Early coronary angiography in NSTEMI: a regional Victorian perspective.

BACKGROUND: Current guidelines highlight a paucity of evidence guiding optimal timing for non-ST-elevation myocardial infarction (NSTEMI) in high-risk and non-high-risk cases. AIM: We assessed long-term major adverse cardiovascular events (MACEs) in NSTEMI patients undergoing early (<24 h) versus delayed (>24 h) coronary angiography at 6 years. Secondary end-points included all-cause mortality and cumulative MACE outcomes. METHODS: Baseline characteristics and clinical outcomes were assessed among 355 patients presenting to a tertiary regional hospital between 2017 and 2018. Cox proportional hazard models were generated for MACE and all-cause mortality outcomes, adjusting for the Global Registry of Acute Coronary Events (GRACE) score, patient demographics, biomarkers and comorbidities. RESULTS: Two hundred and seventy patients were included; 147 (54.4%) and 123 (45.6%) underwent early and delayed coronary angiography respectively. Median time to coronary angiography was 13.3 and 45.4 h respectively. At 6 years, 103 patients (38.1%) experienced MACE; 41 in the early group and 62 in the delayed group (hazard ratio (HR) = 2.23; 95% confidence interval (CI) = 1.50-3.31). After multivariable adjustment, the delayed group had higher rates of MACE (HR = 1.79; 95% CI = 1.19-2.70), all-cause mortality (HR = 2.76; 95% CI = 1.36-5.63) and cumulative MACE (incidence rate ratio = 1.54; 95% CI = 1.12-2.11). Subgroup analysis of MACE outcomes in rural and weekend NSTEMI presentations was not significant between early and delayed coronary angiography (HR = 1.49; 95% CI = 0.83-2.62). CONCLUSION: Higher MACE rates in the delayed intervention group suggest further investigation is needed. Randomised control trials would be well suited to assess the role of early invasive intervention across all NSTEMI risk groups.

Long-Term Implications of Socioeconomic Status on Major Adverse Cardiovascular, Cerebrovascular Events (MACCE), and All-Cause Mortality.

BACKGROUND: Socio-economic status (SES) has a large impact on health through a complex interplay of upstream, midstream and downstream factors. However, little is known about the predictive role of SES on long-term major adverse cardiovascular, cerebrovascular events, and mortality (MACCE). AIM: To determine the long-term relationship between SES and MACCE for men and women. The secondary endpoint was to determine the relationship between SES and all-cause mortality. METHOD: A total of 3,034 participants (1,494 women and 1,540 men) were assessed at baseline in the Geelong Osteoporosis Study, a large regional Australian population cohort study. Area-based SES was assessed, utilising the Index of Relative Socio-Economic Disadvantage (IRSD) and grouped into quintiles. The primary endpoint, MACCE, was defined as a composite of myocardial infarction, heart failure hospitalisation, malignant arrhythmias, stroke, and all-cause mortality. The secondary endpoint was all-cause mortality. Baseline data including age, sex, smoking status and alcohol use, and comorbidities were collected between 1993-1997 for women, and 2001-2006 for men, with follow-up over 30 and 22 years, respectively. Logistic regression was utilised to assess MACCE and all-cause mortality outcomes across the SES quintiles. RESULTS: Participants lost to follow-up or with incomplete data collection were excluded leaving 2,173 participants eligible for analysis. SES was associated with MACCE outcomes. Compared with Quintile I (lowest SES stratum), the odds of MACCE for each IRSD stratum were: Quintile II, odds ratio (OR) 0.85 (95% confidence interval [CI] 0.65-1.13); Quintile III, OR 0.69 (95% CI 0.51-0.91); Quintile IV, OR 0.66 (95% CI 0.50-0.88); and, Quintile V, OR 0.55 (95% CI 0.41-0.72). In the adjusted model, an inverse trend was noted, with reducing MACCE outcomes with an increasing SES status; IRSD Quintile II, OR 0.85 (95% CI 0.62-1.17); Quintile III, OR 0.70 (95% CI 0.50-0.97); Quintile IV, OR 0.73 (95% CI 0.52-1.02); and, Quintile V, OR 0.54 (95% CI 0.39-0.74). SES was inversely associated with all-cause mortality; IRSD Quintile II (OR 0.87, 95% CI 0.66-1.16) failed to achieve significance however IRSD Quintile III (OR 0.65, 95% CI 0.48-0.88), Quintile IV (OR 0.59, 95% CI 0.44-0.80) and Quintile V (OR 0.46, 95% CI 0.34-0.62) had a lower risk of mortality compared with Quintile I. In the adjusted model, an inversely proportional trend was noted between SES and all-cause mortality; IRSD Quintile II (OR 0.82, 95% CI 0.59-1.15), IRSD Quintile III (OR 0.63, 95% CI 0.49-0.95), Quintile IV (OR 0.59, 95% CI 0.45-0.90) and Quintile V (OR 0.44, 95% CI 0.31-0.61) had fewer mortality events compared with IRSD Quintile I. CONCLUSIONS: Our research indicates that being part of a lower socio-economic stratum is linked to a higher likelihood of experiencing negative cardiovascular and cerebrovascular events, along with an increased risk of overall mortality. SES is an important risk stratification marker for long-term prognosis of cardiovascular diseases and stroke, and warrants further investigation.

