To be or not to be on: aspirin and coronary artery bypass graft surgery.

Aspirin's role in secondary prevention for patients with known coronary artery disease (CAD) is well established, validated by numerous landmark trials over the past several decades. However, its perioperative use in coronary artery bypass graft (CABG) surgery remains contentious due to the delicate balance between the risks of thrombosis and bleeding. While continuation of aspirin in patients undergoing CABG following acute coronary syndrome is widely supported due to the high risk of re-infarction, the evidence is less definitive for elective CABG procedures. The literature indicates a significant benefit of aspirin in reducing cardiovascular events in CAD patients, yet its impact on perioperative outcomes in CABG surgery is less clear. Some studies suggest increased bleeding risks without substantial improvement in cardiac outcomes. Specific to elective CABG, evidence is mixed, with some data indicating no significant difference in thrombotic or bleeding complications whether aspirin is continued or withheld preoperatively. Advancements in pharmacological therapies and perioperative care have evolved significantly since the initial aspirin trials, raising questions about the contemporary relevance of earlier findings. Individualized patient assessments and the development of risk stratification tools are needed to optimize perioperative aspirin use in CABG surgery. Further research is essential to establish clearer guidelines and improve patient outcomes. The objective of this review is to critically evaluate the existing evidence into the optimal management of perioperative aspirin in elective CABG patients.

The future is bright: artificial intelligence for trainee medical officers in Australia and New Zealand.

Given their frontline role in Australia and Aotearoa New Zealand (ANZ) healthcare, trainee medical officers (TMOs) will play a crucial role in the development and use of artificial intelligence (AI) for clinical care, ongoing medical education and research. As 'digital natives', particularly those with technical expertise in AI, TMOs should also be leaders in informing the safe uptake and governance of AI within ANZ healthcare as they have a practical understanding of its associated risks and benefits. However, this is only possible if a culture of broad collaboration is instilled while the use of AI in ANZ is still in its initial phase.

Listen to your heart: a critical analysis of popular cardiology podcasts.

Purpose: Podcasts are an increasingly popular medium for medical education in the field of cardiology. However, evidence suggests that the quality of the information presented can be variable. The aim of our study was to assess the quality of the most popular cardiology podcasts on existing podcast streaming services, using tools designed to grade online medical education. Results: We analyzed the five most recent episodes from 28 different popular cardiology podcasts as of 20th of September, 2022 using the validated rMETRIQ and JAMA scoring tools. The median podcast length was 20 min and most episodes were hosted by professors, subspecialty discussants or consultant physicians (87.14%). Although most episodes had only essential content (85%), only a small proportion of episodes provided detailed references (12.9%), explicitly identified conflicts of interest (30.7%), described a review process (13.6%), or provided a robust discussion of the podcast's content (13.6%). We observed no consistent relationship between episode length, seniority of host or seniority of guest speaker with rMETRIQ or JAMA scores. Conclusions: Cardiology podcasts are a valuable remote learning tool for clinicians. However, the reliability, relevance, and transparency of information provided on cardiology podcasts varies widely. Streamlined standards for evaluation are needed to improve podcast quality.

Resuscitation orders demonstrate differences by gender, stroke type and intervention.

BACKGROUND AND PURPOSE: Resuscitation orders describe individual preferences and types of intervention, such as suitability for cardiopulmonary resuscitation (CPR), that may provide benefit in the event of critical deterioration. The purpose of this study was to examine stroke inpatient resuscitation order completion and content. METHODS: This retrospective cohort study examined resuscitation orders in consecutive individuals admitted to a tertiary stroke centre over a 21-month period. Multivariable logistic regression was used to identify factors associated with resuscitation order completion and content. RESULTS: 1924 individuals were included in the study. The proportion of individuals who had resuscitation orders completed was 37.4%. Several factors were associated with an increased likelihood of resuscitation order completion including having received endovascular thrombectomy (p=0.013) and having intracerebral haemorrhage (p=0.001). Females were more likely to have a resuscitation order that is not for CPR (p=0.021, OR 95%CI 1.080-2.542). Patients with intracerebral haemorrhage were also more likely to be not for CPR (p=0.037, OR 95%CI 1.039-3.353). CONCLUSIONS: Disparities exist in resuscitation order completion and content based on demographic and stroke characteristics. Further research is required to identify the reasons for these differences and to optimise resuscitation order completion.

Effect of lixisenatide on liquid gastric emptying in type 2 diabetes - Implications for the use of GLP-1 receptor agonists before procedures.

Gastric emptying of a glucose drink was measured in people with type 2 diabetes given lixisenatide (20 µg/day or placebo) for 8 weeks. Intragastric retention at 240 min (2 (0-11)% vs 48 (3-97)%; P < 0.0001) was much greater with lixisenatide than placebo. Accordingly, lixisenatide may delay liquid gastric emptying markedly.

Meeting medical emergency response criteria for hypertension is not associated with an increased likelihood of in-hospital mortality in a tertiary referral center.

Backgrounds: Rapid response team or medical emergency team (MET) calls are typically activated by significant alterations of vital signs in inpatients. However, the clinical significance of a specific criterion, blood pressure elevations, is uncertain. Objectives: The aim of this study was to evaluate the likelihood ratios associated with MET-activating vital signs, particularly in-patient hypertension, for predicting in-hospital mortality among general medicine inpatients who met MET criteria at any point during admission in a South Australian metropolitan teaching hospital. Results: Among the 15,734 admissions over a two-year period, 4282 (27.2%) met any MET criteria, with a positive likelihood ratio of 3.05 (95% CI 2.93 to 3.18) for in-hospital mortality. Individual MET criteria were significantly associated with in-hospital mortality, with the highest positive likelihood ratio for respiratory rate ≤ 7 breaths per minute (9.83, 95% CI 6.90 to 13.62), barring systolic pressure ≥ 200 mmHg (LR + 1.26, 95% CI 0.86 to 1.69). Conclusions: Our results show that meeting the MET criteria for hypertension, unlike other criteria, was not significant associated with in-hospital mortality. This observation warrants further research in other patient cohorts to determine whether blood pressure elevations should be routinely included in MET criteria.

