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| Journal of the New Zealand Medical Association,
09-July-2004, Vol 117 No 1197
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Management of patients admitted with an Acute Coronary
Syndrome in New Zealand: results of a comprehensive nationwide audit
Chris Ellis, Greg Gamble, John French, Gerald Devlin, Philip
Matsis, John Elliott, Stewart Mann, Michael Williams, Harvey White. (For the New
Zealand Acute Coronary Syndromes [NZACS] Audit Group.)
There is unequivocal evidence
that certain treatments improve the outcome of patients presenting with an
ACS.1 International and local guidelines
support intensive medical treatment, and for many patients early
revascularisation, which is of proven benefit and shown to be cost-effective in
high-risk patient groups.2–6
Comprehensive national
surveys of ACS patients have previously been attempted in several countries,
including Argentina7 and
Italy.8 Other countries such as
Britain9 and the United States of
America10 have performed less complete surveys.
In addition, some international trials and registries, such as the Global
Registry of Acute Coronary Events (GRACE)11 and
the European Heart Survey12 have attempted to
compare the treatment of ACS patients between countries and regions.
In New Zealand, both the
number and management of patients presenting with an ACS, is unknown, although
an earlier Auckland-based study provided useful demographic and outcomes data
from 1993.13 Many clinicians are unable to
optimally manage the ACS patients under their care due a limited provision of
service and a relatively low level of funding.
In May 2001, the Cardiac
Society of New Zealand supported a meeting, which invited representatives from
all major New Zealand hospitals to discuss the appropriate management of
patients with ACS. At this meeting, the need for a national audit was further
developed and endorsed as an important aspect of the strategy to improve patient
care. New Zealand has favourable characteristics to undertake a comprehensive
national survey. There is a history of good collaboration in cardiovascular
research, which is strengthened by the small specialist community across the
country, and the personal contact between clinicians.
We therefore created a
network of practicing clinicians representing every New Zealand hospital that
admits ACS patients and performed a comprehensive National audit of the
in-hospital management of all ACS patients across New Zealand. We chose to
undertake the audit in a 2-week period in the autumn of 2002, to minimise the
known influence of seasonal change on the numbers of ACS
patients.14
MethodsData
collection—A network was created—consisting of one physician
for every hospital in New Zealand that admitted ACS patients (n=36). Most
centres also co-opted one or more research nurses or registrars to assist with
data collection for the study.
The data collection form recorded patient demographics,
initial and discharge diagnosis, medication use in hospital and at discharge, as
well as investigations undertaken and invasive treatments received by patients.
The inclusion criterion for the audit was ‘a patient admitted overnight
with a suspected or definite acute coronary syndrome’.
A 2-week audit period was accepted as a compromise
between the need to collect sufficient patient numbers to obtain an accurate
representative cohort versus the ability of unfunded clinicians and nurses to
collect the consecutive patient data. We collected data from 0000 hours on
Monday 13th May to 2400 hours on Sunday
26th May 2002.
Following input from the 14 other local ethics
committees across New Zealand, ethical approval was obtained from the North
Health Ethics Committee. As an audit of current practice, individual patient
consent was not required. The ethics committees encouraged the collection of
patient names and National Health Index (NHI) numbers to assist with accurate
data collection.
Data (including revascularisation procedures) from
patients subsequently transferred to another institution are
‘attributed’ to their original admitting hospital. Patients
readmitted within the 2 weeks have all admissions included in the data; they
only represented a small % of the overall patient number. Ethnicity was
self-reported at hospital admission.
All 36 hospitals had the facilities for assessing
troponin levels. Five methods were used: troponin T [Roche] (16 hospitals),
troponin I [Abbott] (13 hospitals), troponin I [Bayer] (3 hospitals), troponin I
[Ortho] (1 hospital), ‘Rapid’ troponin T [Roche] (3 hospitals). In
order to divide non-STEMI and unstable angina patients by means of a
‘positive’ troponin,15 we defined
‘normal’ or ‘abnormal’ troponin levels using the
‘cut-off’ for ‘positive’ troponins as Troponin T [Roche]
>0.03ug/L, Troponin I
[Abbott] >0.4ug/L, Troponin
I [Bayer] >0.2ug/L, Troponin
I [Ortho] >0.08ug/L,
‘Rapid’ troponin T ‘positive’ [Roche].
