Titration of medications and outcomes in multi-ethnic heart failure cohorts (with reduced ejection fraction) from Singapore and New Zealand.

AIMS: We investigated titration patterns of angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs) and beta-blockers, quality of life (QoL) over 6 months, and associated 1 year outcome [all-cause mortality/heart failure (HF) hospitalization] in a real-world population with HF with reduced ejection fraction (HFrEF). METHODS AND RESULTS: Participants with HFrEF (left ventricular ejection fraction <40%) from a prospective multi-centre study were examined for use and dose [relative to guideline-recommended maintenance dose (GRD)] of ACEis/ARBs and beta-blockers at baseline and 6 months. 'Stay low' was defined as <50% GRD at both time points, 'stay high' as ≥50% GRD, and 'up-titrate' and 'down-titrate' as dose trajectories. Among 1110 patients (mean age 63 ± 13 years, 16% women, 26% New York Heart Association Class III/IV), 714 (64%) were multi-ethnic Asians from Singapore and 396 were from New Zealand (mainly European ethnicity). Baseline use of either ACEis/ARBs or beta-blockers was high (87%). Loop diuretic was prescribed in >80% of patients, mineralocorticoid receptor antagonist in about half of patients, and statins in >90% of patients. At baseline, only 11% and 9% received 100% GRD for each drug class, respectively, with about half (47%) achieving ≥50% GRD for ACEis/ARBs or beta-blockers. At 6 months, a large majority remained in the 'stay low' category, one third remained in 'stay high', whereas 10-16% up-titrated and 4-6% down-titrated. Patients with lower (vs. higher) N-terminal pro-beta-type natriuretic peptide levels were more likely to be up-titrated or be in 'stay high' for ACEis/ARBs and beta-blockers (P = 0.002). Ischaemic aetiology, prior HF hospitalization, and enrolment in Singapore (vs. New Zealand) were independently associated with higher odds of 'staying low' (all P < 0.005) for prescribed doses of ACEis/ARBs and beta-blockers. Adjusted for inverse probability weighting, ≥100% GRD for ACEis/ARBs [hazard ratio (HR) = 0.42; 95% confidence interval (CI) 0.24-0.73] and ≥50% GRD for beta-blockers (HR = 0.58; 95% CI 0.37-0.90) (vs. Nil) were associated with lower hazards for 1 year composite outcome. Country of enrolment did not modify the associations of dose categories with 1 year composite outcome. Higher medication doses were associated with greater improvements in QoL. CONCLUSIONS: Although HF medication use at baseline was high, most patients did not have these medications up-titrated over 6 months. Multiple clinical factors were associated with changes in medication dosages. Further research is urgently needed to investigate the causes of lack of up-titration of HF therapy (and its frequency), which could inform strategies for timely up-titration of HF therapy based on clinical and biochemical parameters.

Implementation and evaluation of a rural general practice assessment pathway for possible cardiac chest pain using point-of-care troponin testing: a pilot study.

OBJECTIVES: To assess the feasibility and acceptability, and additionally to preliminarily evaluate, the effectiveness and safety of an accelerated diagnostic chest pain pathway in rural general practice using point-of-care troponin to identify patients at low risk of acute myocardial infarction, avoiding unnecessary patient transfer to hospital and enabling early discharge home. DESIGN: A prospective observational pilot evaluation. SETTING: Twelve rural general (family) practices in the Midlands region of New Zealand. PARTICIPANTS: Patients aged ≥18 years who presented acutely to rural general practice with suspected ischaemic chest pain for whom the doctor intended transfer to hospital for serial troponin measurement. OUTCOME MEASURES: The proportion of patients managed using the low-risk pathway without transfer to hospital and without 30-day major adverse cardiac event (MACE); pathway adherence; rate of 30-day MACE; patient satisfaction with care; and agreement between point-of-care and laboratory measured troponin concentrations. RESULTS: A total of 180 patients were assessed by the pathway. The pathway classified 111 patients (61.7%) as low-risk and all were managed in rural general practice with no 30-day MACE (0%, 95% CI 0.0% to 3.3%). Adherence to the low-risk pathway was 95.5% (106 out of 111). Of the 56 patients classified as non-low-risk and referred to hospital, 9 (16.1%) had a 30-day MACE. A further 13 non-low-risk patients were not transferred to hospital, with no events. The sensitivity of the pathway for 30-day MACE was 100.0% (95% CI 70.1% to 100%). Of low-risk patients, 94% reported good to excellent satisfaction with care. Good concordance was observed between point-of-care and duplicate laboratory measured troponin concentrations. CONCLUSIONS: The use of an accelerated diagnostic chest pain pathway incorporating point-of-care troponin in a rural general practice setting was feasible and acceptable, with preliminary results suggesting that it may safely and effectively reduce the urgent transfer of low-risk patients to hospital.

