Ethnicity Is Associated With Differing Presentation and Outcomes of Patients Undergoing Aortic Valve Replacement for Calcific Aortic Stenosis in Aotearoa New Zealand.

AIM: Surgical aortic valve replacement (SAVR) has been the gold standard for treatment of severe symptomatic aortic stenosis (AS) for decades. We examined whether ethnic differences exist in the presentation and outcomes of patients undergoing aortic valve replacement (AVR) for AS in New Zealand. METHODS: Patients of New Zealand European, Maori, and Pacific Island ethnicities undergoing SAVR with or without other procedures in New Zealand public hospitals from 2017 to 2019 were included. Major postoperative outcomes were compared between ethnic groups, with 30-day mortality being the primary outcome. RESULTS: A total of 1,175 patients were included: 1,085 European, 50 Maori, and 40 Pacific. The mean age was 71.1±9.4 years, and men accounted for more than half of all patients (69.9%). Maori (64.7±9.4 years) and Pacific (65.4±10.1 years) patients were younger when undergoing SAVR compared with European patients (71.7±9.2; analysis of variance p<0.001). Maori and Pacific patients had a higher prevalence of diabetes, poorer renal function, and worse left ventricular function; 30-day mortality was higher in Maori and Pacific compared with European patients (6% and 10% vs 2.4%, respectively; Fisher's exact test p=0.011), with odds ratio of 3.06 (95% confidence interval [CI] 0.88-10.66) for Maori patients after adjustment for EuroSCORE II and odds ratio of 5.23 (95% CI 1.79-16.07) for Pacific patients. CONCLUSIONS: There are significant differences in presentation and outcomes of patients undergoing AVR in New Zealand. Maori and Pacific patients undergo SAVR at a younger age, have more preoperative comorbidities, and have higher rates of 30-day mortality than European patients.

Very Elderly Patients With Acute Coronary Syndromes Treated With Percutaneous Coronary Intervention.

BACKGROUND: The rates of very elderly patients (≥85 years old) undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) are rapidly increasing. They are under-represented in clinical trials, and those who are included may not reflect the real-world population. We aim to review the clinical characteristics of very elderly patients undergoing PCI for ACS and identify factors associated with adverse outcomes. METHOD: All very elderly patients undergoing PCI for ACS in the Auckland region between January 2014 to December 2016 were included. Baseline clinical and procedural details were obtained, and the primary endpoint was all-cause mortality measured up to a maximum of 4 years. Secondary endpoints include recurrent myocardial infarction, unplanned revascularisation, stroke and major bleeding. RESULTS: A total of 186 patients were included for analysis (mean age 87.6±2.8 years, 51.6% male). Indications for PCI were ST-elevation myocardial infarction (STEMI) in 74 (39.8%), non-ST elevation myocardial infarction (NSTEMI) in 97 (52.2%) and unstable angina in 15 patients (8.1%). Successful PCI was completed in 180 patients. At a maximal follow-up of 4 years (mean 23.4 mo), the rates of all-cause mortality and recurrent myocardial infarction were 22.0% and 14.0% respectively. The risk of mortality was increased by the presence of diabetes (44.8% vs 17.8%, HR=3.0, 95%CI: 1.6-5.9, p=0.001), STEMI (33.8% vs 13.5%, HR=3.1, 95%CI: 1.6-5.9, p=0.001), and reduced eGFR (every -10 mL/min/1.73m2, HR=1.7, 95%CI: 1.3-2.1, p<0.0001). Major bleeding events while on dual antiplatelet therapy as defined by Bleeding Academic Research Consortium score ≥3 occurred in 14 patients (7.5%; 8 on ticagrelor, 6 on clopidogrel). CONCLUSION: Very elderly patients who undergo PCI for ACS have acceptable survival outcomes. STEMI, diabetes and impaired renal function were predictive of mortality in this elderly cohort.

