Primary care management post gestational diabetes in Australia.

BACKGROUND: Women with a history of gestational diabetes (GD) have a high risk of developing diabetes and subsequent cardiovascular disease (CVD). AIM: To assess whether diabetes screening and CVD risk screening occurred in general practice (GP) among postpartum women with GD. METHODS: This is a retrospective study of clinical record data of women with GD, under active GP management, from the MedicineInsight programme, run by Australia's National Prescribing Service MedicineWise, with GP sites located in Australia from January 2015 to March 2021. Documentation of screening for diabetes, assessment of lipids and measurement of blood pressure (BP) was assessed using proportions and mixed-effects logistic regression with a log follow-up time offset. RESULTS: There were 10 413 women, with a mean age of 37.9 years (standard deviation, 7.6), from 406 clinics with a mean follow-up of 4.6 years (interquartile range, 1.8-6.2 years) A total of 29.41% (3062/10 413; 95% confidence interval [CI], 28.53-30.28) had not been assessed for diabetes, 37.40% (3894/10 413; 95% CI, 36.47-38.32) were not assessed for lipids and 2.19% (228/10 413; 95% CI, 1.91-2.47) had no BP documented. In total, 51.82% (5396/10 413; 95% CI, 50.86-52.78) were screened for all three (diabetes + lipids + BP) at least once. Obesity, comorbidities and dyslipidaemia were associated with increased likelihood of screening. New diabetes diagnosis was documented in 5.73% (597/10 413; 95% CI, 5.29-6.18) of the cohort. CONCLUSION: Screening for diabetes and hyperlipidaemia was suboptimal in this high-risk cohort of women with prior GD. Improved messaging that women with a GD diagnosis are at high cardiovascular risk may improve subsequent screening.

Inpatient cardiac care for acute coronary syndromes in the Top End of Australia.

BACKGROUND: Disparities in cardiovascular outcomes between Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians persist. This has previously been attributed to a combination of differences in burden of cardiovascular disease risk factors, and inpatient access to guideline-recommended care. AIMS: To assess differences in inpatient access to guideline-recommended acute coronary syndrome (GR-ACS) treatment between Aboriginal and Torres Strait Islander and non-indigenous patients admitted to Royal Darwin Hospital (RDH) with index ACS event. METHODS: This retrospective study included index ACS admissions (n = 288) to RDH between January 2016 and June 2017. Outcomes included rates of coronary angiography, percutaneous coronary intervention (PCI), surgical revascularisation, GR-ACS medications prescribed on discharge and short-term outcomes (30-day mortality and ACS readmissions; 12-month all cardiac-related readmissions). RESULTS: Two hundred and eighty-eight patients, including 109 (37.85%) Aboriginal and Torres Strait Islander patients, were included. Compared with non-indigenous patients, they were younger (median age 48 years vs 60 years; P < 0.01), with a greater burden of comorbidities, including diabetes (39% vs 19%; P < 0.01), smoking (68% vs 35%; P < 0.01) and chronic kidney disease (29% vs 5%; P < 0.01). There were no differences in rates of coronary angiography (98% vs 96%; P = 0.24) or PCI (47% vs 57%; P = 0.12), although there was a trend towards surgical revascularisation in Aboriginal and Torres Strait Islander patients (16% vs 8%; P = 0.047). There were no differences in 30-day mortality (1.8% vs 1.7%; P = 0.72), 12-month ACS readmissions (7% vs 4%; P = 0.20) or 12-month cardiac-related readmissions (7% vs 13%; P = 0.11). CONCLUSIONS: Aboriginal and Torres Strait Islander patients received similar inpatient ACS care and secondary prevention medication at discharge, with similar short-term mortality outcomes as non-indigenous patients. While encouraging, these outcomes may not persist long term. Further outcomes research is required, with differences compelling consideration of other primary and secondary prevention contributors.

Rheumatic heart disease in pregnancy: Maternal and neonatal outcomes in the Top End of Australia.