Hypertension and dyslipidaemia were defined as patients
on treatment, or with a previous clinical diagnosis. Patients with diabetes
mellitus were those on diet control, oral hypoglycaemic, or insulin treatment.
Cardiogenic shock was defined as: a systolic blood pressure of <90mmHg for at
least 30 minutes, or the need for supportive measures to maintain a systolic
blood pressure of >90mmHg
with end organ hypoperfusion.16 Sustained
ventricular tachycardia was defined as >30 seconds of ventricular
tachycardia, or requiring electrical cardioversion.
Statistics—Continuous
data are summarised as median and interquartile range. Differences in
frequencies were tested using chi-squared procedures. All tests were two-tailed
and a 5% significance level was used.
Results930 patients with a suspected or
definite ACS were admitted to 36 New Zealand hospitals and enrolled in the ACS
audit over the 14-day period (Figure 1). Thirty-six patients were
readmitted—within the 2 weeks, 35 patients were admitted once and 1
patient was admitted twice (29 readmissions to the same hospital, and 7 to
another hospital). Fifty-seven patients were transferred from their admitting
hospital to another institution for further management (53 [93%] to an
intervention centre). Over the 2 weeks, one hospital had no admissions, 9
hospitals admitted 40 or more patients, and one hospital admitted 131
patients.
Figure
1. New Zealand ACS hospitals (n=36) and patient numbers (n=930)
 Patient
demographics—The median age was 69.6 (IQR 58-78, range 21-102)
years. Forty-two percent of patients were female, 81% Caucasian, 7% Maori, 2%
Indian, 1% Pacific Islander, 1% Asian, and 5% were another ethnic
group—and in 5% the ethnicity was unspecified. Baseline demographics are
shown in Table 1.
Patient
diagnoses—Using both the admission clinical diagnosis and the
measurement of a positive troponin level, we found that 101 (11%) patients
presented with a ST-segment-elevation myocardial infarction (STEMI), 287 (31%)
with a non-STEMI, 333 (36%) with unstable angina pectoris (UAP), and 209 (22%)
patients with another cardiac or medical diagnosis.
Table 1. Baseline demographics (n=930)
IQR: Interquartile range;
MI: Myocardial infarction; PCI: Percutaneous coronary intervention; CABG:
Coronary artery bypass grafting; TIA: Transient ischaemic
attack.
Medical
management—Medical treatments are shown in Table 2. Overall, 55% of
STEMI patients received thrombolytic therapy. Of 77 STEMI patients who were
admitted within 12 hours of symptom onset, 53 (69%) received thrombolytic
therapy and 3 (3.9%) received primary PCI. Sixty-four percent of non-STEMI
patients were treated with low molecular weight heparin (54% enoxaparin, 12%
daltaparin) and 8.8% unfractionated heparin. A few patients received more than
one type of heparin, 92 (32%) patients were not treated with any heparin. Three
percent of non-STEMI patients received a glycoprotein 2b/3a inhibitor, and 13%
clopidogrel therapy.
Cardiac
Investigations—Investigations are listed in Tables 2 and 3. Of the
930 patient admissions, 184 (20%) underwent an echocardiogram, 190 (20%)
received an exercise treadmill test, and 199 received (21%) a cardiac angiogram.
583 (63%) patients received neither an exercise treadmill test nor a cardiac
angiogram.
Revascularisation—Of
721 ‘definite’ ACS patients (STEMI, non-STEMI, UAP), 159 (22%)
patients underwent a cardiac angiogram, 50 (6.9%) patients received a PCI, and
25 (3.5%) patients received CABG (Tables 2 and 3).
Hospital
outcomes—Thirty-eight (4%) patients died during their hospital
admission: 14 (14%) of STEMI patients, 12 (2%) of non-STEMI/UAP patients, and 11
(5%) of ‘other cardiac or medical diagnosis’ patients. Twenty (2%)
patients had a recurrent or subsequent myocardial infarction, and 144 (16%) had
recurrent angina. Cardiogenic shock developed in 41 (4%) patients. Twenty (2%)
patients received an intra-aortic balloon pump, 12 (1%) received a temporary
pacemaker, and 2 patients received a permanent pacemaker. Six patients developed
a stroke (5 non-haemorrhagic), and 13 (1%) sustained ventricular tachycardia.