A Decade of Transcatheter Aortic Valve Implantation in New Zealand: Growth and Inequalities.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an effective treatment increasingly performed for severe aortic stenosis. Developing nationwide accessibility to TAVI can be met with barriers that result in treatment disparities. OBJECTIVES: This nationwide retrospective study aimed to review the first decade of TAVI in New Zealand and identify potential inequalities. METHODS: All patients undergoing TAVI in a New Zealand public hospital between 2008 and 2018 were included. Demographic and geographic details were analysed and TAVI rates were age standardised using census data. One-year survival was compared between groups. RESULTS: A total of 952 patients were included in our study. The mean age was 80.0±7.5 years and women accounted for nearly half of all patients (42.5%). The age-standardised TAVI rate in New Zealand increased from 15 per million in 2013 to 49 per million in 2018. Since 2013, there has been a disproportionate growth in TAVI rates between different ethnicities. TAVI rates for Europeans grew from 16 to 66 per million compared to 7 to 8 per million for Pacific people and 3 to 5 per million for Maori. Despite nationwide access to TAVI in 2018, significant geographic heterogeneity remains, ranging from 2.0 to 12.8 procedures per 100,000 people between regions. One-year (1-yr) survival for Maori were significantly worse than Europeans (80.1% vs 93.9%, HR 4.2, 95%CI: 1.6-11.5, p=0.004) despite being younger (67.9 vs 80.6 years, p<0.05). CONCLUSION: There are significant geographical and ethnic variations in TAVI rates in New Zealand. Maori had worse one-year survival than European patients following TAVI.

Clinical Characteristics and Prognostic Factors of Myocarditis in New Zealand Patients.

BACKGROUND: Myocarditis is an inflammation of the heart muscle and an important cause of dilated cardiomyopathy. Its presentation is heterogeneous, and there are limited studies describing the clinical characteristics of these patients, or which factors predict adverse clinical outcomes. We performed a single-centre retrospective study to explore the clinical characteristics of patients with myocarditis. METHOD: Patients >15 years of age admitted to our centre with an ICD-10 diagnosis of myocarditis on their electronic discharge record between 2007 and 2016 were included. Clinical, biochemical and imaging factors were collected. The primary endpoint was combined major adverse cardiac events (MACE) consisting of all-cause mortality, decompensated heart failure leading to hospital admission, documented ventricular arrhythmia, recurrent myocarditis and heart transplantation. RESULTS: During this period, 178 patients were found to have a diagnosis of myocarditis (71% men, median age 39 years). Men were significantly younger than women (36 vs 53 years, U=4,543, p<0.001). ST-elevation on electrocardiogram was recorded in 59% of patients, and these patients were more likely to be male (85% vs 66%, p=0.012), younger (median age 32 vs 44 years, U=4,129, p=0.001) and to have chest pain (94% vs 65%, p<0.001). At a maximal follow-up of 8 years (mean 4.5 years), MACE occurred in 26 patients. MACE was associated with the presence of dyspnoea (26% vs 9%; hazard ratio [HR] 3.33, 95% confidence interval [CI] 1.53-7.28; p=0.003), pulmonary congestion on chest X-ray (54% vs 11%; HR 5.51; 95% CI 2.3-13.23; p<0.001), and left ventricular ejection fraction <50% on transthoracic echocardiography (24% vs 8%; HR 3.22; 95% CI 1.28-8.12; p=0.013). CONCLUSIONS: Myocarditis was more common in young men in our study. Factors associated with adverse outcomes in acute coronary syndromes were not seen in our younger population. Left ventricular dysfunction appears to be more important in predicting adverse outcomes in myocarditis.

Resting Heart Rate Variability and Emotion Dysregulation in Adolescents with Autism Spectrum Disorder.

Emotion dysregulation is common among individuals with autism spectrum disorder (ASD). This study examined the relationship between emotion dysregulation and resting heart rate variability (HRV), a marker of the autonomic nervous system, in ASD adolescents. Resting HRV data were collected from ASD (n = 23) and typically developing (TD) adolescents (n = 32) via short-term electrocardiogram. Parents/caregivers reported participants' level of emotion dysregulation with the Emotion Dysregulation Inventory (EDI). Controlling for the effects of age and gender, regression analyses revealed moderating effects of group, suggesting that lower resting HRV was more strongly associated with greater emotion dysregulation in ASD than TD adolescents. The results support the view that disruptions in autonomic functioning may contribute to emotion dysregulation in ASD.