High flow oxygen and risk of mortality in patients with a suspected acute coronary syndrome: pragmatic, cluster randomised, crossover trial.

OBJECTIVE: To determine the association between high flow supplementary oxygen and 30 day mortality in patients presenting with a suspected acute coronary syndrome (ACS). DESIGN: Pragmatic, cluster randomised, crossover trial. SETTING: Four geographical regions in New Zealand. PARTICIPANTS: 40 872 patients with suspected or confirmed ACS included in the All New Zealand Acute Coronary Syndrome Quality Improvement registry or ambulance ACS pathway during the study periods. 20 304 patients were managed using the high oxygen protocol and 20 568 were managed using the low oxygen protocol. Final diagnosis of ST elevation myocardial infarction (STEMI) and non-STEMI were determined from the registry and ICD-10 discharge codes. INTERVENTIONS: The four geographical regions were randomly allocated to each of two oxygen protocols in six month blocks over two years. The high oxygen protocol recommended oxygen at 6-8 L/min by face mask for ischaemic symptoms or electrocardiographic changes, irrespective of the transcapillary oxygen saturation (SpO2). The low oxygen protocol recommended oxygen only if SpO2 was less than 90%, with a target SpO2 of less than 95%. MAIN OUTCOME MEASURE: 30 day all cause mortality determined from linkage to administrative data. RESULTS: Personal and clinical characteristics of patients managed under both oxygen protocols were well matched. For patients with suspected ACS, 30 day mortality for the high and low oxygen groups was 613 (3.0%) and 642 (3.1%), respectively (odds ratio 0.97, 95% confidence interval 0.86 to 1.08). For 4159 (10%) patients with STEMI, 30 day mortality for the high and low oxygen groups was 8.8% (n=178) and 10.6% (n=225), respectively (0.81, 0.66 to 1.00) and for 10 218 (25%) patients with non-STEMI was 3.6% (n=187) and 3.5% (n=176), respectively (1.05, 0.85 to 1.29). CONCLUSION: In a large patient cohort presenting with suspected ACS, high flow oxygen was not associated with an increase or decrease in 30 day mortality. TRIAL REGISTRATION: ANZ Clinical Trials ACTRN12616000461493.

CT Angiography Followed by Invasive Angiography in Patients With Moderate or Severe Ischemia-Insights From the ISCHEMIA Trial.

OBJECTIVES: This study aimed to examine the concordance of coronary computed tomographic angiography (CCTA) assessment of coronary anatomy and invasive coronary angiography (ICA) as the reference standard in patients enrolled in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). BACKGROUND: Performance of CCTA compared with ICA has not been assessed in patients with very high burdens of stress-induced ischemia and a high likelihood of anatomically significant coronary artery disease (CAD). A blinded CCTA was performed after enrollment to exclude patients with left main (LM) disease or no obstructive CAD before randomization to an initial conservative or invasive strategy, the latter guided by ICA and optimal revascularization. METHODS: Rates of concordance were calculated on a per-patient basis in patients randomized to the invasive strategy. Anatomic significance was defined as ≥50% diameter stenosis (DS) for both modalities. Sensitivity analyses using a threshold of ≥70% DS for CCTA or considering only CCTA images of good-to-excellent quality were performed. RESULTS: In 1,728 patients identified by CCTA as having no LM disease ≥50% and at least single-vessel CAD, ICA confirmed 97.1% without LM disease ≥50%, 92.2% with at least single-vessel CAD and no LM disease ≥50%, and only 4.9% without anatomically significant CAD. Results using a ≥70% DS threshold or only CCTA of good-to-excellent quality showed similar overall performance. CONCLUSIONS: CCTA before randomization in ISCHEMIA demonstrated high concordance with subsequent ICA for identification of patients with angiographically significant disease without LM disease.

