A framework for overcoming disparities in management of acute coronary syndromes in the Australian Aboriginal and Torres Strait Islander population. A consensus statement from the National Heart Foundation of Australia.

Aboriginal and Torres Strait Islander patients with acute coronary syndromes (ACS) experience lower intervention rates and poorer outcomes compared with non-Indigenous patients. A broad range of geographical, cultural and systemic factors contribute to delays and suboptimal treatment for ACS. Every Indigenous ACS patient, regardless of where they live, should be able to expect a coordinated, patient-centred pathway of care provided by designated provider clinical networks and supported by Indigenous cardiac coordinators, Aboriginal liaison officers (ALOs) and health workers. These designated provider clinical networks provide: appropriate prehospital and inhospital treatment an individualised patient care plan developed jointly with the patient and his or her family culturally appropriate education initiated within the hospital setting and involving families with support from ALOs effective follow-up care and access to relevant secondary prevention programs. We outline generic pathways to provide policymakers, health planners and health care providers with a framework for ACS diagnosis and management that can be implemented across the diverse settings in which Aboriginal and Torres Strait Islander people reside and their care is delivered, in order to optimise care and assertively address the current disparities in outcomes.

Takotsubo cardiomyopathy mid ventricle variant and cardiac arrest: chicken or the egg?

Takotsubo cardiomyopathy (TTC) is uncommon emergency condition usually precipitated by emotional or physical stress and is characterized by near-normal coronary arteries and regional wall motion abnormalities that extend beyond a single coronary vascular territory. Variants of TTC include classic apical ballooning syndrome and less commonly, mid, basal, and biventricular variants. Cardiac arrest is an uncommon complication of TTC. In the convalescence phase of TTC, prolonged QTc interval may cause cardiac arrest, but the reason for cardiac arrest in the acute phase when QTc interval is normal is unclear. We report 3 cases of mid ventricular TTC, with out-of-hospital cardiac arrest as the presenting feature. All 3 patients had normal QTc interval and were found to have normal coronary arteries on cardiac catheterization at presentation. Mid ventricular TTC was confirmed on contrast left ventriculography and echocardiography. Cardiac arrest myocarditis was ruled out by myocardial biopsy in 2 deceased patients and by cardiac magnetic resonance imaging in the one who survived.

Study Protocol: establishing good relationships between patients and health care providers while providing cardiac care. Exploring how patient-clinician engagement contributes to health disparities between indigenous and non-indigenous Australians in South Australia.

BACKGROUND: Studies that compare Indigenous Australian and non-Indigenous patients who experience a cardiac event or chest pain are inconclusive about the reasons for the differences in-hospital and survival rates. The advances in diagnostic accuracy, medication and specialised workforce has contributed to a lower case fatality and lengthen survival rates however this is not evident in the Indigenous Australian population. A possible driver contributing to this disparity may be the impact of patient-clinician interface during key interactions during the health care process. METHODS/DESIGN: This study will apply an Indigenous framework to describe the interaction between Indigenous patients and clinicians during the continuum of cardiac health care, i.e. from acute admission, secondary and rehabilitative care. Adopting an Indigenous framework is more aligned with Indigenous realities, knowledge, intellects, histories and experiences. A triple layered designed focus group will be employed to discuss patient-clinician engagement. Focus groups will be arranged by geographic clusters i.e. metropolitan and a regional centre. Patient informants will be identified by Indigenous status (i.e. Indigenous and non-Indigenous) and the focus groups will be convened separately. The health care provider focus groups will be convened on an organisational basis i.e. state health providers and Aboriginal Community Controlled Health Services. Yarning will be used as a research method to facilitate discussion. Yarning is in congruence with the oral traditions that are still a reality in day-to-day Indigenous lives. DISCUSSION: This study is nestled in a larger research program that explores the drivers to the disparity of care and health outcomes for Indigenous and non-Indigenous Australians who experience an acute cardiac admission. A focus on health status, risk factors and clinical interventions may camouflage critical issues within a patient-clinician exchange. This approach may provide a way forward to reduce the appalling health disadvantage experienced within the Indigenous Australian communities.

The LACE Index: A Predictor of Mortality and Readmission in Patients With Acute Myocardial Infarction.