Urinary sodium concentration predicts time to major adverse coronary events and all-cause mortality in men with heart failure over a 28-33-year period: a prospective cohort study.

BACKGROUND: Lower urinary sodium concentrations (UNa) may be a biomarker for poor prognosis in chronic heart failure (HF). However, no data exist to determine its prognostic association over the long-term. We investigated whether UNa predicted major adverse coronary events (MACE) and all-cause mortality over 28-33 years. METHODS: One hundred and eighty men with chronic HF from the Kuopio Ischaemic Heart Disease Risk Factor Study (KIHD) were included. Baseline data was collected between 1984 and 1989. MACE and all-cause outcomes were obtained using hospital linkage data (1984-2017) with a follow-up of 28-33 years. Cox proportional hazards models were generated using 24-h UNa tertiles at baseline (1 ≤ 173 mmol/day; 2 = 173-229 mmol/day; 3 = 230-491 mmol/day) as a predictor of time-to-MACE outcomes, adjusted for relevant covariates. RESULTS: Overall, 63% and 83% of participants (n = 114 and n = 150) had a MACE event (median 10 years) and all-cause mortality event (median 19 years), respectively. On multivariable Cox Model, relative to the lowest UNa tertile, no significant difference was noted in MACE outcome for individuals in tertiles 2 and 3 with events rates of 28% (HR:0.72; 95% CI: 0.46-1.12) and 21% (HR 0.79; 95% CI: 0.5-1.25) respectively.. Relative to the lowest UNa tertile, those in tertile 2 and 3 were 39% (HR: 0.61; 95% CIs: 0.41, 0.91) and 10% (HR: 0.90; 95% CIs: 0.62, 1.33) less likely to experience to experience all-cause mortality. The multivariable Cox model had acceptable prediction precision (Harrell's C concordance measure 0.72). CONCLUSION: UNa was a significant predictor of all-cause mortality but not MACE outcomes over 28-33 years with 173-229 mmol/day appearing to be the optimal level. UNa may represent an emerging long-term prognostic biomarker that warrants further investigation.

A scoping review of mental health status in Australian medical students and doctors-in-training (DiT).

Background and Aims: The study and practice of medicine are known to contribute to burnout in medical students and junior doctors. There is limited data on the degree of mental health burden for Australian medical students and doctors-in-training (DiT). This scoping review aims to explore the impact of medical training on the mental health of Australian medical students and DiT. Exploring the mental health landscape across different stages of training will help to establish putative factors underlying psychiatric comorbidities in this demographic. Methods: The Joanna Brigs Institute (JBI) framework for scoping review was utilized, involving the Population/Concept/Context (PCC) criteria to identify the target population and develop the search strategy. Peer-reviewed articles, published in English from 2012 to 2022 focusing on Australian medical students' and doctors-in-training mental health were considered. Results: Of the 177 articles identified, 24 studies were included in the review. The majority of the studies focused on DiT (n = 19) of which interns and residents were most well represented (n = 12) followed by surgical training (n = 5), with general practice (GP) (n = 2) and physician specialties (nil) being poorly represented. Most studies were quantitative (n = 18), with qualitative studies(n = 6) under represented. Common mental health themes identified were overall psychological distress, burnout, and depression/suicidal ideation with workplace harassment and discrimination being less well represented. Conclusions: Australian DiT are not equally represented in the literature with how different specialty training pathways impact their mental health. Most studies were cross-sectional, preventing a detailed longitudinal assessment of burnout and work-associated psychological distress.