Outcomes for working age patients after first-time acute coronary syndrome - ANZACS-QI 35.

BACKGROUND: Acute coronary syndrome (ACS) events and the ongoing burden of disease can have a significant impact on the subsequent life-course of working age people. METHODS: We report 12-month clinical outcomes for 10,822 patients hospitalized with first-time ACS between 2015-2016 and enrolled in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry, with a focus on people of working age (defined as <65 years). RESULTS: Nearly half (48%) of first-time ACS occurred in people of working age. Compared to those >65 years, these patients had a high burden of cardiovascular risk factors, and were more likely to be male (75% vs 60%), to be of non-European ethnicity (36% vs 15%), and to be living in areas of high deprivation. Subsequent clinical events were common in the younger patients, with 15% dying or being readmitted for cardiovascular causes within 12 months despite high rates of angiography (96%), revascularization (74%) and evidence-based medical therapy at the time of the index ACS event. CONCLUSIONS: The high risk factor burden and subsequent high rate of clinical events in working age patients reinforces the need for a longer-term focus on strategies to improve clinical outcomes following first-time ACS.

CSANZ Position Statement on the Evaluation of Patients Presenting With Suspected Acute Coronary Syndromes During the COVID-19 Pandemic.

A pandemic of Coronavirus-19 disease was declared by the World Health Organization on March 11, 2020. The pandemic is expected to place unprecedented demand on health service delivery. This position statement has been developed by the Cardiac Society of Australia and New Zealand to assist clinicians to continue to deliver rapid and safe evaluation of patients presenting with suspected acute cardiac syndrome at this time. The position statement complements, and should be read in conjunction with, the National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016: Section 2 'Assessment of Possible Cardiac Chest Pain'.

Rural and Remote Cardiology During the COVID-19 Pandemic: Cardiac Society of Australia and New Zealand (CSANZ) Consensus Statement.

THE CHALLENGES: Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors. The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations, and people with known CVD have increased morbidity and mortality from coronavirus disease 2019 (COVID-19). In addition, COVID-19 is associated with serious cardiac manifestations, potentially placing additional demand on limited regional services at a time of diminished visiting metropolitan support with restricted travel. Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity. Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic. MAIN RECOMMENDATIONS: Health districts, cardiologists and government agencies need to minimise impacts on the already vulnerable cardiovascular health of regional and remote Australians and New Zealanders throughout the COVID-19 pandemic. Changes in management should include.

Study protocol for an observational study to evaluate an accelerated chest pain pathway using point-of-care troponin in New Zealand rural and primary care populations.

INTRODUCTION Accelerated diagnostic chest pain pathways are used widely in urban New Zealand hospitals. These pathways use laboratory-based troponin assays with good analytical precision. Widespread implementation has not occurred in many of New Zealand's rural hospitals and general practices as they are reliant on point-of-care troponin assays, which are less sensitive and precise. An accelerated chest pain pathway using point-of-care troponin has been adapted for use in rural settings. A pilot study in a low-risk rural population showed no major adverse cardiac events at 30 days. A larger study is required to be confident that the pathway is safe. AIMS To assess the safety and effectiveness of an accelerated chest pain pathway adapted for rural settings and general practice using point-of-care troponin to identify low-risk patients and allow early discharge. METHODS This is a prospective observational study of an accelerated chest pain pathway using point-of-care troponin in rural hospitals and general practices in New Zealand. A total of 1000 patients, of whom we estimate 400 will be low risk, will be enrolled in the study. OUTCOME MEASURES The primary outcome is the proportion of patients identified by the pathway as low risk for a 30-day major adverse cardiac event. Secondary outcomes include the proportion of low-risk patients who were discharged directly from general practice or rural hospitals, the proportion of patients reclassified as having acute myocardial infarction by the pathway and the proportion of patients with low and intermediate risk safely managed in the rural hospital.