Dual-Lumen Catheter and Floating-Wire Technique to Access Protruding Aorto-Ostial Stent.

PCI in the setting of previous aorto-ostial stenting can be difficult, especially if there is excessive stent protrusion. Various techniques have been described, including double-wire technique, double-guide snare technique, side-strut sequential ballooning technique, and guide extension facilitated sidestrut stenting. These techniques can sometimes be complicated, and intervention through a side-strut may lead to excessive stent deformation or avulsion of the protruding segment. Our novel technique uses a dual-lumen catheter and floating wire to back the JR4 guide away from the protruding stent while maintaining stability for another guidewire to enter the central lumen.

Synergistic Coronary Artery Calcium Modification With Combined Atherectomy and Intravascular Lithotripsy.

BACKGROUND: Severe coronary artery calcification (CAC) remains challenging during percutaneous coronary intervention (PCI) and often requires 1 or more advanced calcium modification tools. OBJECTIVES: We describe the combination use of rotational (RA) or orbital atherectomy (OA), with intravascular lithotripsy (IVL), termed rotatripsy and orbital-tripsy, respectively, for modifying CAC prior to stent implantation during PCI. METHODS: We performed a retrospective analysis of patients treated with rotatripsy or orbital-tripsy at our center between July 2019 and March 2022. The primary efficacy endpoint was procedural success (successful stent implantation, <30% residual stenosis visually, Thrombolysis in Myocardial Infarction 3 flow; absence of types C to F dissection/perforation or loss of side branch ≥2.0mm visually) without in-hospital major adverse cardiovascular event (MACE, defined as cardiovascular death, myocardial infarction [MI], target-vessel revascularization). RESULTS: A total of 25 patients (14 rotatripsy and 11 orbital-tripsy) were included in our study. The mean age was 72.2 ± 7.6 years and 76% were men. PCI was guided by intravascular imaging in 24 patients (96%). All cases were treated with either RA or OA before utilization of IVL. Procedural success was achieved in 22 cases (88%) with 1 sidebranch loss without periprocedural MI (4%) and 2 in-patient deaths (8%) unrelated to the procedure (1 intracerebral hemorrhage and 1 cardiac arrest). CONCLUSION: We describe efficacious use of both rotatripsy and orbital-tripsy to modify severe CAC during PCI in a real-world setting. Intravascular imaging can guide appropriate use of these devices to complement each other to modify severe CAC to achieve optimal outcomes.

Spontaneous coronary artery dissection: insights from computed tomography coronary angiography follow-up.

METHODS: Patients with SCAD on invasive coronary angiography who underwent a follow-up CTCA between 2010 and 2018 at our institute were included. CTCA was reported by two cardiologists-one with knowledge of the SCAD location, and a second blinded. Assessment of dissection healing were made and optimal timing of CTCA was also calculated. RESULTS: A total of 32 patients with 38 non-contiguous SCAD lesions were included (mean age 50.5 ± 8.8 years, 65.6% women). The left circumflex artery was the most commonly affected vessel (34.2%), and 71.1% of lesions occurred in distal or branch vessels. Median time that CTCA was performed was 40.5 days from the index event, and 25 of 38 lesions had healed (65.8%). On blinded reporting, the sensitivity and specificity of CTCA for assessment of dissection healing was 72% and 53.8%, respectively. The optimal timing of CTCA to assess healing was 80 days (AUC 0.774, p=0.006; sensitivity 76.9%, specificity 84.0%). When early CTCA was performed (<80 days), 21 of 24 lesions (87.5%) were unhealed, whereas late CTCA (≥80 days) showed healing in 10 of 14 lesions (71.4%). CONCLUSION: The usefulness of CTCA in diagnosing SCAD remains challenging due to limitations in spatial and temporal resolution, particularly in distal vessels. The optimal timing of CTCA to assess dissection healing was 80 days.

