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Acute Coronary Syndrome patients in New Zealand receive less
invasive management when admitted to hospitals without invasive
facilities
Chris Ellis, Gerald Devlin, Philip Matsis, John Elliott,
Michael Williams, Greg Gamble, Stewart Mann, John French, Harvey White. (For the
New Zealand Acute Coronary Syndromes [NZACS] Audit Group.)
Recent clinical trials have
demonstrated that ‘high-risk’ acute coronary syndrome (ACS) patients
benefit from vigorous medical management1–5
and an invasive revascularisation
strategy.6–10 Local and international
guidelines have recommended the benefits of this
strategy.11–15
Patients
presenting with an ST-segment-elevation myocardial infarction (STEMI) should
undergo urgent reperfusion of the culprit vessel, using thrombolytic therapy or
primary percutaneous coronary intervention (PCI), in addition to adjunctive
antithrombotic therapy with combinations of aspirin, heparin, and
clopidogrel.11,12
Patients presenting with
unstable angina pectoris (UAP)/Non-STEMI should receive
‘passivation’ of the culprit lesion also using combinations of
aspirin, heparin, a glycoprotein 2b/3a inhibitor, and
clopidogrel.13–15 They should receive
early invasive management6–10 if they are
troponin positive, have dynamic ST segment changes, have an intermediate or high
TIMI-risk score,16,17 ongoing ischaemia or
haemodynamic instability, diabetes, or other features of a worse
outcome.18 These optimal management strategies
have wide-ranging implications for a national programme for the treatment of ACS
patients.
We aimed to determine whether
patients admitted to a hospital not equipped with surgical and percutaneous
revascularisation capabilities were able to access interventional management to
the same extent as patients admitted directly to such centres, and we compared
these rates with international registries. We used data from a comprehensive
national audit from each New Zealand hospital (n=36) that admitted such patients
during a 14-day period in May 2002.19
MethodsData
collection—The development of the New Zealand Acute Coronary
Syndrome (NZACS) Audit Group and the methodology for the national audit, which
was supported by the Cardiac Society of New Zealand, has been published
elsewhere.19 The inclusion criterion for the
audit was ‘a patient admitted overnight with a suspected or definite acute
coronary syndrome’. An extensive four-page case report form was used to
obtain patient demographics, initial and discharge diagnosis, medication use in
hospital and at discharge, as well as investigations undertaken and invasive
treatments received by patients. Ethnicity was self-reported at hospital
admission.
Data from the NZACS Audit was used to compare
patients’ presentation and management at intervention centres (5 public
hospitals and 3 private hospitals), with non-intervention centres (28 public
hospitals) [Table 1]. An additional 5 public hospitals in the non-intervention
centres had the ability to perform a cardiac angiogram, without percutaneous
intervention or coronary artery bypass grafting (CABG) surgery. Cardiac
angiography, PCI, and CABG surgery was also performed at a private hospital in
Christchurch; however, this hospital does not plan to admit ACS patients and
hence is not further considered with this audit. Investigations and
revascularisation of transferred patients was attributed to the referring
centre. The data was collected from 0000 hours on Monday
13th May to 2400 hours on Sunday
26th May 2002.
Statistics:
Continuous data were summarised as median and interquartile range (IQR).
Differences in frequencies were tested using standard chi-squared procedures.
All tests were two-tailed and a 5% significance level was maintained
throughout.
ResultsAdmissions
and transfers—Over the 14-day period, 318 suspected or definite ACS
patients were admitted to an intervention centre and 612 were admitted to a
non-intervention centre. Of these, 36 patients were readmitted within the 2
weeks (35 patients readmitted once, and 1 patient readmitted twice) and 57
patients were transferred to another institution for further management (93% to
an intervention centre). Data from patients transferred were attributed only to
the hospital to which they were initially admitted (Table 1).
Table 1. Admissions and transfers to Intervention and
Non-Intervention Centres.
PCI: Percutaneous coronary intervention; CABG: Coronary
artery bypass grafting.
