5 Australian cardiology research highlights from CSANZ 21

The annual meeting of the Cardiac Society of Australia and New Zealand (CSANZ 2021) was virtual this year, but that did not diminish the quality of the presentations. Here are some of the highlights from the e-posters presented between 5-8 August by Australian cardiologists. You can view posters and on demand content from the meeting here.

MBS billing changes leads to drastic drop in ECG numbers

The number of ECG investigations claimed under the MBS have ‘drastically’ fallen following controversial ECG item number changes introduced last year.

Dr Mandeep Kalsi and colleagues from Northern Health in Melbourne evaluated the impact of several new ECG item descriptors designed to curb inappropriate claiming of unnecessary ‘low value’ services as part of the Department of Health’s extensive Medicare Benefits Schedule review.

A controversial aspect of the changes is the blocking of GP eligibility to claim for tracing and reporting, effectively restricting these services to consultant physicians and other specialists, which has drawn an angry response from GP groups.

The new item 11707, which covers a lower $19 fee for ECG tracing in primary care, continues to be strongly opposed by the Royal Australian College of General Practitioners (RACGP) who say the changes would result in reduced access and longer waits for ECG interpretation for patients.

In the six months to August 2020 some 1,498,579 ECGs were claimed. But that number dropped by more than half a million to 953,995 in the six months from August 2021 when the changes were introduced.

The 36% decline has already saved over $17 million but researchers say further longitudinal studies are needed to determine the impact of the considerable saving on patients’ health.

Meanwhile, an analysis of MBS changes on cardiac investigations reveals cardiac plain echocardiography had fallen by 13% and echocardiography stress testing by 60% in a two month period following implementation of the new rules compared to the same period before.

Investigators say the decline in the number of these investigations could mark an improvement in the quality of care but added that further longitudinal studies are needed to ‘validate the findings and to evaluate a negative impact, if any, on patient care’.

CTCA to rule out ACS in low risk patients safe, reduces hospital stay during COVID

Using computed tomography coronary angiography (CTCA) to rule out acute coronary syndromes in patients presenting with chest pain is safe compared to standard care and could reduce ED and hospital length of stay during periods of COVID-19 lockdown.

Cardiologists led by Dr Gregory Cranney from Prince of Wales Hospital established the new, urgent pathway during the pandemic  to discharge patients presenting with chest pain deemed of low or intermediate risk.

They say the 89-98% sensitivity and specificity of CTCA combined with its high negative predictive value of >90% make it an effective tool to rule out coronary artery disease in the subgroup of patients.

Over three months, 39 patients patients presenting with a heart score <6 and no contra- indications to CTCA were discharged from ED with arrangements made for an expedited outpatient CTCA and follow up. The scans were arranged at private radiology centres to reduce demand on the hospital radiology department.

According to investigators the mean time from presentation to CTCA in the 39 patients involved in the trial was 4 days. Two patients were found to have severe stenosis of one or more coronary arteries, while eight patients were found to have moderate (50-69%) stenosis.

Six patients underwent invasive angiography with two requiring PCI and one patient requiring CABG.

And, based on CTCA results 13 patients were newly commenced on statin therapy.

With one hospital representation and no 30- day non-fatal MI or mortality, investigators say the pathway may be an acceptable model of care throughout the pandemic.

Triple therapy in HFrEF de novo patients reduces CV readmissions

Starting triple therapy in HFrEF de novo  patients at first presentation may reduce CV readmissions in addition to the therapy’s already proven mortality benefits, say cardiologists in South Australia.

The team from Flinders Medical Centre looked at the value of the treatment strategy which includes an ACEi/ARB, beta-blocker, and mineralocorticoid receptor antagonist (MRA), in de novo HFrEF compared to compared to chronic HFrEF among 113 patients admitted to the centre over seven months.

Among the cohort 38 had de novo HF (34%) and 75 had chronic HF.  According to investigators 20 de novo patients (53%) and 35 chronic HF patients (49%) were discharged on TT.

