Late outcomes of ST-elevation myocardial infarction treated by pharmaco-invasive or primary percutaneous coronary intervention.

AIMS: Pharmaco-invasive percutaneous coronary intervention (PI-PCI) is recommended for patients with ST-elevation myocardial infarction (STEMI)who are unable to undergo timely primary PCI (pPCI). The present study examined late outcomes after PI-PCI (successful reperfusion followed by scheduled PCI or failed reperfusion and rescue PCI)compared with timely and late pPCI (>120 min from first medical contact). METHODS AND RESULTS: All patients with STEMI presenting within 12 h of symptom onset, who underwent PCI during their initial hospitalization at Liverpool Hospital (Sydney), from October 2003 to March 2014, were included. Amongst 2091 STEMI patients (80% male), 1077 (52%)underwent pPCI (68% timely, 32% late), and 1014 (48%)received PI-PCI (33% rescue, 67% scheduled). Mortality at 3 years was 11.1% after pPCI (6.7% timely, 20.2% late) and 6.2% after PI-PCI (9.4% rescue, 4.8% scheduled); P < 0.01. After propensity matching, the adjusted mortality hazard ratio (HR) for timely pPCI compared with scheduled PCI was 0.9 (95% CIs 0.4-2.0) and compared with rescue PCI was 0.5 (95% CIs 0.2-0.9). The adjusted mortality HR for late pPCI, compared with scheduled PCI was 2.2 (95% CIs 1.2-3.1)and compared with rescue PCI, it was 1.5 (95% CIs 0.7-2.0). CONCLUSION: Patients who underwent late pPCI had higher mortality rates than those undergoing a pharmaco-invasive strategy. Despite rescue PCI being required in a third of patients, a pharmaco-invasive approach should be considered when delays to PCI are anticipated, as it achieves better outcomes than late pPCI.

Robotic Assisted Percutaneous Coronary Intervention: Initial Australian Experience.

BACKGROUND & AIM: Robotic-assisted percutaneous coronary intervention (R-PCI) has been increasingly performed overseas. Initial observations have demonstrated its clinical efficacy and safety with additional potential benefits of more accurate lesion assessment and stent deployment, with reduced radiation exposure to operators and patients. However, data from randomised controlled trials or clinical experience from Australia are lacking. METHODS: This was a single-centre experience of all patients undergoing R-PCI as part of the run-in phase for an upcoming randomised clinical trial (ACTRN12623000480684). All R-PCI procedures were performed using the CorPath GRX robot (Corindus Vascular Robotics, Waltham, Massachusetts, USA). Key inclusion criteria included patients with obstructive coronary disease requiring percutaneous coronary intervention. Major exclusion criteria included ST-elevation myocardial infarction, cardiogenic shock or lesions deemed unsuitable for R-PCI by the operator. Clinical success was defined as residual stenosis <30% without in-hospital major adverse cardiovascular events (MACE). Technical success was defined as the completion of the R-PCI procedure without unplanned manual conversion. Procedural characteristics were compared between early (cases 1-3) and later (cases 4-21) cases. RESULTS: Twenty-one (21) patients with a total of 24 lesions were analysed. The mean age of patients was 66.5 years, and 66% of cases were male. Radial access was used in 18 cases (86%). Most lesions were American Heart Association/American College of Cardiology class B2/C (66%). Clinical success was achieved in 100% with manual conversion required in four cases (19%). No procedural complications or in-hospital MACE occurred. Compared to the early cases, later cases had a statistically significantly shorter fluoroscopy time (44.0mins vs 25.2mins, p<0.007), dose area product (967.3 dGy.cm2 vs 361.0dGy.cm2, p=0.01) and air kerma (2484.3mGy vs 797.4mGy, p=0.009) with no difference in contrast usage (136.7mL vs 131.4mL, p=0.88). CONCLUSIONS: We present the first clinical experience of R-PCI in Australia using the Corindus CorPath GRX robot. We achieved clinical success in all patients and technical success in the majority of cases with no procedural complications or in-hospital MACE. With increasing operator and staff experience, cases required shorter fluoroscopy time and less radiation exposure but similar contrast usage.

Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome: The TEXTMEDS Randomized Clinical Trial.

BACKGROUND: TEXTMEDS (Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome) examined the effects of text message-delivered cardiac education and support on medication adherence after an acute coronary syndrome. METHODS: TEXTMEDS was a single-blind, multicenter, randomized controlled trial of patients after acute coronary syndrome. The control group received usual care (secondary prevention as determined by the treating clinician); the intervention group also received multiple motivational and supportive weekly text messages on medications and healthy lifestyle with the opportunity for 2-way communication (text or telephone). The primary end point of self-reported medication adherence was the percentage of patients who were adherent, defined as >80% adherence to each of up to 5 indicated cardioprotective medications, at both 6 and 12 months. RESULTS: A total of 1424 patients (mean age, 58 years [SD, 11]; 79% male) were randomized from 18 Australian public teaching hospitals. There was no significant difference in the primary end point of self-reported medication adherence between the intervention and control groups (relative risk, 0.93 [95% CI, 0.84-1.03]; P=0.15). There was no difference between intervention and control groups at 12 months in adherence to individual medications (aspirin, 96% vs 96%; ß-blocker, 84% vs 84%; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 77% vs 80%; statin, 95% vs 95%; second antiplatelet, 84% vs 84% [all P>0.05]), systolic blood pressure (130 vs 129 mm Hg; P=0.26), low-density lipoprotein cholesterol (2.0 vs 1.9 mmol/L; P=0.34), smoking (P=0.59), or exercising regularly (71% vs 68%; P=0.52). There were small differences in lifestyle risk factors in favor of intervention on body mass index <25 kg/m2 (21% vs 18%; P=0.01), eating ≥5 servings per day of vegetables (9% vs 5%; P=0.03), and eating ≥2 servings per day of fruit (44% vs 39%; P=0.01). CONCLUSIONS: A text message-based program had no effect on medical adherence but small effects on lifestyle risk factors. REGISTRATION: URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364448; Unique identifier: ANZCTR ACTRN12613000793718.

Exploration of Cardiology Patient Hospital Presentations, Health Care Utilisation and Cardiovascular Risk Factors During the COVID-19 Pandemic.

OBJECTIVES: COVID-19 and the lockdowns have affected health care provision internationally, including medical procedures and methods of consultation. We aimed to assess the impact of COVID-19 at two Australian hospitals, focussing on cardiovascular hospital admissions, the use of community resources and cardiovascular risk factor control through a mixed methods approach. METHODS: Admissions data from the quaternary referral hospital were analysed, and 299 patients were interviewed from July 2020 to December 2021. With the admissions data, the number, complexity and mortality of cardiology hospital admissions, prior to the first COVID-19 lockdown (T0=February 2018-July 2019) were compared to after the introduction of COVID-19 lockdowns (T1=February 2020-July 2021). During interviews, we asked patients about hospital and community health resource use, and their control of cardiovascular risk factors from the first lockdown. RESULTS: Admission data showed a reduction in hospital presentations (T0=138,099 vs T1=128,030) and cardiology admissions after the lockdown period began (T0=4,951 vs T1=4,390). After the COVID-19-related lockdowns began, there was an increased complexity of cardiology admissions (T0=18.7%, 95% CI 17.7%-19.9% vs T1=20.3%, 95% CI 19.1%-21.5%, chi-square test: 4,158.658, p<0.001) and in-hospital mortality (T0=2.3% of total cardiology admissions 95% CI 1.9%-2.8% vs T1=2.8%, 95% CI 2.3%-3.3%, chi-square test: 4,060.217, p<0.001). In addition, 27% of patients delayed presentation due to fears of COVID-19 while several patients reported reducing their general practitioner or pathology/imaging appointments (27% and 11% respectively). Overall, 19% reported more difficulty accessing medical care during the lockdown periods. Patients described changes in their cardiovascular risk factors, including 25% reporting reductions in physical activity. CONCLUSION: We found a decrease in hospital presentations but with increased complexity after the introduction of COVID-19 lockdowns. Patients reported being fearful about presenting to hospital and experiencing difficulty in accessing community health services.

