DR: The comparison of prasugrel at the time of Percutaneous Coronary Intervention or as Pretreatment at the Time of Diagnosis in Patients with Non-ST Elevation Myocardial Infarction was conducted by as mentioned in this paper.
Abstract: ACC
: American College of Cardiology
ACCOAST
: Comparison of Prasugrel at the Time of Percutaneous Coronary Intervention or as Pretreatment at the Time of Diagnosis in Patients with Non-ST Elevation Myocardial Infarction
ACE
: angiotensin-converting enzyme
ACS
: acute coronary syndromes
ACT
449 citations
01 Jan 2015
182 citations
01 Jan 2015
TL;DR: ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation were published by the European Society of Cardiology (ESC).
Abstract: ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation : The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC).
157 citations
TL;DR: The comparison of prasugrel at the time of Percutaneous Coronary Intervention or as Pretreatment at the Time of Diagnosis in Patients with Non-ST Elevation Myocardial Infarction was conducted by.
Abstract: ACC
: American College of Cardiology
ACCOAST
: Comparison of Prasugrel at the Time of Percutaneous Coronary Intervention or as Pretreatment at the Time of Diagnosis in Patients with Non-ST Elevation Myocardial Infarction
ACE
: angiotensin-converting enzyme
ACS
: acute coronary syndromes
ACT
65 citations
TL;DR: Aguilar et al. as discussed by the authors present a Guia de Practica Clinica de the Sociedad Europea de Cardiologia (ESC) that recoge the opinion of the ESC and se ha elaborado tras el estudio minucioso de los datos and la evidencia disponibles hasta la fecha.
Abstract: Los miembros del Comite de la ESC para la Elaboracion de GPC y los revisores del documento representantes de las sociedades nacionales de cardiologia aparecen listados en el apendice.
Entidades de la ESC que han participado en el desarrollo de este documento:
Asociaciones: Asociacion de Cuidados Cardiovasculares Agudos (ACCA), Asociacion Europea para la Prevencion y Rehabilitacion Cardiovascular (EACPR), Asociacion Europea de Imagen Cardiovascular (EACVI), Asociacion Europea de Intervencionismo Coronario Percutaneo (EAPCI), Asociacion de Insuficiencia Cardiaca (HFA).
Consejos: Consejo de Enfermeria Cardiovascular y Profesiones Afines (CCNAP), Consejo de Practica Cardiologica (CCP), Consejo de Cuidados Cardiovasculares Primarios (CCPC).
Grupos de Trabajo: Farmacoterapia Cardiovascular, Cirugia Cardiovascular, Fisiopatologia y Microcirculacion Coronaria, Trombosis.
El contenido de esta Guia de Practica Clinica de la Sociedad Europea de Cardiologia (ESC) se publica exclusivamente para uso personal y educativo. No se autoriza su uso comercial. No se autoriza la traduccion o reproduccion de ningun fragmento de esta guia sin la autorizacion escrita de la ESC. La autorizacion se solicitara por escrito a Oxford University Press, editorial de European Heart Journal y representante autorizado de la ESC para gestionar tales permisos.
Descargo de responsabilidad. Esta guia recoge la opinion de la ESC y se ha elaborado tras el estudio minucioso de los datos y la evidencia disponibles hasta la fecha. La ESC no es responsable en caso de que haya alguna contradiccion, discrepancia o ambiguedad entre la guia de practica clinica (GPC) de la ESC y cualquier otra recomendacion oficial o GPC publicada por autoridades relevantes de la sanidad publica, particularmente en lo que se refiere al buen uso de la atencion sanitaria y las estrategias terapeuticas. Se espera que los profesionales de la salud tengan en consideracion esta GPC a la hora de tomar decisiones clinicas, asi como al implementar estrategias medicas preventivas, diagnosticas o terapeuticas. No obstante, esta guia no anula la responsabilidad individual de cada profesional al tomar las decisiones oportunas relativas a cada paciente, de acuerdo con dicho paciente y, cuando fuera necesario, con su tutor o representante legal. Ademas, las GPC de la ESC no eximen al profesional medico de su obligacion etica y profesional de consultar y considerar atentamente las recomendaciones y las GPC actualizadas emitidas por autoridades sanitarias competentes. Es tambien responsabilidad del profesional verificar la normativa y la legislacion sobre farmacos y dispositivos medicos a la hora de prescribirlos.