Patients admitted to each type of hospital were the same age
(median 70 years, p=0.88) with similar risk factors, but at a non-intervention
centre they were more likely to be Maori (8.2% vs 3.8%, p=0.0063) [Table 2].
Patients admitted to a non-intervention hospital were more likely to have had a
prior MI, (38% vs 28%, p=0.003) but less likely to have previously undergone a
cardiac angiogram (26% vs 28%, p=0.02) or PCI (9.6% vs 14%, p=0.03).
Table 2. Baseline demographics
MI: Myocardial infarction; PCI: Percutaneous coronary
intervention; CABG: Coronary artery bypass grafting; TIA: Transient ischaemic
attack.
In-hospital
investigations—Overall, patients admitted to a non-intervention
centre were more likely to have had a chest X-ray (88% vs 81%, p<0.0024), but
had the same rates of exercise treadmill tests (20% vs 22%, p=0.39) as patients
admitted to an intervention centre (Table 3). Patients admitted to
non-intervention centres were less likely to receive an echocardiogram (17% vs
26%, p<0.0005), or a cardiac angiogram (17% vs 30%, p<0.0001), or either
test (68% vs 53%, p=0.0001) for cardiac risk assessment. For patients with a
definite ACS (STEMI, Non-STEMI, UAP, n=721), those admitted to a
non-intervention centre received less angiography (17% vs 32%, p<0.0001)
(Table 4).
Table 3. Investigations and revascularisations (all
patients: n=930)
PCI: Percutaneous coronary intervention; CABG: Coronary
artery bypass grafting.
Table 4. Investigations and Revascularisations
(Patients with a ‘definite’ ACS: STEMI, non-STEMI, UAP:
n=721)
PCI: Percutaneous coronary intervention; CABG: Coronary
artery bypass grafting.
In-hospital
treatments—Only two patients admitted to an intervention centre,
and one patient rapidly transferred from a non-intervention centre, received a
primary PCI. Intervention centre STEMI patients received the same rate of
thrombolytic therapy as non-intervention centre STEMI patients (50% vs 57%,
p=0.65)—including those patients admitted within 12 hours of symptom onset
(67% vs 69%, p=0.99). (Table 5).
Table 5. Investigations and treatments of
ST-segment-elevation myocardial infarction (STEMI) (n=101) and Non-STEMI (n=287)
patients according to hospital type
*P<0.05: Comparisons between same patient
groups.
‡Comparing
intervention with non-intervention groups.
+Neither enoxaparin,
daltaparin or UF heparin.
**In days (median and Interquartile range).
PCI: Percutaneous coronary intervention; UF:
Unfractionated; ETT: Exercise treadmill test; CABG: Coronary artery bypass
grafting; Angio: Cardiac angiogram; ACE: Angiotensin converting
enzyme.
Patients with non-STEMI
admitted to an intervention centre were as likely to receive some type of
heparin treatment (70% vs 67%, p=NS), but more likely to receive enoxaparin (67%
vs 48%, p<0.05) [Table 5]. The use of glycoprotein 2b/3a inhibitors was low
in patients admitted to either group of hospitals (3% vs 2.6%, p=NS).
UAP patients had similar
medical management when admitted to either an intervention or a non-intervention
centre (Table 6), although they were more likely to receive enoxaparin (47% vs
32%, p<0.05) at an intervention centre. The use of clopidogrel was low for
patients at the non-intervention centres,
probably largely reflecting different levels of PCI treatment.
Table 6. Investigations and treatments of unstable
angina pectoris [UAP] (n=333) patients according to hospital type
*P<0.05: Comparisons
between same patient groups.
+
Neither enoxaparin, daltaparin or UF heparin.
** Length of stay (In days
and Interquartile range).
UF: Unfractionated, ETT:
Exercise treadmill test, CABG: Coronary artery bypass grafting, Angio:
Angiogram, ACE: Angiotensin Converting enzyme.
PCI was performed significantly less for all patients
(n=721) with a definite ACS admitted to a non-intervention centre vs an
intervention centre: (3% vs 14%, p<0.0001) [Table 4]. This finding was
consistent across the 3 patient groups: STEMI (8% vs 27%, p<0.05), non-STEMI
(2.6% vs 20%, p<0.05), UAP patients (2% vs 7%, p<0.05) [Tables 5 and 6].