Utility of prehospital electrocardiogram interpretation in ST-segment elevation myocardial infarction utilizing computer interpretation and transmission for interventional cardiologist consultation.

OBJECTIVES: We examined the appropriateness of prehospital cardiac catheter laboratory activation (CCL-A) in ST-segment elevation myocardial infarction (STEMI) utilizing the University of Glasgow algorithm (UGA) and remote interventional cardiologist consultation. BACKGROUND: The incremental benefit of prehospital electrocardiogram (PH-ECG) transmission on the diagnostic accuracy and appropriateness of CCL-A has been examined in a small number of studies with conflicting results. METHODS: We identified consecutive PH-ECG transmissions between June 2, 2010 and October 6, 2016. Blinded adjudication of ECGs, appropriateness of CCL-A, and index diagnoses were performed using the fourth universal definition of MI. The primary outcome was the appropriate CCL-A rate. Secondary outcomes included rates of false-positive CCL-A, inappropriate CCL-A, and inappropriate CCL nonactivation. RESULTS: Among 1088 PH-ECG transmissions, there were 565 (52%) CCL-As and 523 (48%) CCL nonactivations. The appropriate CCL-A rate was 97% (550 of 565 CCL-As), of which 4.9% (n = 27) were false-positive. The inappropriate CCL-A rate was 2.7% (15 of 565 CCL-As) and the inappropriate CCL nonactivation rate was 3.6% (19 of 523 CCL nonactivations). Reasons for appropriate CCL nonactivation (n = 504) included nondiagnostic ST-segment elevation (n = 128, 25%), bundle branch block (n = 132, 26%), repolarization abnormality (n = 61, 12%), artefact (n = 72, 14%), no ischemic symptoms (n = 32, 6.3%), severe comorbidities (n = 26, 5.2%), transient ST-segment elevation (n = 20, 4.0%), and others. CONCLUSIONS: PH-ECG interpretation utilizing UGA with interventional cardiologist consultation accurately identified STEMI with low rates of inappropriate and false-positive CCL-As, whereas using UGA alone would have almost doubled CCL-As. The benefits of cardiologist consultation were identifying "masquerading" STEMI and avoiding unnecessary CCL-As.

Achieving lipid targets within 12 months of an acute coronary syndrome: an observational analysis.

OBJECTIVES: To assess lipid levels in people six or 12 months after hospitalisation with acute coronary syndrome (ACS); to identify factors associated with not achieving lipid level targets. DESIGN, SETTING: Retrospective cohort study; analysis of data from CONCORDANCE, an Australian ACS registry, 2009-2018. PARTICIPANTS: Adult patients who had experienced confirmed ACS of cardiovascular origin, for whom serum lipid levels had been assessed on admission and six or 12 months after discharge. MAIN OUTCOME MEASURES: Not achieving lipid targets by most recent follow-up (in order of priority: low-density lipoprotein cholesterol [LDL-C] ≤ 1.8 mmol/L or total cholesterol ≤ 4 mmol/L); factors associated with not achieving target lipid levels. RESULTS: Lipid levels measured at 6- or 12-month follow-up were available for 2671 of 10 578 people discharged from hospital alive; 1194 (45%) had not achieved lipid targets at their most recent follow-up, including 876 (73%) who had been prescribed intensive lipid-lowering therapy at discharge. People under 65 years of age, those using lipid-lowering therapy or with higher cholesterol levels on admission, patients prescribed fewer than four evidence-based therapies or not prescribed intensive lipid-lowering therapy on discharge, and women were more likely to not reach lipid level targets. CONCLUSION: Almost half the patients did not achieve target lipid levels within 12 months of an admission to hospital with ACS. These people are at elevated risk of recurrent cardiovascular disease, and therapy could be optimised (eg, dose escalation, drug combinations, novel therapies) to improve outcomes.

In Hospital Outcomes for High-Risk Percutaneous Coronary Intervention (PCI) in Patients Referred From a Rural Centre to Metropolitan Sites.