Only 1% of patients were enrolled in a research project whilst in
hospital.
Table 2. Treatments and investigations of STEMI,
Non-STEMI, and UAP patients
**Compares
STEMI/Non-STEMI/UAP Post hoc tests.
aUAP
different from Non- STEMI, Non- STEMI different from STEMI.
bSTEMI
different from Non- STEMI and UAP.
cSTEMI
different from UAP, Non- STEMI different from UAP.
dUAP
different from Non-STEMI and STEMI.
eUAP
and Non-STEMI different.
fAll
different.
gUAP
and STEMI different.
***Neither enoxaparin,
daltaparin, nor UF heparin.
PCI: Percutaneous
coronary intervention; UF: Unfractionated; CABG: Coronary artery bypass
grafting; Angio: Angiogram; ETT: Exercise treadmill test; UAP: Unstable angina
pectoris; ACE: Angiotensin converting enzyme.
Clinicians
from 13 hospitals, which admitted ACS patients exclusively to their coronary
care unit (CCU), were confident of collecting all ACS patient admissions
(n=202). 10 hospitals that admitted patients with an ACS to either a CCU or to a
medical ward were able to fully enrol these patients into the audit (n=320). 4
hospitals, which admitted patients to either the CCU or to a medical ward, were
able to enrol all CCU patients and most of the medical ward patients (n=172),
estimating that 2–5% of medical ward patients (6 patients) were missed. 9
hospitals, which admitted ACS patients to both the CCU and the medical ward,
were able to enrol all CCU patients (n=266) but none of the medical ward
patients, and missed an estimated 5 to 30% of patients (37 patients). Hence, an
estimated total of 43 ACS patients (4%) were admitted to a medical ward over the
2 weeks, and not included nor further considered in this audit.
Table 3. Investigations and invasive
treatments
PCI: Percutaneous
coronary intervention; CABG: Coronary artery bypass grafting; *Patients with
STEMI (n=101, non-STEMI (n=287), and unstable angina pectoris (n=333);
**Physician/Radiologist assessment.
DiscussionThe major strength of this study
has been the demonstration that a collaborative group of clinicians can perform
a prospective, comprehensive audit of patients admitted to 36 hospitals in New
Zealand with an ACS. Our approach has allowed clinicians to collect the data,
which we believe has resulted in an accurate collection. It also allows
clinicians to collectively have responsibility for the data. By benchmarking
current practice, the ACS audit will enable physicians to examine the provision
of equitable and good practice throughout the country. Moreover, the
infrastructure created will facilitate future audit with the goal of assessing
temporal trends and improving patient outcomes.
We identified 930 patients admitted with presentations of
STEMI (11%), non-STEMI (31%), UAP (36%), and other cardiac or medical diagnosis
(22%). The hospital management and outcomes of these patients throughout New
Zealand had not previously been known.
In-hospital
investigations: For the entire cohort, the use of a chest X-ray following
presentation with a suspected or definite ACS was 85%. The use of an
echocardiogram (20%), exercise treadmill test (20%), or cardiac angiogram (21%)
was low.
For the STEMI and non-STEMI patients (n=388), with
myocardial damage and at the highest risk, the use of echocardiography (25%) or
angiography (26%) was low, with 59% receiving neither as a method of assessing
left ventricular systolic function, which is important in risk
stratification.17
Furthermore, for the same group, the use of an exercise
treadmill test (18%) or a cardiac angiogram (26%) as methods of risk assessment
was also low—with 61% of patients not receiving either test. These levels
of investigation contrast with the recommendations of local and international
guidelines,2–6 which recommend that all
STEMI and non-STEMI patients be considered for assessment in these
ways.
International
comparisons—Previous international ACS patient
cohorts7–12 have selected different
patient populations, which limits the ability to compare these studies with the
New Zealand ACS Audit. The GRACE registry11,18
is probably the most appropriate comparator for our audit, although the
methods used to enrol patients were similar, but not identical. It was not
designed as a comprehensive national survey, rather as a collection of 95
hospitals in 14 countries in North and South America, Europe, Australia, and New
Zealand (2 sites) which has allowed comparisons to be made between countries.