Se puede consultar las declaraciones de conflicto de intereses de los expertos participantes en el desarrollo de esta guia en la pagina web de la ESC: www.escardio.org/guidelines
El texto completo solo esta disponible en PDF
31 citations
TL;DR: The EnligHTN I study shows that the multi-electrode ablation system provides a safe method of RDN in dRHT accompanied by a clinically relevant and sustained BP reduction.
30 citations
TL;DR: 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) is assessed.
Abstract: 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 ¼ 1326) were more likely to undergo coronary angiography than those presenting to non-CC hospitals (n ¼ 1031) (61.5% v 50.8%; P ¼ 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 ¼ 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%e37%) 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 longterm 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.
29 citations
TL;DR: The AGRIS trial as discussed by the authors employed a PROBE (prospective cluster [hospital-level] randomized open-label, blinded endpoint) design to evaluate objective measures of hospital performance, with clinical events adjudicated by a blinded event committee.
27 citations
TL;DR: In this article, the authors describe the gaps in evidence-based care offered to patients with acute coronary syndrome and concomitant chronic kidney disease (CKD) and show that CKD independently predicts failure to undergo CA but not failure to receive EBM or CR.
23 citations
TL;DR: Tronin elevation precipitated by non-coronary events is common and demonstrates an associations with late mortality that is analogous to spontaneous MI resulting from unstable coronary plaque, which could help inform the design of randomized clinical trials exploring the benefits and risk of therapies with established benefits in other cardiac conditions.
Abstract: Background:Myonecrosis provoked by illness unrelated to unstable coronary plaque is common, but uncertainty about a cause-effect relationship with future events challenges the appropriateness of initiating therapies known to be effective in cardiac conditions. We examined the causal relationship between troponin elevation in non-coronary diagnoses and late cardiac events using the Bradford Hills criteria for causality.Methods and results:Patients presenting acutely to South Australian public hospitals receiving at least one troponin between September 2011–September 2012 were included. Diagnoses were classified as coronary, non-coronary cardiac and non-cardiac using the International Classification of Diseases, version 10 Australian Modified, codes. The relationship between peak in-hospital troponin, using a high-sensitivity troponin T assay and adjudicated cardiac and non-cardiac mortality, and subsequent myocardial infarction (MI) was assessed using competing-risk flexible parametric survival models. Tro...
21 citations
TL;DR: To examine differences in care and inhospital course of patients with possible acute coronary syndrome in Australia and New Zealand based on whether a highly sensitive troponin assay was used at the hospital to which they presented.
Abstract: Free to read on journal website (may need to create free account first) Summary Objectives: To examine differences in care and inhospital course of patients with possible acute coronary syndrome (ACS) in Australia and New Zealand based on whether a highly sensitive (hs) troponin assay was used at the hospital to which they presented. Design, setting and patients: A snapshot study of consecutive patients presenting to hospitals in Australia and New Zealand from 14 to 27 May 2012 with possible ACS. Main outcome measures: Rates of major adverse cardiac events (inhospital death, new or recurrent myocardial infarction, stroke, cardiac arrest or worsening heart failure); association between assay type and outcome (via propensity score matching and a generalised estimating equation [GEE]; averages of the predicted outcomes among patients who were treated with and without the availability of an hs assay (via inverse probability-weighting [IPW] with regression-adjusted estimators). Results: 4371 patients with possible ACS were admitted to 283 hospitals. Over half of the hospitals (156 [55%]) reported using the hs assay and most patients (2624 [60%]) had hs tests (P = 0.004). Use of the hs assay was independent of hospital coronary revascularisation capability. Patients tested with the hs assay had more non-invasive investigations (exercise tests, stress echocardiography, stress nuclear scans, and computed tomography coronary angiography) than those tested with the sensitive assay. However, there were no differences between the groups in rates of angiography or revascularisation. All adjusted analyses showed a consistently lower rate of inhospital events, including recurrent heart failure in patients for whom the hs assay was used (GEE odds ratio, 0.75; 95% CI, 0.60–0.94; P = 0.014); IPW analysis showed a 2.3% absolute reduction in these events with the use of the hs assay (P = 0.018). Conclusion: Use of hs troponin testing of patients hospitalised with possible ACS was associated with an increased rate of non-invasive cardiac investigations and fewer inhospital adverse events.