BACKGROUND: Cardiac Society of Australia and New Zealand (CSANZ) guidelines recommend elective high-risk percutaneous coronary intervention (PCI) is not performed in sites greater than 1 hour from cardiac surgery. METHODS: In hospital outcomes for all patients from Orange Health Service (OHS) from January 2017 to January 2020 who were transferred electively to tertiary centres in Sydney for high risk PCI were examined. RESULTS: One hundred and fourteen (114) patients were identified, with 1,259 PCIs performed at OHS over the same period without transfer. The mean age of these 114 patients was 71 years, with 74.6% male. Receiving hospitals were Royal Prince Alfred Hospital, Sydney, NSW (66.7%), Concord Repatriation General Hospital, Concord, NSW (19.3%) and Strathfield Private Hospital, Strathfield, NSW (14%). The definition of high risk and indication for transfer included at least one of: moderate or greater calcification of the target lesion or proximal segment (34%), single or multiple target lesions that in aggregate jeopardised over 50% of remaining viable myocardium (27%), degenerated saphenous vein grafts (14.8%), chronic total occlusions (7.0%) and severe left ventricular (LV) impairment (3.9%). American Heart Society/American College of Cardiology (AHA/ACC) lesion types were A (1%), B1 (4.2%), B2 (40.2%), and C (54.6%). PCI was performed via the femoral route in 96.2%. The mean procedure duration was 72 minutes, mean combined fluoroscopy time was 19 minutes and mean radiation dose as defined by Reference Air Kerma was 1,630 mGy. Complications occurred in 13 patients and were: acute vessel dissection requiring stenting (4), perforation (2), acute vessel closure (4), puncture site related (1), and life-threatening arrhythmia (2). There were no cases of emergent coronary artery bypass graft (CABG) or death. CONCLUSION: This contemporary cohort of high-risk patients transferred electively from a regional PCI centre to a tertiary cardiac unit underwent lengthy PCI procedures, with high radiation doses, and a modest rate of peri-procedural complications, but had otherwise excellent procedural and clinical outcomes.

Right ventricular myocardial infarction: pathophysiology, clinical implications and management.

Right ventricular myocardial infarction (RVMI) and right ventricular (RV) failure are complications from an acute occlusion of a dominant right coronary artery (RCA) or left anterior descending (LAD) artery. Although some patients have good long-term RV recovery, RVMI is associated with high rates of in-hospital morbidity and mortality driven by hemodynamic compromise, cardiogenic shock, and electrical complications. As such, it is important to identify specific clinical signs and symptoms, initiate resuscitation and commence reperfusion therapy with fibrinolytic therapy or percutaneous coronary intervention. This review will discuss RVMI pathophysiology, describe the current diagnostic measures, highlight current therapies, and explore future management options.

Comparing the clinical and prognostic impact of proximal versus nonproximal lesions in dominant right coronary artery ST-elevation myocardial infarction.

OBJECTIVE: To evaluate the prognostic significance of culprit lesion location in dominant right coronary artery (RCA) ST-elevation myocardial infarction (STEMI). BACKGROUND: In RCA STEMI, proximal culprit lesions have been shown to have higher rates of acute complications such as bradycardia and cardiogenic shock (CS) but data on mortality is limited. METHODS: We retrospectively identified and analyzed data from consecutive patients with a dominant RCA STEMI who underwent either primary or rescue percutaneous coronary intervention (PCI) between January 2003 and December 2016. We compared the rates of sustained ventricular tachycardia (VT), CS, intra-aortic balloon pump (IABP), temporary cardiac pacing (TCP) and death between culprit lesions located proximal and distal to the origin of the last right ventricular (RV) marginal artery >1 mm in diameter. RESULTS: The 939 patients were included; 599 (63.7%) had a proximal lesion and 340 (36.3%) had a nonproximal lesion. The 801 (85.3%) underwent primary PCI and 138 (14.7%) underwent rescue PCI. There was no difference in first medical contact to balloon or fibrinolysis times between the groups; p = .98 and .71. There was no significant difference in the rate of sustained VT (3.0%vs. 3.2%, p = .85) but proximal lesions were more likely to develop CS (10.9%vs. 5.8%, p = .01), require IABP (7.3%vs.2.9%, p < .01) and TCP (6.3%vs. 2.6%, p = .01). Thirty-day mortality was higher for proximal lesions (5.0%vs. 0.9%, p < .01) particularly for those with CS (35.3%vs. 10.0%, p = .05). CONCLUSION: Culprit lesions located proximal to the origin of the last RV marginal artery had a higher rate of acute complications such as CS and mortality.