INTRODUCTION: Improving patient outcomes after acute myocardial infarction (AMI) may be facilitated by identifying patients at a high risk of adverse events before hospital discharge. We aimed to determine the accuracy of the LACE (Length of stay, Acuity, Comorbidities, Emergency presentations within prior 6 months) index score (a prediction tool) for predicting 30-day all-cause mortality and readmission rates (independently and combined) in South Australian AMI patients who had an angiogram. METHODS: All consecutive AMI patients enrolled in the Coronary Angiogram Database of South Australia Registry at two major tertiary hospitals and discharged alive between July 2016 to June 2017. A LACE score was calculated for each patient, and receiver operating characteristic curve analysis was performed. RESULTS: Analysis of registry patients found a 30-day unplanned readmission rate of 11.8% and mortality rate of 0.7%. Moreover, the LACE index was a moderate predictor (C-statistic = 0.62) of readmissions in this cohort, and a score ≥10 indicated moderate discriminatory capacity to predict 30-day readmissions. CONCLUSION: The LACE index shows moderate discriminatory capacity to predict 30-day readmissions and mortality. A cut-off score of nine to optimize sensitivity may assist clinicians in identifying patients at a high risk of adverse outcomes.

Frequency, trends and institutional variation in 30-day all-cause mortality and unplanned readmissions following hospitalisation for heart failure in Australia and New Zealand.

AIMS: National 30-day mortality and readmission rates after heart failure (HF) hospitalisations are a focus of US policy intervention and yet have rarely been assessed in other comparable countries. We examined the frequency, trends and institutional variation in 30-day mortality and unplanned readmission rates after HF hospitalisations in Australia and New Zealand. METHODS AND RESULTS: We included patients >18 years hospitalised with HF at all public and most private hospitals from 2010-15. The primary outcomes were the frequencies of 30-day mortality and unplanned readmissions, and the institutional risk-standardised mortality rate (RSMR) and readmission rate (RSRR) evaluated using separate cohorts. The mortality cohort included 153 592 patients (mean age 78.9 ± 11.8 years, 51.5% male) with 16 442 (10.7%) deaths within 30 days. The readmission cohort included 148 704 patients (mean age 78.6 ± 11.9 years, 51.7% male) with 33 158 (22.3%) unplanned readmission within 30 days. In 392 hospitals with at least 25 HF hospitalisations, the median RSMR was 10.7% (range 6.1-17.3%) with 59 hospitals significantly different from the national average. Similarly, in 391 hospitals with at least 25 HF hospitalisations, the median RSRR was 22.3% (range 17.7-27.1%) with 24 hospitals significantly different from the average. From 2010-15, the adjusted 30-day mortality [odds ratio (OR) 0.991/month, 95% confidence interval (CI) 0.990-0.992, P < 0.01] and unplanned readmission (OR 0.998/month, 95% CI 0.998-0.999, P < 0.01) rates declined. CONCLUSION: Within 30 days of a HF hospitalisation, one in 10 patients died and almost a quarter of those surviving experienced an unplanned readmission. The risk of these outcomes varied widely among hospitals suggesting disparities in HF care quality. Nevertheless, a substantial decline in 30-day mortality and a modest decline in readmissions occurred over the study period.

Depression Mediates the Relationship between Food Insecurity and Pain Interference in College Students.

Food insecurity (FI) typically produces unfavorable health conditions. Research shows the high prevalence of FI among college students, and depression is one of the adverse effects of FIamong them. It is possible that FI may increase the risk of pain via depression; however, it is currently unclear whether FI is linked to pain among college students. Therefore, this study compared pain experiences between students with and without FI, and examined the relationship between FI, depression, and pain. One hundred seventy-six college students at a Hispanic-serving institution in the southwestern region of US completed self-report measures to assess FI, depression, pain severity, and pain interference. Results indicated that approximately 24% of the students were categorized as food insecure, and those students scored higher on pain interference compared to food-secure students. FI was positively associated with depression and pain interference scores, and depression scores were positively associated with pain interference scores. The mediation analyses based on the counterfactual framework demonstrated a significant mediation effect of depression, where 50.59% of the total effect of FI on pain interference was attributable to the depression. These results suggest that FI extends its negative effects into pain interference among college students, but better management of depression may help alleviate the effects of FI on pain interference.

Crowd behavior at mass gatherings: a literature review.

Gaining an understanding of crowd behavior is important in supporting timely and appropriate crowd management principles in the planning and provision of emergency services at mass gatherings. This paper provides a review of the current understanding of the psychological factors of a crowd within the psychosocial domain as they apply to mass-gathering settings. It can be concluded from this review that there is a large theory-practice gap in relation to crowd psychology and the mass-gathering setting. The literature has highlighted two important elements of crowd behavior-there must be a "seed" and people must engage. Understanding these behaviors may provide opportunities to change crowd behavior outcomes.