While there were no significant differences in events within the groups regardless of TT use, de novo patients on TT had significantly lower CV readmissions (p=0.021) and events (p=0.032), but no difference in deaths (p=0.355).

Screening with hs-troponin justified in patients admitted without cardiac complaints

Melbourne cardiologists say there is justification for using high sensitive troponin as a screening test for general medical patients admitted to hospital regardless of whether they present with cardiac complaints.

The team from Werribee Mercy Hospital, an outer metropolitan hospital, said an audit of its General Medicine admission records reveals that more than half (53%) of patients had hs-troponin measured. It’s a practice they suggest could be generalised to describe current practice in other similar hospitals.

Investigators say the test was ordered for a wide variety of clinical presentations, including 41 patients (30%) presenting with non-cardiac presenting complaints.

Hs-troponin was found to be elevated in 60 patients (24%) including 42% of patients with potentially cardiac presenting complaints, 10% of patients with non cardiac presenting complaints and 28% of patients with a history of prior CVD or risk factors.

While only one patient with a non cardiac presenting complaint and hs-troponin elevation was subsequently diagnosed with ACS, investigators say their findings suggest that there is justification to accept the current real-world use of hs-troponin as a screening test in general medical patents.

Patients with hs-troponin ordered were more likely to be admitted to intensive care and monitored beds, more likely to have an echocardiogram and be referred for outpatient cardiology follow up regardless of whether troponin was elevated or not.

“Although patients found to have an incidentally elevated troponin may not have an ACS, hs-troponin still identifies patients at elevated cardiovascular risk who may benefit from early detection of risk, investigation of underlying cardiovascular disease and optimisation of risk factors,” they said.

This data was clinically useful as it highlighted the importance of integrating the clinical and ECG findings in making the diagnosis of ACS in general medical patients with elevated troponin.

Furthermore given there was strong evidence base for the prognostic value of hs-troponin outside its role in the diagnosis of ACS, this data suggested that there was pragmatic justification to accept the current real world use of hs-troponin as a screening test in general medical patients.

They concluded that although patients founds to have an incidentally elevated troponin may not have ACS, hs-troponin still identified patients at elevated cardiovascular risk who may benefit from early detection of risk, investigation for underlying cardiovascular disease and optimisation of risk factors.

Despite undergoing CABG and high-intensity statin use most patients struggle to reach LDL-C 

A large proportion of patients who have undergone CABG surgery are not attaining LDL-C targets despite prescription of high-intensity statins, according to a review of patient data from a Queensland hospital.

The study also reveals that the use of effective non statin lipid-lowering therapies is very limited among patients.

The research team from the University of Western Australia and the Fiona Stanley Hospital in Perth looked at data from  484 patients undergoing CABG surgery at the hospital between 2015 and 2020 and who had follow up lipid results available.

At discharge, 469 (96.9%) were prescribed statin therapy with most 425 (90.6%) on high-intensity. Ezetimibe was prescribed for 62 (12.8%) patients, and only one was discharged on a PCSK9 inhibitor.

LDL-C <1.4 mmol/L and <1.8 mmol/L was attained in 118 (24.4%) and 231 (47.7%) patients respectively, lead author Dr Nick Lan and colleagues reported.

Meanwhile, patients discharged on high-intensity statin therapy plus ezetimibe were more likely to attain LDL-C targets of <1.4 mmol/L (trend p-value=0.020) and <1.8 mmol/L (trend p-value<0.001) compared with patients discharged on high-intensity statin only, or moderate- or low-intensity statin with or without ezetimibe.

The team stressed further research should be undertaken to identify barriers and optimise lipid management among this very high-risk population. The establishment of a new cardiometabolic speciality, with integration into inpatient cardiothoracic units and outpatient clinics, may be a potential avenue to bridge the gap in lipid management, they concluded.

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