Ethnic differences in atrial fibrillation in patients with heart failure from Asia-Pacific.

OBJECTIVE: Ethnic differences in the prevalence of atrial fibrillation (AF) in heart failure (HF) remain unclear. We compared the prevalence and clinical correlates of AF among different ethnicities in an Asian-Pacific population with HF. METHODS: Patients with validated HF were prospectively studied across Singapore and New Zealand (NZ). RESULTS: Among 1746 patients with HF (62% Asian, 26% women, mean age 66 (SD 13) years, mean ejection fraction (EF) 37 (SD 16%), 39% had AF. The prevalence of AF was markedly lower in Singapore-Asians than NZ-Europeans (24% vs 63%; p<0.001), even after adjusting for age, clinical and echocardiographic covariates, regardless of EF group (pinteraction for EF=0.39). Patients with AF were older, had higher body mass index and were more likely to have a history of hypertension, stroke, peripheral vascular disease, renal disease, chronic respiratory disease and increased alcohol intake, but less likely to have diabetes. Clinical correlates were similar for Asians and NZ-Europeans, except diabetes: Asian diabetic patients with HF had less AF compared with Asian patients without diabetes (OR 0.66, 95% CI 0.50 to 0.88), whereas among NZ-Europeans there was no significant association between diabetes and AF (OR 1.22, 95% CI 0.85 to 1.75) (pinteraction for ethnicity=0.01). AF was associated with a higher crude composite outcome of mortality and HF hospitalisations at 2 years (HR 1.19, 95% CI 1.02 to 1.38). CONCLUSION: There is a strikingly lower prevalence of AF among Asian compared with NZ-European patients with HF. The underlying mechanisms for the lower prevalence of AF among Asians, particularly in the presence of diabetes, deserve further study. TRIAL REGISTRATION NUMBER: ACTRN12610000374066.

Absence of Myostatin Improves Cardiac Function Following Myocardial Infarction.

BACKGROUND: Myostatin inhibits the development of skeletal muscle and regulates the proliferation of skeletal muscle fibroblasts. However, the role of myostatin in regulating cardiac muscle or myofibroblasts, specifically in acute myocardial infarction (MI), is less clear. This study sought to determine whether absence of myostatin altered left ventricular function post-MI. METHODS: Myostatin-null mice (Mstn-/-) and wild-type (WT) mice underwent ligation of the left anterior descending artery to induce MI. Left ventricular function was measured at baseline, days 1 and 28 post-MI. Immunohistochemistry and immunofluorescence were obtained at day 28 for cellular proliferation, collagen deposition, and myofibroblastic activity. RESULTS: Whilst left ventricular function at baseline and size of infarct were similar, significant differences in favour of Mstn-/- compared to WT mice post-MI include a greater recovery of ejection fraction (61.8±1.1% vs 57.1±2.3%, p<0.01), less collagen deposition (41.9±2.8% vs 54.7±3.4%, p<0.05), and lower mortality (0 vs. 20%, p<0.05). There was no difference in the number of BrdU positive cells, percentage of apoptotic cardiomyocytes, or size of cardiomyocytes post-MI between WT and Mstn-/- mice. CONCLUSIONS: Absence of myostatin potentially protects the function of the heart post-MI with improved survival, possibly by limiting extent of fibrosis.

ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome): A Study of Cross-System Implementation of a National Clinical Pathway.

BACKGROUND: Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. METHODS: This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation RESULTS: There were 11 529 participants in the preimplementation phase (range, 284-3465) and 19 803 in the postimplementation phase (range, 395-5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%-37.7%) to 18.4% (6.8%-43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3-2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4-3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P=0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. CONCLUSIONS: Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. CLINICAL TRIAL REGISTRATION: URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.