Near-death experiences after cardiac arrest: a scoping review.

BACKGROUND: This scoping review aimed to characterise near-death experiences in the setting of cardiac arrest, a phenomenon that is poorly understood and may have clinical consequences. METHOD: PubMed/MEDLINE was searched to 23 July 2023 for prospective studies describing near-death experiences in cardiac arrest. PRISMA-ScR guidelines were adhered to. Qualitative and quantitative data were synthesised. Meta-analysis was precluded due to data heterogeneity. RESULTS: 60 records were identified, of which 11 studies involving interviews were included from various countries. Sample size ranged from 28-344, and proportion of female patients (when reported) was 0-50%, with mean age (when reported) ranging 54-64 years. Comorbidities and reasons for cardiac arrest were heterogeneously reported. Incidence of near-death experiences in the included studies varied from 6.3% to 39.3%; with variation between in-hospital (6.3-39.3%) versus out-of-hospital (18.9-21.2%) cardiac arrest. Individual variables regarding patient characteristics demonstrated statistically significant association with propensity for near-death experiences. Reported content of near-death experiences tended to reflect the language of the questionnaires used, rather than the true language used by individual study participants. Three studies conducted follow-up, and all suggested a positive life attitude change, however one found significantly higher 30-day all-cause mortality in patients with near-death experiences versus those without, in non-controlled analysis. CONCLUSIONS: From prospective studies that have investigated the phenomenon, near-death experiences may occur in as frequent as over one-third of patients with cardiac arrest. Lasting effects may follow these events, however these could also be confounded by clinical characteristics.

Participants' views of ultra-low dose combination therapy for high blood pressure: a mixed-methods study from the QUARTET trial.

Single-pill combination therapy containing four quarter-dose medications for high blood pressure improves BP control compared to monotherapy, however patient-reported acceptance of the quadpill as a treatment strategy remains undescribed. We collected within-trial feedback and interviewed participants from the quadruple ultra-low-dose treatment for hypertension (QUARTET) trial to characterise patient attitudes to this intervention. All trial participants were asked about ease and preference for the quadpill and provided an opportunity to give further comments on the trial at 12 weeks (trial primary endpoint) and 52 weeks extended follow-up. Separately, we used purposive and quota sampling for the semi-structured telephone interviews, with the resultant verbatim transcripts analysed using an inductive thematic analysis approach. Themes were re-evaluated after each successive interview, and at suspected data saturation, an additional interview conducted for confirmation. At 12 weeks follow-up, 502 of 591 (85%) participants responded to acceptability questions, and 359 of 417 (86%) responded at week 52. Most reported the trial capsule easy or very easy to take. From eight sites, 16 participants were interviewed between 5 August 2020 and 19 November 2020. All described a positive experience, preferred once-daily morning dosing and found routine facilitated adherence. Participants valued individual responsibility for adherence, and involvement of the general practitioner in blood-pressure management. Most reported capsule size did not deter adherence but desired a smaller capsule. Participants described a preference for minimising number and dosage of medications, reduced capsule size, and once-daily morning dosing. These findings suggest a preference for single-pill combination therapy for blood pressure lowering.

Renal disease is not associated with delays in hyperacute stroke management in South Australia.

OBJECTIVE: The aims of the present study were to determine how renal disease is associated with the time to receive hyperacute stroke care. METHODS: The present study involved a 5-year cohort of all patients admitted to stroke units in South Australia. RESULTS: In those with pre-existing renal disease there were no significant differences in the time taken to receive a scan, thrombolysis or endovascular thrombectomy. CONCLUSIONS: The present study shows that in protocolised settings there were no significant delays in hyperacute stroke management for patients with renal disease.

Prognostic value of left ventricular systolic function before vascular surgery: a systematic review.

BACKGROUND: Vascular surgery carries a high risk of post-operative cardiac complications. Recent studies have shown an association between asymptomatic left ventricular systolic dysfunction and increased risk of major adverse cardiovascular events (MACE). This systematic review aims to evaluate the prognostic value of left ventricular function as determined by left ventricular ejection fraction (LVEF) measured by resting echocardiography before vascular surgery. METHODS: This review conformed to PRISMA and MOOSE guidelines. PubMed, OVID Medline and Cochrane databases were searched from inception to 27 October 2022. Eligible studies assessed vascular surgery patients, with multivariable-adjusted or propensity-matched observational studies measuring LVEF via resting echocardiography and providing risk estimates for outcomes. The primary outcomes measures were all-cause mortality and congestive heart failure at 30 days. Secondary outcome included the composite outcome MACE. RESULTS: Ten observational studies were included (4872 vascular surgery patients). Studies varied widely in degree of left ventricular systolic dysfunction, symptom status, and outcome reporting, precluding reliable meta-analysis. Available data demonstrated a trend towards increased incidence of all-cause mortality, congestive heart failure and MACE in patients with pre-operative LVEF <50%. Methodological quality of the included studies was found to be of moderate quality according to the Newcastle Ottawa Checklist. CONCLUSION: The evidence surrounding the prognostic value of LVEF measurement before vascular surgery is currently weak and inconclusive. Larger scale, prospective studies are required to further refine cardiac risk prediction before vascular surgery.