The Learning Curves for Transradial and Ultrasound-Guided Arterial Access: An Analysis of the SURF Trial.

INTRODUCTION: Historically, coronary angiography and percutaneous coronary intervention involved accessing the femoral artery via palpation. However, recently there has been a trend towards using a transradial approach and ultrasound guidance for arterial access. Studies have shown that these techniques respectively improve major bleeding rates and access outcomes. There have been no studies conducted that assess the time it takes to train operators to attain proficiency. This sub-analysis of the Standard versus Ultrasound-guided Radial and Femoral access in coronary angiography and intervention (SURF) trial aims to assess the number of procedures required to attain proficiency in ultrasound-guided transradial and transfemoral access. METHODS: The SURF trial randomised 1,388 patients undergoing coronary angiography and/or percutaneous coronary intervention into standard or ultrasound-guidance and radial or femoral access in a 2×2 factorial design. Operators who participated in this trial were required to have performed at least 50 standard and 10 ultrasound-guided punctures for each of transradial and transfemoral access. Cases were then chronologically ordered and stratified into groups of five, from which the primary endpoint measured was a progression in mean access time and first-pass success rates. RESULTS: Across all operators, there was a reduction in mean access time between procedures one to five and six to 10 with ultrasound-guided femoral punctures (60.5 secs-51.5 secs, p=0.029) and between procedures 11 to 15 and 16 to 20 ultrasound-guided radial punctures (74s to 62.5 secs, p=0.082). This trend was more obvious in trainees, with significant reductions in mean access time between procedures one to five and six to 10 from 73.5 to 53.5 seconds (p<0.001) for ultrasound-guided femoral access and from 99.5 seconds to 60 seconds (p=0.024) for ultrasound-guided radial access. There were no trends with standard transradial access. CONCLUSION: The numbers required to attain competency in ultrasound-guided femoral and radial access are 15 and 25 punctures, respectively. Fifty (50) punctures appear adequate for proficiency in a standard transradial approach. These numbers are useful in incorporating into training program for advanced trainees and interventionalists.

Diabetes and Incomplete Revascularisation in ST Elevation Myocardial Infarction.

BACKGROUND: Incomplete revascularisation is common and prognostically important. The degree to which incomplete revascularisation (IR) is associated with adverse cardiac outcomes in patients with diabetes and ST-elevation myocardial infarction (STEMI) is unknown. METHODS: Late outcomes (3.6 years) were evaluated in 589 consecutive STEMI patients treated with percutaneous coronary intervention in this observational study. Associations between incomplete revascularisation, and diabetes were assessed. A residual SYNergy Between Percutaneous Coronary Intervention With TAXus and Cardiac Surgery (SYNTAX) Score (rSS) >8 defined IR. The primary endpoint studied was cardiac death, myocardial infarction or cerebrovascular accident. RESULTS: Incomplete revascularisation occurred in 36% of patients with diabetes (46/127) and 32% of patients without diabetes (147/462); p=0.329. The primary endpoint occurred in 27% of patients with diabetes compared to 18% of patients without diabetes (p=0.042); and in 28% with a rSS>8 compared to 16% of patients with a rSS≤8 (p<0.001). The primary endpoint occurred in 35% of patients with both diabetes and a rSS>8, 27% without diabetes with a rSS>8, 22% with diabetes and a rSS≤8, and 14% of with patients neither factor (p<0.001), with cardiac death rates respectively of 22%, 9%, 6%, 2% (p<0.001). Patients with both IR and diabetes accounted for only 8% of STEMI patients but 30% of all cardiac deaths. On multivariable analyses diabetes and IR were independently associated with cardiac death, myocardial infarction and cerebrovascular accident; both p<0.05. CONCLUSIONS: Diabetes and IR contribute independently to late outcomes in STEMI patients. The prognostic impact of diabetes was not due to IR alone. Diabetes acts synergistically with incomplete revascularisation to worsen prognosis.