Clinical and coronary haemodynamic determinants of recurrent chest pain in patients without obstructive coronary artery disease - A pilot study.

BACKGROUND: Coronary haemodynamic testing frequently identifies abnormal pathophysiological parameters in patients with angina and non-obstructed coronaries on angiography (NoCAD) but the clinical utility of these measures has received limited attention. OBJECTIVE: This study aims to identify the clinical and coronary haemodynamic determinants of recurrent chest pain at one month in patients with NoCAD. METHODS: Patients with angina, NoCAD (<50% stenosis) and normal LV systolic function underwent invasive coronary haemodynamic testing involving: (1) angiographic TIMI frame and opacification rate, (2) microvascular functional measures including coronary flow reserve (CFR) and hyperaemic microvascular resistance (HMR), (3) coronary endothelial function assessment with low dose intracoronary acetylcholine (IC-ACh) infusions (0.18 µg/min & 1.8 µg/min over 2 min), and (4) Provocative spasm testing with high dose IC-ACh boluses (25, 50 and 100 µg). Clinical and health status were assessed at baseline and one month. RESULTS: In the 49 NoCAD patients (78% female, mean age of 54 ±â€¯11) undergoing comprehensive coronary haemodynamic testing, 33 (67%) continued to experience chest pain at one month. Determinants of recurrent chest pain on univariate analysis included baseline chest pain status or a HMR > 1.9. Multivariate logistic regression analysis identified frequent angina at baseline (OR: 68.9 [4.1, 1165.0], p = 0.003), previous unstable angina admission (OR: 43.9 [3.5, 547.9], p = 0.003) and a HMR > 1.9 (OR: 15.6 [2.1, 114.0], p = 0.007) as independent predictors of recurrent chest pain. CONCLUSION: In this small pilot study, an abnormal HMR was the only coronary haemodynamic parameter that was a determinant of ongoing angina at short-term follow-up.

Evidence against a major role for angiotensin converting enzyme-related carboxypeptidase (ACE2) in angiotensin peptide metabolism in the human coronary circulation.

OBJECTIVE: To investigate the role of angiotensin-converting enzyme-related carboxypeptidase (ACE2) in angiotensin peptide metabolism in the human coronary circulation. METHODS: Angiotensin I and angiotensin II, and their respective carboxypeptidase metabolites, angiotensin-(1-9) and angiotensin-(1-7), were measured in arterial and coronary sinus blood of heart failure subjects receiving angiotensin-converting enzyme (ACE) inhibitor therapy and in normal subjects not receiving ACE inhibitor therapy. In addition, angiotensin I, angiotensin II and angiotensin-(1-7) were measured in arterial and coronary sinus blood of subjects with coronary artery disease before, and at 2, 5 and 10 min after, intravenous administration of ACE inhibitor. RESULTS: In comparison with normal subjects, heart failure subjects receiving ACE inhibitor therapy had a greater than 40-fold increase in angiotensin I levels, but angiotensin-(1-9) levels were low (1-2 fmol/ml), and similar to those of normal subjects. Moreover, angiotensin-(1-7) levels increased in parallel with angiotensin I levels and the angiotensin-(1-7)/angiotensin II ratio increased by 7.5-fold in coronary sinus blood. Intravenous administration of ACE inhibitor to subjects with coronary artery disease rapidly decreased angiotensin II levels by 54-58% and increased angiotensin I levels by 2.4- to 2.8-fold, but did not alter angiotensin-(1-7) levels or net angiotensin-(1-7) production across the myocardial vascular bed. CONCLUSIONS: The failure of angiotensin-(1-9) levels to increase in response to increased angiotensin I levels indicated little role for ACE2 in angiotensin I metabolism. Additionally, the levels of angiotensin-(1-7) were more linked to those of angiotensin I than angiotensin II, consistent with its formation by endopeptidase-mediated metabolism of angiotensin I, rather than by ACE2-mediated metabolism of angiotensin II.

The acquisition and maintenance of defibrillation skills by lay first responders.