CABG rates during hospital admission were not different between different
centres: STEMI patients (2.7% vs 7.7%, p=NS), non-STEMI (2.1% vs 4.2%, p=NS),
UAP patients (3.4% vs 4.7%, p=NS) for non-intervention vs intervention
centres.
Discharge
medications—The use of aspirin, beta-blockers, ACE-inhibitors, and
statins was broadly similar for patients admitted to either a non-intervention
or intervention centre. (Tables 5 and 6). However, non-STEMI patients had a
higher rate of ACE-inhibitor medication at discharge from a non-intervention
centre, and UAP patients had a higher rate of beta-blocker medication at
discharge from a non-intervention centre. Patients presenting with a STEMI,
non-STEMI, or UAP had a higher rate of use of clopidogrel at discharge from an
intervention centre.
DiscussionWe have shown that New Zealand ACS
patients admitted to a non-intervention centre receive lower levels of
investigational procedures and revascularisation than patients admitted to an
intervention centre. However, medical management was generally similar at both
types of centre. Of the 36 hospitals in New Zealand that admit such
patients, the NZ ACS Audit Group
identified 318 ACS patients admitted to an intervention centre (n=8 hospitals)
and 612 ACS patients admitted to a non-intervention centre (n=28 hospitals) over
14 days. These findings have significant implications for the equitable
management of ACS patients.
ST-segment-elevation
myocardial infarction patients: Primary PCI is only routinely available
at one intervention centre, over 24 hours and 7 days, and it is of no surprise
that little primary PCI is performed on patients initially admitted to a
non-intervention centre. In particular, benefit over thrombolytic therapy has
been shown for STEMI patients with contraindications for thrombolysis
(approximately 5–10%), and for those patients presenting more than 3 hours
after symptom onset.20,21
For patients presenting less than 3 hours after symptom
onset, outcomes are more similar. Across New Zealand, thrombolytic therapy is
likely to remain the standard method of reperfusion for most eligible STEMI
patients. However facilitated PCI (thrombolysis followed by PCI) is being
actively investigated and may be shown to be a better strategy than either
therapy alone.
Approximately one quarter of patients following
thrombolysis21 may need to urgently access
‘rescue angioplasty’. Advanced planning for this eventuality should
be in place for the efficient transfer of these patients. At non-intervention
centres, early land or air transport could allow patients to access
‘rescue angioplasty’.7,22 at the
regional intervention centre. This would be a significant benefit for a small
number of severely unwell STEMI patients. A cohesive referral structure should
be readily achievable in New Zealand.
Non-ST-segment-elevation
myocardial infarction patients—Non-STEMI patients admitted to
either type of centre received similar rates of some type of heparin therapy.
However, patients admitted to intervention centres were more likely to receive
enoxaparin therapy than those admitted to a non-intervention centre.
This finding may reflect policies in smaller hospitals where
the subcutaneous heparin chosen for use across the Hospital has had to satisfy
the wishes of a variety of clinicians—some favouring daltaparin for
surgical prophylaxis and others favouring enoxaparin for the treatment of ACS
patients.23
The European guidelines14
favour a strategy of low molecular weight heparins over unfractionated heparin,
with enoxaparin being specified as preferable in the
American15 and Australia and New Zealand
guidelines.16 Some flexibility in
pharmaceutical provision at each hospital would allow different groups of
clinicians to access optimal medications for their patient group.
For non-STEMI patients, the overall use of glycoprotein
2b/3a inhibitors is low across both intervention and non-intervention centres.
An improvement in this rate of treatment is important particularly for high-risk
patients including those with elevated troponins and diabetes
mellitus.4,24 Clinicians’ access to these
medicines is often denied by local hospital pharmaceutical policies. Of the 36
hospitals admitting ACS patients, only 14 hospitals had tirofiban on their
formulary, and another 2 hospitals had some non-formulary stock. A less
restrictive policy appears to be needed across New Zealand. The Health Ministry
may need to direct local District Health Boards to allow appropriate formulary
listing.