Auckland City Hospital1, Royal Brisbane and Women's Hospital2, The George Institute for Global Health3, Liverpool Hospital4, University of Western Australia5, Waikato Hospital6, Christchurch Hospital7, Royal Melbourne Hospital8, Concord Hospital9, Canberra Hospital10, Wellington Hospital11, University of Otago12, Flinders University13, University of Auckland14
TL;DR: Overall more similarities were seen, than differences, in the management of suspected or confirmed ACS patients between Australia and New Zealand, however, in several management areas, both countries could improve the service delivery to this high-risk patient group.
Abstract: We aimed to assess differences in patient management, and outcomes, of Australian and New Zealand patients admitted with a suspected or confirmed acute coronary syndrome (ACS). We used comprehensive data from the binational Australia and New Zealand ACS 'SNAPSHOT' audit, acquired on individual patients admitted between 00.00 h on 14 May 2012 to 24.00 h on 27 May 2012. There were 4387 patient admissions, 3381 (77%) in Australia and 1006 (23%) in New Zealand; Australian patients were slightly younger (67 vs 69 years, P = 0.0044). Of the 2356 patients with confirmed ACS, Australian patients were at a lower cardiovascular risk with a lower median Global Registry Acute Coronary Events score (147 vs 154 P = 0.0008), but as likely to receive an invasive coronary angiogram (58% vs 54%, P = 0.082), or revascularisation with percutaneous coronary intervention (32% vs 31%, P = 0.92) or coronary artery bypass graft surgery (7.0% vs 5.6%, P = 0.32). Of the 1937 non-segment elevation myocardial infarction/unstable angina pectoris (NSTEMI/UAP) patients, Australian patients had a shorter time to angiography (46 h vs 67 h, P Overall more similarities were seen, than differences, in the management of suspected or confirmed ACS patients between Australia and New Zealand. However, in several management areas, both countries could improve the service delivery to this high-risk patient group.
TL;DR: The evidence-base informing the management of acute coronary syndromes (ACS) is substantial and now encapsulated in numerous local and international clinical practice guidelines, but registries of Australian and New Zealand clinical practice continue to demonstrate evidence of incomplete clinical care and sub-optimal clinical outcomes.
Abstract: The evidence-base informing the management of acute coronary syndromes (ACS) is substantial and now encapsulated in numerous local and international clinical practice guidelines. These guidelines have sought to assimilate this evidence into carefully crafted and robustly debated practice recommendations representing the foundation of modern ACS care. [1–5] Yet, registries of Australian and New Zealand clinical practice continue to demonstrate evidence of incomplete clinical care and sub-optimal clinical outcomes among many patients presenting with ACS. [6–10] Disappointingly, sequential registries spanning nearly a decade of clinical experience continue to show significant challenges in the provision of reperfusion for ST segment elevation MI, variation in rates of angiography in non-ST elevation ACS, incomplete utilisation of secondary prevention therapies and low rates of referral to cardiac rehabilitation. This inertia in the evolution of clinical practice suggests that elements beyond physician ‘‘knowledge of the evidence’’ are at play in compromising the optimal adherence to guideline recommended care. Such factors may include:
TL;DR: Re-infarction rates are altered by pharmacological strategy and stent selection in primary PCI, and may require more novel strategies such as administrative data collection for patient characteristics and key outcomes.