Hospitalisation during lockdown-patients' beds-eye views.

AIMS: The global COVID-19 pandemic and lockdowns have affected the patterns of hospital presentations for non-COVID related illnesses. Apprehension and perceived risk of hospitalisation has been postulated to be a significant deterrent to presentation. This study aims to explore pandemic- and- lockdown-related concerns with regards to hospital admission from a patient's perspective. METHODS: A cross-sectional study was undertaken in the form of an inpatient questionnaire for patients admitted to a coronary care unit and the cardiology ward during the Level 4 lockdown. The questionnaire included six questions designed to gather patient perception of the impact of lockdown on their hospital presentation. RESULTS: Out of 91 patients who completed the questionnaire, 41 (45%) were >70 years old. Twenty (22%) patients answered that lockdown delayed or affected their decision to present to hospital. Within this cohort, there was a statistical difference between those aged 70 years and younger, and those over 70 years old (16/50 (32%) versus 4/41 (10%), p=0.011). CONCLUSIONS: Apprehension and concerns regarding the risk of COVID-19 was prevalent in a significant proportion of patients and affected/delayed their decision to present to hospital. This may partly explain lower rates of presentation during the pandemic.

M-commerce adoption among youths in Malaysia: Dataset article.

The covid-19 pandemic which took the world by storm changed our behaviour towards m-commerce with enforced movement restrictions across the world. This dataset documents the factors of consideration among Malaysian youths (age 15 to 24 years old) in their intention to adopt m-commerce. Collected from October to November 2020, a total of 396 useable responses were finalized. The questionnaire consists of individual demographic variables and factors which influence the intention of youths to adopt m-commerce in Malaysia. The dataset of demographics and m-commerce related variables can be used to further explore the correlations and description of variables. The dataset is valuable for m-commerce service providers and future works of literature in understanding the behaviour of youths and hence increase the adoption rate of m-commerce among youths.

Striving to Avoid Inferiority and Procrastination among University Students: The Mediating Roles of Stress and Self-Control.

The current study intended to examine whether the relationship between university students' striving to avoid inferiority (SAI) and procrastination was serially mediated by stress and self-control. The sample consisted of 154 Hong Kong university students. Their levels of striving to avoid inferiority, stress, self-control, and procrastination were measured by the Striving to Avoid Inferiority Scale (SAIS), the stress subscale of the Depression Anxiety Stress Scales (DASS-21), the Short Self-Regulation Questionnaire (SSRQ), and the General Procrastination Scale (GPS), respectively. The results of structural equation modeling revealed that SAI positively predicted stress, stress negatively predicted self-control, and self-control negatively predicted procrastination. SAI did not directly predict procrastination. The results of bootstrapping analyses supported the hypotheses that the effect of stress on procrastination was mediated by self-control, the effect of SAI on self-control was mediated by stress, and more importantly, the effect of SAI on procrastination was serially mediated by stress and self-control. Further research is suggested to investigate the thoughts and feelings pertinent to procrastination and the actual duration of procrastination among university students.

Effectiveness and Mechanisms of Mindfulness Training for School Teachers in Difficult Times: A Randomized Controlled Trial.

OBJECTIVES: Research in recent years has shown that mindfulness-based interventions can enhance teachers' mental and physical health. However, the existing studies were predominantly conducted in Western, educated, industrialized, rich, and democratic (WEIRD) societies. As a randomized controlled trial in a non-WEIRD society, the present study examined the effectiveness and mechanisms of mindfulness training for Hong Kong teachers in difficult times. METHODS: Teachers from primary and secondary schools (n = 186) were randomly assigned to mindfulness training (eight-week .b Foundations) or waitlist control condition. They completed online self-report surveys on measures of well-being, emotion management, and mindfulness in teaching at baseline, post-intervention, and two-month follow-up. RESULTS: The intervention group reported significantly higher levels of life satisfaction, positive affect, general health, along with significantly lower levels of insomnia, stress, and negative affect than the control group at post-test and two-month follow-up. The effect sizes were medium to large (η p 2 = 0.06 to 0.14). More importantly, teachers' baseline well-being had a significant moderating effect on the intervention effectiveness. Those with a lower baseline in well-being benefitted more than their counterparts with a higher baseline. In addition, teachers' emotion management was found to be the mediator through which mindfulness training enhanced teachers' well-being. Such improvement in well-being also predicted higher levels of mindfulness in teaching. CONCLUSIONS: This study provides evidence on the efficacy of mindfulness training for teachers beyond WEIRD societies. It suggests the universality and practicality of mindfulness training in enhancing teachers' well-being and reducing their distress in difficult times.