Troponin measurements, myocardial infarction diagnoses and outcomes. An analysis of linked data from New South Wales, Australia.

BACKGROUND: Cardiac troponin assays are very widely requested tests, particularly in emergency departments. Thus, many seriously ill patients who may not have heart disease as their primary discharge diagnosis have undergone troponin testing during hospitalisation. AIMS: To determine associations between cardiac troponin levels and mortality, including from cardiovascular and non-cardiovascular causes, among patients hospitalised in New South Wales, Australia over a 2-year period. METHODS: Over a 2-year period (2006-2008), 172 753 hospitalised patients had a quantitative or qualitative troponin assay performed in New South Wales (Australia). The associations were examined, using data linked to late outcomes, between elevations in levels of troponins T or I and 1-year mortality. Mortality was determined for International Statistical Classification of Diseases 10th Revision diagnostic groups. RESULTS: Of 172 753 patients undergoing troponin testing, 44 357 (25%) had a cardiovascular diagnosis of whom (7% had myocardial infarction) 47 827 (28%) had a probable ischaemic heart disease diagnosis if the 23 873 (14%) of patients coded with 'chest pain' were included. In patients with a cardiovascular diagnosis and elevated troponin 3060 (1.8%) died in 12 months in comparison to 6262 (3.6%) in those with a non-cardiovascular disease diagnoses and elevated troponin. The 1-year mortality hazard with respect to a troponin elevation was 2.5 (95% confidence interval 2.3-2.7) and 2.0 (95% confidence interval 1.99-2.01) for those with a cardiovascular and non-cardiovascular diagnosis respectively. CONCLUSION: In a very large state-wide hospitalised patient cohort, among patients with elevated troponin levels and non-cardiac diagnoses, mortality was higher than in those with cardiovascular diagnoses, including MI.

Assessing Coronary Microvascular Dysfunction in Ischaemic Heart Disease: Little Things Can Make a Big Difference.

The role of coronary microvascular dysfunction (CMD) in the pathogenesis of ischaemic heart disease and in determining long-term prognosis is increasingly recognised. In selected patients, a comprehensive coronary assessment including an assessment of microvascular function may help refine risk stratification and improve patient outcomes. Various non-invasive and invasive techniques have been developed to assess the coronary microcirculation. Many of these tests utilise the indicator-dilution principle to determine coronary or myocardial blood flow. However, these techniques are often limited by their variability and lack of specificity for the coronary microvasculature. Consequently, there is still paucity of data on targeted therapies for CMD and their implications on long-term clinical outcomes, particularly in the setting of non-ST elevation acute coronary syndromes. Recent technical advancements, such as the index of microcirculatory resistance, have largely overcome these limitations and are able to provide novel insights into the assessment and treatment of CMD. This review summarises the currently available techniques for the assessment of CMD and provides an overview of its clinical implications.

Mortality at 5 Years Among Very Elderly Patients Undergoing High Sensitivity Troponin T Testing for Suspected Acute Coronary Syndromes.