Abstract: Purpose of review Thrombus formation, usually on a ruptured atherosclerotic plaque, is pivotal in the pathogenesis of ST segment elevation myocardial infarction (STEMI). This thrombus formation provides the milieu for re-occlusion of the infarct-related artery, the main location of re-infarction post-STEMI. Although rates of re-infarction are lower after reperfusion by primary percutaneous coronary intervention (PCI) than after fibrinolytic therapy, re-infarction remains a major cause of morbidity and mortality. Recent findings The predominant cause of re-infarction after primary PCI is stent thrombosis. Two recent trials [A Prospective, Randomized Trial of Ambulance Initiation of Bivalirudin vs. Heparin ± Glycoprotein IIb/IIIa Inhibitors in Patients with STEMI Undergoing Primary PCI (EUROMAX) and Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI)] have each reported higher rates of stent thrombosis in the first 24 h after primary PCI in patients assigned to receive bivalirudin, which affects the balance of risks and benefit of bivalirudin post-STEMI. Also, in a subanalysis of the Platelet Inhibition And Patient Outcomes trial, ticagrelor reduces re-infarction compared with clopidogrel in patients with STEMI after primary PCI. Other nonpharmacological or mechanical interventions during primary PCI, with the exception of newer-generation drug-eluting stents in the Swedish Coronary Angiography and Angioplasty Registry, have not affected rates of re-infarction. Summary Re-infarction remains a major cause of morbidity and mortality. Re-infarction rates are altered by pharmacological strategy and stent selection in primary PCI. The design of future trials to detect possible treatment differences in relatively low event rates will provide challenges, and may require more novel strategies such as administrative data collection for patient characteristics and key outcomes.
TL;DR: Fee-for-service reimbursement may explain differences in the provision of selected guideline-advocated components of ACS care between privately insured and public patients.
Abstract: Objective The aim of the present study was to explore the association of health insurance status on the provision of guideline-advocated acute coronary syndrome (ACS) care in Australia. Methods Consecutive hospitalisations of suspected ACS from 14 to 27 May 2012 enrolled in the Snapshot study of Australian and New Zealand patients were evaluated. Descriptive and logistic regression analysis was performed to evaluate the association of patient risk and insurance status with the receipt of care. Results In all, 3391 patients with suspected ACS from 247 hospitals (23 private) were enrolled in the present study. One-third of patients declared private insurance coverage; of these, 27.9% (304/1088) presented to private facilities. Compared with public patients, privately insured patients were more likely to undergo in-patient echocardiography and receive early angiography; furthermore, in those with a discharge diagnosis of ACS, there was a higher rate of revascularisation (P < 0.001). Each of these attracts potential fee-for-service. In contrast, proportionately fewer privately insured ACS patients were discharged on selected guideline therapies and were referred to a secondary prevention program (P = 0.056), neither of which directly attracts a fee. Typically, as GRACE (the Global Registry of Acute Coronary Events) risk score rose, so did the level of ACS care; however, propensity-adjusted analyses showed lower in-hospital adverse events among the insured group (odds ratio 0.68; 95% confidence interval 0.52–0.88; P = 0.004). Conclusion Fee-for-service reimbursement may explain differences in the provision of selected guideline-advocated components of ACS care between privately insured and public patients. What is known about this topic? There is variation in the pattern of acute coronary syndrome care across Australia. What does this paper add? Clear differences in the provision of selected proven therapies for acute coronary syndrome apply independent of whether a fee is charged or not. What are the implications for practitioners? Consideration should be given to the remuneration for proven therapies for acute coronary syndrome care in preference to those not supported by the evidence base.
TL;DR: In this article, the authors investigated the impact of subspecialization on patient outcomes and concluded that the benefits of sub-specialty care seem attributable to the appropriate selection of patients who would benefit from technological innovations in care.
Abstract: BACKGROUND Inpatient management of cardiac patients by cardiologists results in reduced mortality and hospitalisation. With increasing subspecialisation of the field because of growing management complexity and use of technological innovations, the impact of sub-specialisation on patient outcomes is unclear. AIM To investigate whether management by subspecialty cardiologists impacts the outcomes of patients with subspecialty-specific diseases. METHODS All patients admitted to a tertiary centre over nine years with a diagnosis of heart failure, acute coronary syndrome (ACS) or primary arrhythmia were reviewed. The outcomes of these patients managed by cardiologists subspecialised in their admission diagnosis (heart failure specialists, interventionalists and electrophysiologists) were compared with those treated by general cardiologists. RESULTS Heart failure was diagnosed in 1704 patients, ACS in 7763 and arrhythmia in 4398. There was no difference in length of stay (LOS) (P = 0.26), mortality (P = 0.57) or cardiovascular readmissions (P = 0.50) in heart failure patients treated by general cardiologists compared with subspecialists. In ACS patients, subspecialty management was associated with reduced LOS, cardiovascular readmissions and mortality (all P < 0.05). This reduction in mortality was seen mainly in lower risk patients (P < 0.05). There was a reduction in LOS and cardiovascular readmissions in arrhythmia patients receiving subspecialty management (both P < 0.05) but no difference in mortality (P = 0.14). ACS patients managed by interventionalists were more likely to undergo coronary intervention (P < 0.05). Electrophysiologists more frequently referred patients for catheter ablation and pacemaker implantation than general cardiologists (P < 0.05). CONCLUSIONS The benefits of subspecialty care seem attributable to the appropriate selection of patients who would benefit from technological innovations in care. These results suggest that the development of healthcare systems which align cardiovascular disease with the subspecialist may be more effective.