The All New Zealand Acute Coronary Syndrome Quality Improvement Programme: Implementation, Methodology and Cohorts (ANZACS-QI 9).

The All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI) uses a web-based system to create a clinical registry of patients with acute coronary syndrome (ACS) and other cardiac problems admitted to hospitals across New Zealand. This detailed clinical registry is complemented by parallel analyses of, and individual linkage to, New Zealand's multiple routine health information datasets. The programme is primarily designed to support secondary care clinicians to implement evidence based guidelines and to meet national performance targets for New Zealand cardiac patients. ANZACS-QI simultaneously generates a large-scale research database and provides an electronic data infrastructure for clinical registry studies. ANZACS-QI has been successfully implemented in all the 41 public hospitals across New Zealand where acute cardiac patients are admitted. By June 2015 25,273 patients with suspected ACS and 30,696 referred for coronary angiography were registered in ANZACS-QI. In this report we describe the development and national implementation of ANZACS-QI, its governance, the data collection processes and the current ANZACS-QI cohorts and available outputs.

Incidence and type of bleeding complications early and late after acute coronary syndrome admission in a New Zealand cohort (ANZACS-QI-7).

AIMS: Use of anti-thrombotic agents has reduced ischaemic events in acute coronary syndromes (ACS), but can increase the risk of bleeding. Identifying bleeding events using a consistent methodology from routinely collected national datasets would be useful. Our aims were to describe the incidence and types of bleeding in-hospital and post-discharge in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) cohort. METHODS: 3,666 consecutive patients admitted with ACS (2007-2010) were identified within the ANZACS-QI registry. A set of International Classification of Disease 10 (ICD-10) codes that identified bleeding events was developed. Anonymised linkage to national mortality and hospitalisation datasets was used to identify these bleeding events at the index admission and post-discharge. RESULTS: Three hundred and ninety-nine (10.8%) out of 3,666 patients had at least one bleeding event during a mean follow-up of 1.94 years. One hundred and sixty-one (4.4%) had a bleeding event during their index admission, and 271 (7.4%) patients were re-hospitalised with bleeding during follow-up. Sixty-one patients (37.9%) were transfused for bleeding in the index admission cohort, and 59 patients (21.8%) at a subsequent admission. Procedural bleeding was the most common event during the index admission, whereas gastrointestinal bleeding was the most common delayed bleeding presentation. CONCLUSION: One in ten ACS patients experienced a significant bleeding event within 2 years. The use of this ICD-10 bleeding definition in national ACS cohorts will facilitate the study of bleeding event incidence and type over time and between geographical regions, both nationally and internationally, and the impact of changes in anti-thrombotic therapy and interventional practice.

Optimising diagnostic accuracy with the exercise ECG: opportunities for women and men with stable ischaemic heart disease.

UNLABELLED: The exercise ECG is an integral part within the evaluation algorithm for diagnosis and risk stratification of patients with stable ischaemic heart disease (SIHD). There is evidence, both older and new, that the exercise ECG can be an effective and cost-efficient option for patients capable of performing at maximal levels of exercise with suitable resting ECG findings. In this review, we will highlight the major dilemmas in interpreting suspected coronary artery disease symptoms in women and identify optimal strategies for employing exercise ECG as a first-line diagnostic test in the SIHD evaluation algorithm. We will highlight current evidence as well as recent guideline statements on this subject. TRIAL REGISTRATION NUMBER: NCT01471522; Pre-results.

Falling cholesterol trend at acute coronary syndrome presentation is strongly related to statin use for secondary prevention.