BACKGROUND: Patients aged ≥80 years old often present to Emergency Departments (ED) with symptoms potentially due to an acute coronary syndrome (ACS). This study aimed to evaluate associations between baseline level(s) of high sensitivity troponin T (HsTnT), adjudicated diagnoses and outcomes. METHODS: Consecutive patients aged ≥80 years were studied, who presented to the ED at Liverpool Hospital, NSW, Australia during the 4 months period March to June 2014 (inclusive) with symptoms suggestive of an ACS, and who had at least one HsTnT assay performed. Diagnoses were based on the fourth universal definition of MI (myocardial infarction) including type-1 MI, type-2 MI, acute myocardial injury, chronic myocardial injury; the rest were termed "other diagnoses". Patients were categorised by baseline HsTnT levels 1) ≤14 ng/L, 2) 15-29 ng/L, 3) 30-49 ng/L and 4) ≥50 ng/L. RESULTS: Of 2,773 patients screened, 545 were aged ≥80 years (median age 85 [IQR 82-88]); median follow-up was 32 months (IQR 5-56). The respective rates of adjudicated diagnoses were type-I MI 3.1%, type-2 MI 13%, acute myocardial injury 9.5%, chronic myocardial injury 56% and 18.6% had other diagnoses. Mortality rates increased, irrespective of adjudicated diagnoses with increasing HsTnT levels (ng/L): 17% (16/96) for ≤14; 35% (67/194) for 15-29; 51% (65/127) for 30-49; and 64% (82/128) for ≥50 ng/L; log rank p≤0.001. On multi-variable analyses, after adjusting for potential confounding factors including age, hypertension, chronic kidney disease (CKD) and chronic obstructive pulmonary disease (COPD), MI type was not associated with late mortality. CONCLUSIONS: Among patients aged ≥80 years higher HsTnT levels, irrespective of adjudicated diagnoses, were associated with increased mortality. Most very elderly patients presenting with symptoms suggestive of an ACS undergoing HsTnT testing in EDs had elevated levels most commonly due to chronic myocardial injury. Whether any interventions can modify outcomes require prospective evaluation.

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.

COVID-19 and Acute Heart Failure: Screening the Critically Ill - A Position Statement of the Cardiac Society of Australia and New Zealand (CSANZ).

Up to one-third of COVID-19 patients admitted to intensive care develop an acute cardiomyopathy, which may represent myocarditis or stress cardiomyopathy. Further, while mortality in older patients with COVID-19 appears related to multi-organ failure complicating acute respiratory distress syndrome (ARDS), the cause of death in younger patients may be related to acute heart failure. Cardiac involvement needs to be considered early on in critically ill COVID-19 patients, and even after the acute respiratory phase is passing. This Statement presents a screening algorithm to better identify COVID-19 patients at risk for severe heart failure and circulatory collapse, while balancing the need to protect health care workers and preserve personal protective equipment (PPE). The significance of serum troponin levels and the role of telemetry and targeted transthoracic echocardiography (TTE) in patient investigation and management are addressed, as are fundamental considerations in the management of acute heart failure in COVID-19 patients.

Clinical and Angiographic Predictors of Mortality in Sudden Cardiac Arrest Patients Having Cardiac Catheterisation: A Single Centre Registry.

BACKGROUND: Immediate cardiac catheterisation (CC) is recommended in ST-elevation myocardial infarction (STEMI) following sudden cardiac arrest (SCA). Guidelines advise urgent CC for SCA patients without-STEMI, at clinician discretion. We examined the clinical and angiographic factors predicting mortality in SCA patients having CC. METHODS: Consecutive SCA patients having CC at Liverpool Hospital, Sydney (January 2011-September 2015) were retrospectively analysed. Patient data were retrieved from hospital records, and angiographic SYNTAX scores (SS) were quantified online. Independent predictors of mortality were derived using multivariate logistic analysis. RESULTS: The study cohort comprised 104 SCA patients; mean age 61±12years, and 79% male. Immediate CC (<2hours post-SCA) was performed in 35% overall. Compared to the without-STEMI subgroup, STEMI patients had more ventricular fibrillation (91 vs 50%; p<0.0001), and higher mean peak serum high-sensitivity troponin-T (8.25±14.7 vs 1.97±6.13 ug/L; p=0.006); in the context of higher median SS (18 vs 6.5; p=0.002) and target-lesion SS (tSS, 10 vs 0; p<0.001). Percutaneous coronary intervention (PCI; 75 vs 23%; p<0.0001) and target vessel revascularisation (11 vs 0%; p=0.005) were more frequent for STEMI. All-cause mortality was 39%, at 1.3±1.5years follow-up. Independent mortality predictors were: delayed CC (HR 4.08), serum lactate >7mmol/L (HR 3.47), and tSS (HR 1.05). CONCLUSIONS: Elevated serum lactate, tSS, and delayed CC, were predictive of longer-term mortality in SCA patients having CC. Late CC in patients without-STEMI suggest scope for improvement in real-world systems of care. Closer scrutiny of target lesion complexity may aid prognostication in SCA survivors.