Discharge medications are generally similar for patients
leaving either type of centre but rates are low compared to internationally. Use
of clopidogrel in all patient groups was more common from the intervention
centres, and the use of ACE-inhibitors for non-STEMI patients, and the use of
beta-blockers for UAP patients was more common from non-intervention
centres.
In-hospital
investigations—There is a disparity between patients admitted to
intervention and non-intervention centres. Non-intervention-centre patients were
more likely to have the basic examination of a chest X-ray, and the same (low)
rates of exercise treadmill tests as intervention centre patients.
Patients admitted to a non-intervention centre had fewer
echocardiograms (17% vs 26%), fewer cardiac angiograms (17% vs 30%), and more
patients received neither a treadmill nor an angiogram for cardiac risk
assessment (68% vs 53%). The low level of investigations undertaken on patients
at New Zealand intervention centres, when compared to international
figures,19 is compounded by the even lower
level of investigations for patients at the non-intervention centres (Tables 3
and 4).
In-hospital
revascularisation—There is a major discrepancy in the rate of PCI
between patients admitted to interventional and non-interventional hospitals in
each category of ACS: STEMI, non-STEMI, and UAP. Patients admitted to a
non-intervention centre were 3 to 8 times less likely to receive an in-hospital
PCI, compared to those patients admitted to an intervention centre. Few patients
underwent CABG at intervention or non-intervention centres.
Over the past 7 years, several clinical trials have
demonstrated a benefit for ACS patients who were randomised to receive an
‘invasive’ rather than a ‘conservative’ management
strategy.6–10 For STEMI patients,
post-thrombolytic therapy, the DANAM-1 study6
revealed a significant benefit for an invasive strategy in patients who had
spontaneous or inducible post-infarct ischaemia.
For non-STEMI/UAP patients, three randomised trials of
invasive versus conservative management of
patients8–10 have shown significant
benefits of an invasive over a conservative strategy when accompanied by
antithrombotic therapy: daltaparin for 4–7
days,8 unfractionated heparin, and tirofiban
for 4–48 hours,9 or enoxaparin for
2–8 days.10
In the FRISC 2 trial, with one year follow-up, for every 100
patients randomised to an invasive strategy on the background of daltaparin
therapy saved 1.7 lives, prevented 2 myocardial infarctions, and prevented 20
re-admissions to hospital—as well as providing earlier and better symptom
relief for patients.25 To achieve this result,
21 more PCI procedures and 15 more CABG surgery operations were required per 100
patients.
Because the hospital re-admission rate with the additional
costs was so much lower, the calculated overall cost of this strategy after 1
year was only an additional 12%,26 prompting
the accompanying editorial to the health economics paper to be entitled
‘What are we waiting for?’.27
Indeed, the cost-analysis paper for TACTICS9
(which showed a 22% reduction in the composite of death, nonfatal MI, and
rehospitalisation with an ACS within 6 months) showed a cost neutral effect of
an invasive strategy in combination with unfractionated heparin and
tirofiban.28
Comparison of the NZACS non-STEMI/UAP patient data with both
the ‘invasive’ and ‘conservative’ rates of
investigations and revascularisation of these three
studies8–10 is revealing (Table 7 and
Figure 1). In many cases, even the ‘conservative’ strategy in the
three trials led to higher rates of investigations and revascularisation than
those found in the NZACS Audit patients. However, data collection in these three
trials was somewhat different to the NZACS data collection methods, where a
review of current hospital practice was being audited. Hence, the discrepancies
identified could be partly explained by methodology.
However, the large differences in practice do suggest that
New Zealand non-STEMI/UAP ACS patients are currently not benefiting from these
proven advances in treatment. New treatments including the addition of ADP
receptor antagonists and drug eluting stents are likely to lead to even better
patient outcomes of an invasive strategy.
Figure 1. Comparison of NZACS Audit non-STEMI/UAP
patients, and their centre—with FRISC 2,8
TACTICS,9 and RITA
310 data
 Data
collection—The traditional method of data collection has been to
code patients’ admissions at each hospital according to the current
International Classification of Diseases (ICD)
standard.29 These data are collected by the
Health Information Service (NZHIS) group within the Ministry of Health, and are
used to plan hospital services.