Patients entered in the GRACE
registry had to be admitted with an ACS as the presumptive diagnosis and to have
>1 of the following:
electrocardiographic changes consistent with ACS, serial increases in serum
biochemical markers of cardiac necrosis, and/or documentation of coronary artery
disease.18
Reperfusion therapy,
heparin, and platelet inhibitor use—In the current audit, 77 STEMI
patients were admitted within 12 hours of symptom onset and had the most to gain
from reperfusion: 53 (69%) received thrombolytic therapy and 3 (3.9%) were
treated with PCI. In the widely spread population of New Zealand, this finding
was expected as 24-hour cover for primary PCI was routinely available at only 1
centre in New Zealand, with the 4 other public interventional centres offering
it to a variable extent. The overall level of thrombolytic therapy for STEMI
patients (55%) is consistent with data from GRACE where thrombolytic therapy use
was 47%—although primary PCI use was higher in GRACE at
18%,19 compared to 3% in the New Zealand ACS
Audit.
Some non-reperfused patients are likely to have
contraindications to treatment (although we did not specifically record
this)—but some patients will probably have missed an opportunity for
reperfusion, which has also been reported from
GRACE.20 Further study of this issue would be
helpful.
Although there will certainly be a small group of non-STEMI
patients with a clear contraindication to the use of heparin, these treatment
levels are lower than expected and may be an area where clinicians can improve
their medical treatment. Again, further study of this issue would be helpful.
All 36 hospitals had access to heparins—although not all hospitals had
access to enoxaparin, which is specified as preferable to unfractionated heparin
by the Australia and New Zealand, and the United States
Guidelines.2,6
There was a very low use of intravenous glycoprotein 2b/3a
inhibitors (3%) for the management of non-STEMI patients, despite the
recommendations of international and local guidelines, and despite the expected
9% reduction in death or myocardial
infarction.22
Many hospitals do not have glycoprotein 2b/3a inhibitor
drugs available for clinicians to use, a result of local pharmaceutical
policies. In addition, some clinicians try to ‘target’ glycoprotein
2b/3a inhibitor drugs to particularly ‘high-risk’ patients, such as
those with elevated troponins and diabetes
mellitus.22
Medically treated patients were also largely unable to
benefit from the use of clopidogrel (used in 13%)—despite a 20% reduction
in cardiovascular death, myocardial infarction or stroke demonstrated in
similarly treated patients in the Clopidogrel in Unstable Angina to Prevent
Recurrent Events (CURE) trial.23 Patients
receiving a PCI were the only group to routinely access clopidogrel.
In-hospital
revascularisation—Overall, revascularisation was undertaken in 17%
of STEMI, 11% of non-STEMI and 8% of UAP patients. We found that PCI during the
hospital admission was performed in 13%, 8%, and 4% of patients and CABG in 4%,
3% and 4% of patients, from each group. This intervention level is low compared
to figures from the GRACE Registry,11 which
reported PCI rates as being 40%, 28%, 18%, and CABG surgery rates being 4%, 10%
and 5% (Table 4 and Figure 2).
Table 4. Cardiac interventions by baseline condition:
comparison with the GRACE Registry11
STEMI: ST-segment-elevation
myocardial infarction; UAP: Unstable angina pectoris; PCI: Percutaneous coronary
intervention; CABG: Coronary artery bypass grafting.
Indeed, many STEMI, non-STEMI and UAP patients will
potentially benefit if treated with
revascularisation,2–6,24–27—and
the low levels found in the current audit are a cause of concern.
Figure
2. Cardiac interventions by baseline condition: comparison with the GRACE
Registry11
 Discharge
medications—Patients (without clear contraindications), and
discharged following a presentation with an ACS, should be routinely prescribed
aspirin—resulting in a reduction in vascular events of about
25%28 and clopidogrel with a 20% reduction for
those with a non-STEMI
presentation.23
In addition, a beta-blocker, with a reduction in risk of
death of around 20%29, and a statin, with a
reduction in risk of death of approximately 30% in 5
years,30,31 should be given to these patients.
