Invasive management and late clinical outcomes in contemporary Australian management of acute coronary syndromes: observations from the ACACIA registry.
OBJECTIVE
To describe the impact of invasive management on 12-month survival among patients with suspected acute coronary syndrome (ACS) in Australia.


METHODS
Prospective nationwide multicentre registry.


METHODS
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.


METHODS
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.
Chew
Derek P
DP
Flinders University, Adelaide, SA. Derek.Chew@flinders.edu.au
Amerena
John V
JV
Coverdale
Steve G
SG
Rankin
Jamie M
JM
Astley
Carolyn M
CM
Soman
Ashish
A
Brieger
David B
DB
D054058:Acute Coronary Syndrome / Q000145:classification / Q000188:drug therapy / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000959:Antihypertensive Agents / Q000627:therapeutic use; D001315:Australia; D017023:Coronary Angiography; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000517:prevention & control*; D009204:Myocardial Revascularization; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011446:Prospective Studies; D012042:Registries
D000959:Antihypertensive Agents; D010975:Platelet Aggregation Inhibitors