The impact of incomplete revascularization on early and late outcomes in ST-elevation myocardial infarction.

BACKGROUND: In ST-elevation myocardial infarction (STEMI) in patients with multivessel disease, there is a lack of consensus regarding the importance of complete revascularization and the timing of treatment of nonculprit stenoses. Our objective was to investigate the impact of incomplete revascularization in STEMI patients using the residual Synergy Between PCI with TAXUS and Cardiac Surgery score (rSS) to define completeness of revascularization. METHODS: This study examined associations between incomplete revascularization, determined by the rSS, and the combined outcome of cardiac death and myocardial infarction (MI). Patients were divided into groups: rSS = 0 (complete revascularization), rSS = 1-8 (incomplete revascularization with a low burden of residual disease), or rSS >8 (incomplete revascularization with a high burden of residual disease). RESULTS: The rSS score was calculated in 589 consecutive patients; 25% had an rSS of 0, 42% rSS 1-8, and 33% rSS >8. At median follow-up of 3.5 years, cardiac death and MI occurred in 5% of rSS = 0 patients, 15% rSS = 1-8, and 26% with rSS >8 (P < .001). The rSS was powerful independent predictor of cardiac death and MI (hazard ratio 5.05, CI 2.89-12.00, rSS >8 vs rSS 0, P < .001 and hazard ratio 2.96, CI 1.31-6.69, rSS = 1-8 vs rSS = 0, P = .009), respectively, and an independent predictor of mortality, MI, unplanned revascularization, and major adverse cardiovascular events. CONCLUSIONS: In patients with STEMI, the rSS independently predicts cardiac death and MI. Patients with an rSS >8 had substantially higher rates of cardiac death or MI. The rSS can be used to define incomplete revascularization in STEMI and predict adverse outcomes.

Differences in management and outcomes for men and women with ST-elevation myocardial infarction.

OBJECTIVE: To examine whether there are sex differences in the characteristics, management, and clinical outcomes of patients with an ST-elevation myocardial infarction (STEMI). Design, setting: Cohort study; analysis of data collected prospectively by the CONCORDANCE acute coronary syndrome registry from 41 Australian hospitals between February 2009 and May 2016. PARTICIPANTS: 2898 patients (2183 men, 715 women) with STEMI. MAIN OUTCOME MEASURES: Rates of revascularisation (percutaneous coronary intervention [PCI], thrombolysis, coronary artery bypass grafting [CABG]), adjusted for GRACE risk score quartile. SECONDARY OUTCOMES: timely vascularisation rates; major adverse cardiac event rates; clinical outcomes and preventive treatments at discharge. RESULTS: The mean age of women with STEMI at presentation was 66.6 years (SD, 14.5 years), of men, 60.5 years (SD, 12.5 years). The proportions of women with hypertension, diabetes, prior stroke, chronic kidney disease, chronic heart failure, or dementia were larger than those of men; fewer women had histories of previous coronary artery disease or myocardial infarction, or of prior PCI or CABG. Women were less likely to have undergone coronary angiography (odds ratio, adjusted for GRACE score quartile [aOR], 0.53; 95% CI, 0.41-0.69) or revascularisation (aOR, 0.42; 95% CI, 0.34-0.52); they were less likely to have received timely revascularisation (aOR, 0.72; 95% CI, 0.63-0.83) or primary PCI (aOR, 0.76; 95% CI, 0.61-0.95). Six months after admission, the rates of major adverse cardiovascular events (aOR, 2.68; 95% CI, 1.76-4.09) and mortality (aOR, 2.17; 95% CI, 1.24-3.80) were higher for women. At discharge, significantly fewer women than men received ß-blockers, statins, and referrals to cardiac rehabilitation. CONCLUSION: Women with STEMI are less likely to receive invasive management, revascularisation, or preventive medication at discharge. The reasons for these persistent differences in care require investigation.