TL;DR: This low cost intervention demonstrates that individuals who have a family history of PIHD and are at moderate or high risk of CVD can be targeted for early intervention of modifiable risk factors.
Abstract: This study aimed to increase cardiovascular disease (CVD) risk assessment in adult first degree relatives of patients with premature ischaemic heart disease (PIHD) using written and verbal advice.
TL;DR: This work investigated the safety and efficacy of the EnligHTN ablation system developed by St. Jude Medical and found it to be safe and effective.
Abstract: Renal denervation is an emerging technique for the treatment of patients with drug-resistant hypertension. Long-term results using multi-electrode systems have not been reported. We investigated the safety and efficacy of the EnligHTN ablation system developed by St. Jude Medical.
The EnligHTN
Journal Article•
TL;DR: A significant disparity in cardiovascular care is highlighted with approximately half of AMI patients not referred to CR, despite it being a key performance measure, and increased physician awareness about the benefits of CR is required.
Abstract: Background: Despite the known benefits of cardiac rehabilitation (CR) and widespread endorsement of its use, CR is vastly underutilised, with less than 30% of eligible patients participating in a CR program after a cardiac event. The current study assessed the factors independently associated with referral to CR following acute myocardial infarction (AMI).
Methods: The CR referral rate and factors associated with referral were assessed among all consecutive patients undergoing coronary angiography for AMI and surviving to hospital discharge, attending South Australian public hospitals from January 2012 [[Unable to Display Character: –]] December 2013. Data was maintained by the Coronary Angiogram Database of South Australia (CADOSA), a comprehensive registry compatible with the NCDR ® CathPCI ® Registry.
Results: Among 3,212 patients undergoing angiography for AMI, CR referral occurred in 1,530 patients (48%). Compared to patients without CR referral, these patients were younger (62±13 vs. 64±14, p 0.5), hypertension (61% vs. 64%, p>0.5), and dyslipidaemia (59% vs. 60%, p>0.5), but CR referral patients were more likely to be active smokers (40% vs. 33%, p<0.01). CR referral patients were less likely to have additional comorbidities including current dialysis (0.9% vs. 2.2%, p<0.01) and cerebrovascular disease (6.0% vs. 8.8%, p<0.01). In multivariable analyses, factors associated with increased CR referral were (c statistic 0.68): presentation with ST-elevation MI (STEMI) (1.4, 1.2-1.7, p<0.01), undergoing percutaneous coronary intervention (PCI) following angiography (1.6, 1.4-1.9, p<0.01) and younger age (1.0, 0.98-1.0, p<0.01). Prior CABG (0.6, 0.5-0.8, p<0.01) and absence of significant coronary artery disease, defined by stenosis <50%, (0.2, 0.1-0.3, p<0.01) were associated with decreased referral. Lastly, secondary prevention therapies were more often prescribed at discharge in patients with CR referral compared to patients without referral including: aspirin (93% vs. 82%, p<0.01), beta-blockers (64% vs. 61%, p<0.05), statin (92% vs. 78%, p<0.01), and ACE-inhibitor/angiotensin receptor blocker (84% vs. 74%, p<0.01).
Conclusion: This study highlights a significant disparity in cardiovascular care with approximately half of AMI patients not referred to CR, despite it being a key performance measure. STEMI presentation, younger age and undergoing PCI are associated with increased referral. Alarmingly, AMI patients not referred to CR are also less likely to receive other guideline-based therapies. Increased physician awareness about the benefits of CR is required and initiatives to overcome barriers to referral may improve the delivery of evidence-based care.