Calcified Coronary Lesions Treated With Intravascular Lithotripsy: One-Year Outcomes.

Calcified lesions often increase the complexity of percutaneous coronary intervention (PCI) and risk of future adverse events. Shockwave intravascular lithotripsy (S-IVL; Shockwave Medical) has been shown to be an effective calcium-modification tool in preparing calcified coronary lesions prior to stent placement. Its circumferential, pulsatile soundwaves provide a different mechanism to fracture calcium compared with existing devices such as rotational atherectomy and cutting balloons. Although short-term safety outcomes have been positive, longer-term outcomes have yet to be reported. We previously described the first real-world series of PCI involving S-IVL, including use in acute coronary syndromes and left main interventions. We report the 1-year outcomes of patients treated with S-IVL during their PCI.

Extensive intracardiac thrombi in a patient with heart failure and hepatic congestion: a case report.

BACKGROUND: Left ventricular (LV) thrombi is a complication associated with anterior ST-elevation myocardial infarction, dilated cardiomyopathies, or LV aneurysms. Right sided intracardiac thrombi may be associated with other prothrombotic causes. CASE SUMMARY: A 66-year-old man admitted with congestive heart failure was found to have extensive intracardiac masses on transthoracic echocardiography and cardiac magnetic resonance imaging (MRI). This occurred in the absence of a recent myocardial infarction. During his hospital stay, he was found to have deranged liver enzymes and coagulation profile due to hepatic congestion. The patient was presumed to have intracardiac thrombi and was treated with warfarin therapy. There was complete resolution of the masses on repeat cardiac MRI after 4 weeks of treatment, confirming the diagnosis. DISCUSSION: Cardiac MRI is useful in the diagnosis of intracardiac thrombi. Clinicians should appreciate the prothrombotic risks associated with liver disease, despite the inability of standard coagulation tests to quantify this risk.

Shockwave Intravascular Lithotripsy for Calcified Coronary Lesions: First Real-World Experience.

BACKGROUND: Calcified coronary lesions often cause suboptimal stent expansion, which is one of the greatest predictors of adverse outcomes such as stent thrombosis and restenosis. Shockwave intravascular lithotripsy (S-IVL; Shockwave Medical, Inc) is a recently approved technique used in the treatment of heavily calcified coronary lesions. We present our early real-world experience with the S-IVL device. METHODS: All patients treated with S-IVL between October 2018 and January 2019 during their percutaneous coronary intervention (PCI) at our center were included. RESULTS: During this period, a total of 26 patients undergoing PCI were treated with S-IVL prior to stent deployment (69% male; age, 72 ± 8 years). Indications for PCI were acute coronary syndromes (ACS) in 14 patients (54%), stable angina in 11 patients (42%), and PCI before transcatheter aortic valve implantation in 1 patient (4%). Seventy-one percent of the ACS cases undergoing PCI with S-IVL were to the perceived ACS culprit lesion during the index procedure, while 29% were staged PCIs to severe non-culprit lesions. Upfront S-IVL usage occurred in 58% of cases; the rest were bail-out procedures due to suboptimal initial balloon predilation. S-IVL was used most commonly in the left anterior descending coronary artery (50%), with 1.3 ± 0.5 stents implanted/target vessel. Angiographic success (<20% residual stenosis) occurred in all cases, with no procedural complications. CONCLUSION: S-IVL appears to be a useful modality in coronary calcium modification to optimize stent expansion. This device obviates the need for more complex lesion preparation strategies such as rotational atherectomy, except in severe undilatable cases where S-IVL is impossible. Further study is warranted to compare different calcium modification devices with conventional balloon angioplasty.