BACKGROUND: Lifestyle changes are believed responsible for temporal trends of reduced population total cholesterol (TC), but it is uncertain whether this applies to patients with known coronary heart disease (CHD) often prescribed lipid lowering therapy (LLT). We studied temporal TC trends at presentation with acute coronary syndrome (ACS) to determine the contribution of LLT given for secondary prevention. METHODS: TC and LLT were obtained in 5592 patients in annual surveys of ACS admissions in Australia between 1999 and 2013, and annual mean trends analysed by linear and segmented regression. RESULTS: TC declined from 5.13±1.1 to 4.53±1.2mmol/L (p<0.001) and LLT (96% statin) use at presentation increased from 37.4% to 47.5% (p=0.005). TC decline was greater in those on LLT vs. those not on therapy, with LLT contributing to 57% of the TC decline. The decline in TC and increase in LLT use was non-linear and much steeper in those with, than without CHD history, and LLT contributed substantially more to the TC decline (79%, p<0.001 vs. 27%, p=0.06 respectively). The rapid decline in TC and increase in LLT, plateauing after 2005 in those with CHD history differed markedly from trends in recent population studies, while TC trend for those without CHD history was slower, linear and consistent with population trends. CONCLUSIONS: Declining TC level at presentation for ACS was strongly associated with increasing LLT use in those with a history of CHD, indicating that increasing uptake of LLT for secondary prevention has impacted TC changes in the new millennium.

National variation in coronary angiography rates and timing after an acute coronary syndrome in New Zealand (ANZACS-QI 6).

AIM: The New Zealand Cardiac Clinical Network and the Ministry of Health recommend a "3-day door-to-catheter target" for acute coronary syndromes (ACS) admissions, requiring that at least 70% of ACS patients referred for invasive coronary angiography (ICA) undergo this within 3 days of hospital admission. We assessed the variability in use of ICA, timing of ICA, and duration of hospital admission across New Zealand District Health Boards (DHBs). METHODS: All patients admitted to all New Zealand public hospitals with suspected ACS undergoing ICA over 1 year ending November 2014 had demographic, risk factor, and diagnostic data collected prospectively using the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. Complete datasets were available in 7,988 (98.4%) patients. DHBs were categorised as those able to perform percutaneous coronary intervention on-site (intervention-capable) or not. RESULTS: There was a near two-fold variation between DHBs in the age standardised rate (ASR) of ICA ranging from 16.8 per 10,000 to 34.1 per 10,000 population (New Zealand rate; 27.9 per 10,000). Patients in intervention-capable DHBs had a 30% higher ASR of ICA. The proportion of ACS patients meeting the 3-day target ranged from 56.7% to 92.9% (New Zealand; 76.4%). Those in intervention-capable DHBs were more likely to meet the target (78.7% vs 68.0%, p<0.0001) and spent 0.84 days (p<.0001) less in hospital. CONCLUSIONS: There is a considerable variation in the rate and timing of ICA in New Zealand. Patients with ACS admitted to DHBs without interventional-capability are disadvantaged. New initiatives to correct this discrepancy are needed.

Radial artery spasm and perforation: simple solutions for challenging cases.

Transradial access for percutaneous coronary intervention and diagnostic coronary angiography has been increasingly utilised in the routine practice in most catheterisation laboratories as it reduces the incidence of major access site complications such as bleeding and haematoma. Radial artery spasm with or without perforation is one of the more frequent reasons for converting from radial to femoral access. In this article, the balloon-assisted technique and Sheathless EauCath (Asahi Intecc, Aichi, Japan) are demonstrated to overcome radial artery spasm with associated significant perforation in two cases.

Recurrent ventricular tachycardia managed with balloon aortic valvuloplasty: an unusual presentation of severe aortic stenosis.

A 68-year-old woman was transferred from a regional hospital with recurrent polymorphic ventricular tachycardia associated with haemodynamic instability. A diagnosis of severe aortic stenosis (AS) with normal left ventricular systolic function had recently been established on echocardiography. Correction of hypokalaemia and intravenous amiodarone infusion were ineffective. On transfer, ongoing ventricular arrhythmias requiring repeat defibrillation occurred. Urgent coronary angiography was unremarkable. Following consultation with the cardiosurgical team, emergency bridging balloon aortic valvuloplasty (BAV) was performed. Two weeks later the patient proceeded to an uneventful inpatient surgical aortic valve replacement (AVR). This case highlights an unusual presentation of severe AS, and describes the use of emergency BAV to correct arrhythmia-induced haemodynamic instability prior to surgical AVR.