Furthermore, an angiotensin converting enzyme (ACE) inhibitor should be given
acutely for all patients with anterior MIs, second or subsequent MIs, and for
those patients with heart failure and an ejection fraction of
<40%—resulting in a reduction of the risk of death of
25%.32
ACE-inhibitors should also be prescribed for all patients
with coronary or other vascular disease, due to their role in preventing
vascular events.33,34 In addition, other
medications may also be appropriate for some sub-groups of these
patients.
For STEMI/non-STEMI/UAP patients, the use of various
therapies at discharge (May 2002) was generally lower than the rates reported in
patients enrolled in GRACE from April 1999 to December
200011: aspirin (80–89% vs 90–95%),
beta-blockers (59–76% vs 75–81%), ACE inhibitors (39–51% vs
50–57%), and statins (52–67% vs 37–51%), respectively.
Unfortunately we did not record the presence of
contraindications for the use of secondary prevention therapies. Nevertheless,
only half of New Zealand ACS Audit patients received a statin—a
sub-optimal level,30,31
which in New Zealand has been partly due
to PHARMACs previous funding restrictions, resulting in a low level of statin
use across the community.35
The results of the Heart Protection
Study36showed a benefit for vascular patients
(individuals with prior coronary, cerebral or peripheral vascular events, or
with diabetes mellitus or hypertension, at high-risk of developing events) with
a cholesterol level of 3.5mmol/L and above, and implied that all vascular
patients should be considered for statin therapy after presentation with an
ACS.
Although there are Australia and New Zealand guidelines for
the management of patients with ACS (endorsed by the Cardiac Society of
Australia and New Zealand), it is recognised that it would be of value to have
local guidelines addressing some of the unique aspects of the New Zealand health
scene where there are restrictions to funding and the availability of various
therapies. These local, guidelines are being developed with the help of the
Cardiac Society and the New Zealand Guidelines Group.
Modern medical and revascularisation treatments enhance
patient outcomes2–6 and many have been
shown to be ‘cost-effective’. These include the use of statin
therapy following a MI,37-39 and the use of an
invasive revascularisation strategy for non-STEMI
patients.40–42 It should be emphasised
how cost-ineffective it is to
not have adequate facilities available
for use, or for them not to be used. This point must be emphasised to
politicians, health administrators, PHARMAC, physicians and the public of New
Zealand.
Study limitations include the
fact that a short audit may produce some chance findings and bias in patient
selection. Furthermore, we were reliant on local investigators to check the
accuracy of individual patient data, without there being a central system of
review. Nevertheless, this audit has revealed deficiencies with the delivery of
optimal management for ACS patients, with a low level of service provision for
this high-risk group. These data show that few hospitals in New Zealand are
practising evidence-based medicine according to local and international
guidelines.43 It is probable that this
situation results, at least in part, from both a limited central coordination of
clinical service as well as a lack of local support services.
Conclusions—There
appear to be deficiencies in the availability and use of modern medicines, as
well as inadequate facilities for appropriate investigations and
revascularisation of patients with acute coronary syndromes. Continuing audit
and feedback to local clinicians will probably help to improve the clinical
service. Furthermore, open, informed public debate needs to be encouraged as to
the level of service provision available in all regions of New Zealand. We
believe that there is an urgent need to develop a comprehensive nation-wide
strategy for patients presenting to a New Zealand hospital with an
ACS.
Author
information: Chris Ellis, Cardiologist and Senior Lecturer in Cardiology,
University of Auckland, Auckland; Gerald Devlin, Cardiologist, Waikato Hospital,
Hamilton; Philip Matsis, Cardiologist, Wellington Hospital, Wellington; John
Elliott, Cardiologist, Christchurch Hospital, Christchurch; Michael Williams,
Cardiologist, Dunedin Hospital, Dunedin; Greg Gamble, Statistician; University
of Auckland, Auckland; Stewart Mann, Associate Professor of Cardiovascular
Medicine, Wellington School of Medicine and Health Sciences, University of
Otago, Wellington; Professor John French, Liverpool Hospital, Sydney, Australia;
Professor Harvey White; Director of the Coronary Care and Green Lane
Cardiovascular Research Unit, Green Lane Cardiovascular Service Auckland City
Hospital, Auckland. (For the New Zealand Acute Coronary Syndromes (NZACS) Audit
Group.)