Shockwave Intravascular Lithotripsy of Calcified Coronary Lesions in ST-Elevation Myocardial Infarction: First-in-Man Experience.

We present the first cases of Shockwave intravascular lithotripsy (S-IVL; Shockwave Medical), a novel coronary calcium modification device, being used in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI). The 3 presented cases include an upfront use of S-IVL in a right coronary artery, an in-stent restenosis, and a community cardiac arrest/STEMI equivalent where S-IVL was used as a bail-out technique to facilitate stent delivery in a tortuous calcified vessel.

Treatment of Heavily Calcified Unprotected Left Main Disease With Lithotripsy: The First Case Series.

We present the first case series using Shockwave Intravascular Lithotripsy (S-IVL; Shockwave Medical), a novel coronary calcium modification device, in patients with heavily calcified unprotected left main (LM) coronary artery disease (CAD). Decisions regarding surgical vs percutaneous revascularization in LM-CAD patients are based on anatomical complexity and perceived surgical risk. In this series, we present the use of S-IVL in a patient with LM-CAD with multivessel disease who declined surgery, a patient with an isolated LM-CAD and severe cardiomyopathy, and a late nonagenarian patient where surgical revascularization was not an option.

Will Victims Become Aggressors or Vice Versa? A Cross-Lagged Analysis of School Aggression.

Peer aggression and victimization are ubiquitous phenomena in schools which warrant the attention of educators and researchers. The high connection between aggression and victimization behooves researchers to look into how the comorbidity of them develops over time. The present study investigated the associations between aggression and victimization over 3 years in early adolescence and whether these associations are moderated by gender and teacher support. Participants were 567 Grade 7, 8 and 9 students (49.38% girls) from 3 schools in Hong Kong. Over the course of study, they were asked to fill in a set of questionnaires that consisted of items related to peer aggression, victimization, and teacher support at 5 time points. Four models of cross-lagged relations between peer aggression and victimization were tested. The results supported a reciprocal model of peer aggression and victimization for both boys and girls although girls engaged in less peer aggression and victimization than boys. Further analyses also revealed that teacher support acted as a suppressor of the reciprocal relations. The present study sheds lights on intervention strategies that may remediate peer aggression and victimization in schools.

Hypertension treatment in the Asia-Pacific: the role of and treatment strategies with nebivolol.

Hypertension is a common disease, and hypertensive patients are at increased risk of cardiovascular events. The prevalence and socioeconomic burden of hypertension in the Asia-Pacific region are predicted to increase in the coming decades. Effective blood pressure lowering reduces overall cardiovascular morbidity and mortality in patients, yet doubt has been raised regarding the use of (mainly older generation) ß-blockers as initial therapy in hypertension. Consequently, several international treatment guidelines do not recommend ß-blockers for the treatment of hypertension. However, in contrast to first-generation and second-generation ß-blockers, the third-generation, vasodilating ß-blocker nebivolol has a considerably better metabolic, haemodynamic and side effect profile. In addition to providing effective blood pressure control similar to other ß-blockers and drugs from other antihypertensive classes, nebivolol exerts a dual mechanism for increasing the bioavailability of the naturally occurring vasodilator nitric oxide. The clinical benefits and significance of enhancing nitric oxide levels in hypertensive patients have been shown in direct comparisons of nebivolol with other ß-blockers. While ß-blockers generally provide comparable blood pressure reductions, only nebivolol demonstrated enhanced vasodilation and blood flow by increasing the expression of endothelial nitric oxide synthase and therefore increasing nitric oxide release from the endothelium. In contrast to other ß-blockers, therefore, it has been suggested that nebivolol has beneficial effects in several hypertensive subgroups due to its vasodilating properties. Considering the existing data, it may be timely for treatment guidelines to recommend third-generation vasodilating ß-blockers as a first-line option for the pharmacotherapy of hypertension.