There are two major limitations to this system. Firstly, the
ICD coding structure is progressively developed to reflect current diagnostic
thinking, which limits the accuracy of data comparisons over time. Secondly, the
quality of this data is limited by the complexities of patient presentation, and
both the junior doctor and coding clerk’s interpretation of this. The
current NZACS audit uses modern terminology and accurately outlines the type and
number of ACS patients, who are currently requiring treatment in New Zealand.
These data should prove a valuable addition to health information already
collected.
Over 14 days, the audit enrolled 930 patients, which
extrapolates to approximately 24 180 (930 x 26) patients over 1 year if a
similar admissions policy existed throughout this time. This is likely to be a
reasonable annual estimate as data was collected in the autumn, hence avoiding
the seasonal difference of 38% which exists between winter and summer admissions
of ischaemic heart disease patients in New
Zealand.30 Furthermore, it is close to the
figure of 27, 573 given by the New Zealand Health Information
Service31 for 1999/2000. By extrapolation, 2626
STEMI, 7462 Non-STEMI, and 8658 UAP patients would be admitted to a New Zealand
hospital in 1 year.
Cost
analysis—Over 14 days, 199 definite or suspected ACS patients
received a cardiac angiogram, 69 patients received a PCI, and 35 patients
received a CABG operation. Extrapolated over 1 year, these numbers approximate
to 5174 angiograms, 1794 PCIs, and 910 CABG operations, respectively.
The approximate costs at a public hospital are: cardiac
angiography $2,000, PCI $10,000, and CABG $20,000. A commitment to increase
these procedures for ACS patients by 50%, (2587 more angiograms, 897 more PCI
procedures, 455 more CABG operations) would equate to an undiscounted financial
cost of approximately $23 million per year. However as major cost savings can be
made (mainly from a reduction in hospital re-admissions of UAP/non-STEMI
patients) the actual figure may be cost
neutral,28 or there might be a saving on costs
due to the current in-hospital waiting lists for angiograms and
revascularisation. These make it not uncommon for patients to spend 7 or more
days waiting for their treatment. Costs of transfers from non-intervention
centres to intervention centres should also be considered.
Hence the additional hospitalisation costs of this current
‘rationed’ revascularisation policy could easily approach the cost
of the subsequent investigation and revascularisation, and gives no advantage to
the patient or the New Zealand taxpayer. Furthermore, the costs associated with
the loss of earnings, and the requirement for State support of patients who can
no longer actively contribute to the community, are likely to be very large.
Patients who unnecessarily develop heart failure and chronic angina will only
add to subsequent health costs, which will be considerable.
Study
limitations—There are a number of limitations of our
audit,19 including the fact that we did not
collect data for investigations and treatment following hospitalisation. However
the current data suggest that there is a lower level of investigation and
revascularisation performed on ACS patients admitted to a non-intervention
centre when compared to ACS patients admitted to an intervention centre and
indicates the need for further study of this finding. New Zealand intervention
centres themselves perform fewer investigations and revascularisations when
compared to international
comparisons.19
Several areas need to be considered if there is to be an
improvement in the treatment of New Zealand patients with an ACS. Each regional
intervention centre and referral hospital should encourage optimal in-hospital
medical management and facilitate the transfer of appropriate ACS patients for
invasive investigations and revascularisation.
Each regional intervention centre and non-interventional
centre should review the local provision for the emergency transfer of acutely
unwell ACS patients. More centres with facilities for angiography, and the
expansion of Intervention Centres will be required.
Conclusion—We
have demonstrated that a collaborative group of clinicians can perform a
nation-wide audit of ACS patients. This has revealed an inequitable service
provision in New Zealand. In particular, patients admitted to a non-intervention
centre have lower levels of modern cardiac investigations and are markedly less
likely to receive optimal revascularisation treatment. Having collected this
data, the opportunity now exists for clinicians to work with the health
department to develop a comprehensive nation-wide strategy for patients
presenting 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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