Invasive management and late clinical outcomes in contemporary Australian management of acute coronary syndromes: observations from the ACACIA registry

Abstract

Objective: To describe the impact of invasive management on 12‐month survival among patients with suspected acute coronary syndrome (ACS) in Australia. Design and setting: Prospective nationwide multicentre registry. Patients: Patients presenting to 24 metropolitan and 15 non‐metropolitan hospitals with ST‐segment‐elevation myocardial infarction (STEMI), and high‐risk and intermediate‐risk non‐ST‐segment‐elevation ACS (NSTEACS) between 1 November 2005 and 31 July 2007. Main outcome measures: Death, myocardial infarction (MI) or recurrent MI, revascularisation and stroke at 12 months. Results: Among 3402 patients originally enrolled, vital status at 12 months was available for 3393 (99.7%). Patients from non‐metropolitan areas (810) constituted 23.9% of patients. Early invasive management was more commonly undertaken among patients with STEMI (STEMI, 89.7% v non‐STEMI, 70.8% v unstable angina, 44.8% v stable angina, 35.8%; P < 0.001). Factors most associated with receiving invasive management included admission with suspected STEMI or high‐risk NSTEACS, being male and the hospital having an onsite cardiac surgical service. Overall mortality by 12 months among patients with STEMI, non‐STEMI, unstable angina and stable angina was 8.0%, 10.5%, 3.3%, and 3.7% (P < 0.001), respectively. After adjusting for a propensity model predicting early invasive management and other known confounders, early invasive management was associated with a 12‐month mortality hazard ratio of 0.53 (95% CI, 0.34–0.84, P = 0.007). Conclusions: A substantial burden of late morbidity and mortality persists among patients with ACS within contemporary Australian clinical practice. Under‐use of invasive management may be associated with an excess in 12‐month mortality, suggesting the need for more use of invasive management among these patients.

Current discharge management of acute coronary syndromes: baseline results from a national quality improvement initiative

“…These findings are consistent with those of the ACACIA study. 14 As reported previously, patients taking beta-blockers and all four guideline-recommended medications decreased between discharge and the patient survey at 3 months. The main reason for discontinuing medications during this period was the 'GP stopped it' (44%).…”

The invasive approach to acute coronary syndrome: true promise or false premise?

“…Firstly, the 1-year mortality in the ICTUS study was 2.5%, which was lower than the 1-year mortality in typical Australian patients with NSTEACS (10.5% for NSTEMI and 3.3% for unstable angina), 8 indicating that patients in the ICTUS trial were not high-risk patients.…”

Evidence-to-practice gaps in the management of community-dwelling Australian patients with ischaemic heart disease

“…5 Despite the proven mortality and morbidity gains from combination treatment, evidence-to-practice gaps persist. 4,[7][8][9][10][11][12] With increased use of these proven treatments for secondary prevention, a further 104 lives could be saved and 191 recurrent ischaemic events prevented for every 10 000 MI presentations. 13 Disparities in medication use in some clinical and demographic patient subgroups have been identified internationally 14,15 ; however, Australian research has been inadequate, lacking data pertaining to long-term medication persistence, and focusing largely on patients with ACS.…”