BACKGROUND: Women with rheumatic heart disease (RHD) can have a lower cardiac reserve to cope with pregnancy and labour, leading to increased obstetric and cardiac risks. The Northern Territory has been repeatedly reported to have the highest prevalence of RHD in Australia, yet evidence specific to pregnancy is scarce in the literature. AIMS: The primary aim of this paper is to describe the baseline characteristics and maternal outcomes of pregnant women with RHD presenting to the largest obstetrics referral hospital in the Northern Territory. The secondary aim is to evaluate the current model of care in relation to their cardiac status. METHODS: A retrospective observational study was conducted over a 9.5-year period. Demographics, cardiac, obstetrics and anaesthetics data were collected for analysis. RESULTS: One hundred and twenty-nine pregnancies were included for analysis. All women were identified as Aboriginal or Torres Strait Islander, and 85% were of a RHD priority of 2 or 3. Of all 28 patients who had an emergency caesarean section, only one patient was indicated for cardiac reasons. There was no maternal or neonatal death reported. Three preterm births were induced secondary to maternal concerns related to RHD cardiac decompensation. There were no major adverse neonatal outcomes, including neonatal death, intraventricular haemorrhage or respiratory distress syndrome. Multidisciplinary care was also evaluated. CONCLUSION: We observed a low rate of maternal and fetal morbidity and no mortality in a cohort of women with mild to severe RHD. These favourable outcomes have occurred in a multidisciplinary centre with significant experience in managing the medical and cultural complexities of this group.

Randomised clinical trial using Coronary Artery Calcium Scoring in Australian Women with Novel Cardiovascular Risk Factors (CAC-WOMEN Trial): study protocol.

INTRODUCTION: Cardiovascular disease (CVD) is the leading cause of death in women around the world. Aboriginal and Torres Strait Islander women (Australian Indigenous women) have a high burden of CVD, occurring on average 10-20 years earlier than non-Indigenous women. Traditional risk prediction tools (eg, Framingham) underpredict CVD risk in women and Indigenous people and do not consider female-specific 'risk-enhancers' such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM) and premature menopause. A CT coronary artery calcium score ('CT-calcium score') can detect calcified atherosclerotic plaque well before the onset of symptoms, being the single best predictor for future cardiac events. A CT-calcium score may therefore help physicians intensify medical therapy in women with risk-enhancing factors. METHODS AND ANALYSIS: This multisite, single-blind randomised (1:1) controlled trial of 700 women will assess the effectiveness of a CT-calcium score-guided approach on cardiovascular risk factor control and healthy lifestyle adherence, compared with standard care. Women without CVD aged 40-65 (35-65 for Aboriginal and Torres Strait Islander women) at low-intermediate risk on standard risk calculators and with at least one risk-enhancing factor (eg, HDP, GDM, premature menopause) will be recruited. Aboriginal and Torres Strait Islander women will be actively recruited, aiming for ~10% of the sample size. The 6-month coprimary outcomes will be low-density lipoprotein cholesterol and systolic blood pressure. Barriers and enablers will be assessed, and a health economic analysis performed. ETHICS AND DISSEMINATION: Western Sydney Local Health District Research Ethics Committee (HREC 2021/ETH11250) provided ethics approval. Written informed consent will be obtained before randomisation. Consent will be sought for access to individual participant Medicare Benefits Schedule, Pharmaceutical Benefits Scheme claims usage through Medicare Australia and linked Admitted Patient Data Collection. Study results will be disseminated via peer-reviewed publications and presentations at national and international conferences. TRIAL REGISTRATION NUMBER: ACTRN12621001738819p.

The Australian New Zealand Spontaneous Coronary Artery Dissection (ANZ-SCAD) Registry - A Multi-Centre Cohort Study: Protocol, Background and Significance.

INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is an under-recognised cause of acute coronary syndrome (ACS) with a strong female predominance. There are currently limited prospective studies and no randomised controlled trials that inform on SCAD's best clinical care. Little is also known about predictors of acute SCAD deterioration or recurrence. We describe the study design of a multi-centre prospective and historical cohort study recruiting patients with SCAD across 15-20 sites in Australia/New Zealand (NZ). The primary aim is to describe the clinical presentation, management and outcomes along with predictors of acute deterioration and recurrence in a large Australian/NZ SCAD cohort, with international data pooling. METHODS AND ANALYSIS: Consented patients diagnosed with SCAD during a hospital admission for an ACS will be prospectively followed at 30 days then yearly, for up to 5 years. Each recruiting site will also retrospectively identify historical cases of SCAD from the proceeding 10 years, with a waiver of consent. For historical cases, data will be collected in a de-identified manner with date of last follow-up or death obtained from the medical records. All cases undergo core laboratory adjudication of coronary angiography and any accompanying imaging to confirm SCAD diagnosis. The primary endpoint will be occurrence of major adverse cardiovascular events; a composite of all-cause mortality, recurrent myocardial infarction (including SCAD recurrence), stroke/transient ischaemic attack, heart failure, cardiogenic shock, cardiac arrest/ventricular arrhythmia, heart transplantation and, repeat/unplanned revascularisation. Secondary endpoints will include each individual primary outcome as well as acute SCAD extension and quality of life/Seattle Angina Score in prospectively recruited participants. Endpoints will be assessed at the end of the hospital admission and at 30-days, 1 year, and median long-term follow-up. ETHICS: Multicentre ethics approval has been granted from the Western Sydney Local Health District Human Research Ethics Committee (2021/ETH00040). DISSEMINATION OF RESULTS: The analysed results will be published in peer-reviewed journals on completion of the historical data collection and then on completion of the prospective data collection. REGISTRATION DETAILS: The ANZ-SCAD registry has been prospectively registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12621000824864).

Managing asymptomatic severe rheumatic mitral stenosis in pregnancy: a case report.

BACKGROUND: Rheumatic heart disease (RHD) is a disease of disparity most prevalent in developing countries and among immigrant populations. Mitral stenosis (MS) is a common sequalae of RHD and affects females disproportionately more than males. Rheumatic MS remains a significant management challenge as severe MS is usually poorly tolerated in pregnancy due to haemodynamic changes and increased cardiovascular demands of progressing pregnancy. Pregnancy remains contraindicated in current management guidelines based on expert consensus, due to a paucity of evidence-based literature. CASE SUMMARY: A 28-year-old aboriginal woman with known severe MS was found to be pregnant during routine health review, despite contraceptive efforts. Echocardiography demonstrated mean mitral valve (MV) gradient 14 mmHg; stress echocardiography demonstrated increased MV gradient 28-32 mmHg at peak exercise and post-exercise pulmonary artery pressure 56 + 3 mmHg with marked dynamic D-shaped septal flattening. Left ventricular systolic function remained preserved. She remained remarkably asymptomatic and underwent successful elective induction of labour at 34 weeks. Postpartum, she remained euvolaemic despite worsening MV gradients and new atrial fibrillation (AF). She subsequently underwent balloon mitral valvuloplasty with good result. DISCUSSION: Severe rheumatic MS in pregnancy carries significant morbidity and mortality, due to an already fragile predisposition towards heart failure development compounded by altered haemodynamics. Pregnancy avoidance and valvular intervention prior to conception or in the second trimester remain the mainstay of MS management; however, we present an encouraging case of successful near-term pregnancy with minimal complications in a medically managed asymptomatic patient with critical MS, who subsequently underwent valvular intervention post-partum.

Nutrition has a pervasive impact on cardiac microRNA expression in isogenic mice.

The complex interaction between obesity, Western-style diets, and cardiovascular disease is of increasing interest, with a growing number of children being born to obese parents with poor lifestyle choices. These offspring have themselves an increased susceptibility to obesity and subsequent cardiovascular disease in adult life, which may be 'programmed' by their intrauterine environment. Cardiac microRNAs (miRNAs) are affected by multiple disease states, and have also been shown to be capable of exerting a hormone-like control on whole body metabolism. Here we sought to determine the effect of prenatal exposure to maternal obesity and/or postnatal exposure to a Western diet on miRNA expression in the heart. Unbiased small RNA sequencing was carried out on cardiac tissue from young adult mice born to lean or obese mothers; offspring were weaned onto either a low-fat control diet or a high-fat Western-style diet. We found 8 cardiac miRNAs that were significantly altered in response to maternal obesity, but only when the offspring were challenged postnatally with the Western diet. In contrast, postnatal exposure to the diet alone induced significant changes to the expression of a much larger number of miRNAs (33 in offspring of lean and 46 in offspring of obese). Many of the affected miRNAs have previously been implicated in various cardiac pathologies. The pervasive cardiac miRNA changes induced by a Western diet suggest that an individual's lifestyle choices outweigh the impact of any programming effects by maternal obesity on miRNA-related cardiac health.