Acknowledgements:
The NZACS Audit Group is supported by small, unrestricted educational grants
from Aventis Pharmaceuticals Ltd and MSD Pharmaceuticals Ltd who responded to an
investigator initiated request to assist with data entry, statistical, and
administrative support. The project was, however, entirely devised and executed
by the Steering Committee with total independence from the companies above; and
endorsed by the Cardiac Society of New Zealand. All collection of data was
unfunded at local centres.
We thank these audit leaders and assistants in the
following hospitals—from north to south by region. (Patient numbers in the
study are given inside brackets.) #Chairman. *Steering Committee
member.
Auckland/Northland
(North Island)
Kawakawa
Hospital, Dr P Burgoyne, Ms S August (4),
Whangarei
Hospital, Dr B Wong, Ms K O’Keefe
(30), North Shore
Hospital,
Auckland,
Dr H Hart, Ms J Wickham (66),
Auckland
Hospital, Dr C Ellis#*, Mr G Gamble*, Ms W
Benjamin (48), Mercy
Private
Hospital,
Auckland, Dr T Clarke, (4),
Green Lane
Hospital,
Auckland,
Assoc Prof J French*, Prof H White*, Ms B Williams (26),
Ascot Private Hospital,
Auckland, Dr A Maslowski,
(0), Middlemore
Hospital, Auckland, Dr A Ko, Dr M Lund, Dr
H Oettli (40).
Waikato/Central
North Island
Thames
Hospital, Dr J Lennane, Dr Aftabuzzaman
(23), Tauranga
Hospital, Dr J Tisch, Dr G Porter, Ms V
Watts, Ms J Braid (48),
Waikato
Hospital,
Hamilton,
Dr G Devlin*, Ms D Penney (63),
Whakatane
Hospital, Dr E Edwards, Ms D Garner (13),
Rotorua
Hospital, Dr K Logan, Ms A Morley (26),
Tokoroa
Hospital, Dr P Reeve, Dr F Kanan (1),
Te Kuiti
Hospital, Dr P Reeve, Dr J Pusupati (2),
Taupo
Hospital, Dr A Ludbrook
(11), Gisborne
Hospital, Dr F Aitcheson, Ms K Weytmans
(7), Tauramunui
Hospital, Dr P Reeve, Dr R Shepherd (1),
New Plymouth Hospital,
Dr I Ternouth (28).
Wellington/Southern
North Island
Hastings
Hospital, Dr R Luke, Ms J Mackenzie (66),
Wanganui
Hospital, Dr T Thompson, Ms K Olsen (30),
Palmerston North
Hospital, Dr R Shameem (27),
Masterton
Hospital, Dr T Matthews, Ms K Lee (12),
Hutt
Hospital, Dr S Mann*, Ms A Cuthbert (19),
Wellington
Hospital, Dr P Matsis*, Ms D Middlemitch,
Ms B Scott (50),
Wakefield Private
Hospital, Wellington, Dr M Abernethy (2),
Nelson
Hospital, Dr A Hamer, Ms R Price (21),
Blenheim
Hospital, Dr M Heynike, Ms M Udy
(16).
Christchurch,
Canterbury (South Island)
Greymouth
Hospital, Dr Y Al Khairulla, Ms L Skeats
(9),
Christchurch
Hospital,
Dr J Elliott*, Prof M Richards, Ms L Campbell, Ms A Alspach (131),
Ashburton
Hospital, Dr N Abdul-Ghaffar, Ms A Smart
(11), Timaru
Hospital, Dr M Hills, Ms Maria Hammond, Ms
C Barker (16).
Dunedin,
Otago (South Island)
Oamaru
Hospital, Dr P Curzon
(4), Dunstan Hospital
Clyde, Dr G Nixon, Ms S Meaden (9),
Dunedin
Hospital, Dr MJ Williams*, Ms M McLelland
(42), Invercargill
Hospital, Dr C Renner, Dr A Maloney
(23).
Correspondence: Dr
Chris Ellis, Chairman of the NZACS Audit Group, University Department of
Medicine, 12th Floor, Services Building, Auckland City Hospital, Grafton,
Auckland 1001. Fax: (09) 302 2101; email: cj.ellis@auckland.ac.nz
References:
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