OBJECTIVE: Non-traditional and lay first responders increasingly are being trained in the skill of defibrillation. With simplification of new devices, there is a need to determine optimal first responder selection and training and maintenance of this important skill. These issues are of prime importance for the St John Ambulance Australia Operations Branch which already has a substantial first response defibrillation programme. DESIGN: We trained 12 trainers (3 h and 30 min), who subsequently instructed 41 further first responders (2 h and 30 min), a total group with a broad range of pre-existing experience and skill level, in the use of an automated external defibrillator (AED). Acquisition and maintenance of the AED skill was determined by four criteria at three monthly intervals. RESULTS: St John first responders with higher qualification levels were more likely to acquire the skill of defibrillation successfully (r=0.37, P<0.05). However, once acquired, the skill was easily maintained by virtually all (98%) members. A positive correlation was noted between the overall score achieved at the 6-month re-assessment and the number of times members had taken an AED 'on duty' (r=0.31, P<0.05). CONCLUSION: For St John first responders proficient in cardiopulmonary resuscitation (CPR), the skill of defibrillation with an AED is readily acquired and maintained. While less experienced members may be less likely to acquire the skill initially, once acquired the skill is equally maintained by all, provided ongoing 'on duty' exposure is available.

Mass gathering events: retrospective analysis of patient presentations over seven years.

INTRODUCTION: St John Ambulance Operations Branch Volunteers have been providing first-aid services at the Royal Adelaide Show for 90 years. The project arose from a need to more accurately predict the workload for first-aid providers at mass gathering events. A formal analysis of workload patterns and the determinants of workload had not been performed. HYPOTHESIS: Casualty presentation workload would be predicted by factors including day of the week, weather, and crowd size. METHOD: Collated and analyzed casualty reports over a seven-year period representing >7,000 patients who presented for first-aid assistance for that period (63 show days) were reviewed retrospectively. RESULTS: Casualty presentations correlated significantly with crowd size, maximum daily temperature, humidity, and day of the week. Patient presentation rate had heterogeneous determinants. The most frequent presentation was minor medical problems with Wednesdays attracting higher casualty presentations and more major medical categories. CONCLUSION: Individual event analysis is a useful mechanism to assist in determining resource allocation at mass gathering events providing an evidence base upon which to make decisions about future needs. Subsequent analysis of other events will assist in supporting accurate predictor models.

Can we make sense of takotsubo cardiomyopathy? An update on pathogenesis, diagnosis and natural history.

Takotsubo cardiomyopathy (TTC) is a form of reversible acute cardiac dysfunction of uncertain pathogenesis, which occurs predominantly in postmenopausal women, often with antecedent severe stress. Systolic dysfunction most commonly affects the apex of the left ventricle. There is considerable uncertainty regarding the pathogenesis of TTC and the optimal diagnostic methodology. Acute catecholamine release may play a component role, but the regional hypokinesis is associated with an acute inflammatory process, with resultant early release of brain natriuretic peptide (BNP) and N-terminal pro-BNP. As the diagnosis of TTC has largely been a process of exclusion, there has been considerable underdiagnosis. The combination of demographics, preceding history, ECG appearances and N-terminal pro-BNP elevation may provide the basis for improved early diagnosis. Complete recovery takes at least several months, with a risk of recurrent episodes. Efforts to delineate pathogenesis, expedite diagnosis and evaluate residual disability may assist in the development of appropriate treatment regimens.

N-terminal pro-brain natriuretic protein levels in takotsubo cardiomyopathy.

Takotsubo cardiomyopathy (TTC) is characterized by reversible left ventricular (LV) systolic dysfunction independent of fixed coronary disease or coronary spastic pathogenesis. A number of investigators have documented marked elevation of natriuretic peptide levels at presentation in such patients. We sought to determine the pattern, extent, and determinants of the release of N-terminal pro-B type natriuretic peptide/B type natriuretic peptide (NT-proBNP/BNP) in patients with TTC. We evaluated NT-proBNP/BNP release acutely and during the first 3 months in 56 patients with TTC (96% women, mean age 69 ± 11 years). The peak plasma NT-proBNP levels were compared to the pulmonary capillary wedge pressure and measures of regional and global LV systolic dysfunction (systolic wall stress, wall motion score index, and LV ejection fraction) as potential determinants of NT-proBNP/BNP release. In patients with TTC, the plasma concentrations of NT-proBNP (median 4,382 pg/ml, interquartile range 2,440 to 9,019) and BNP (median 617 pg/ml, interquartile range 426 to 1,026) were substantially elevated and increased significantly during the first 24 hours after the onset of symptoms (p = 0.001), with slow and incomplete resolution during the 3 months thereafter. The peak NT-proBNP levels exhibited no significant correlation with either pulmonary capillary wedge pressure or systolic wall stress. However, the peak NT-proBNP level correlated significantly with the simultaneous plasma normetanephrine concentrations (r = 0.53, p = 0.001) and the extent of impairment of LV systolic function, as measured by the wall motion score index (r = 0.37, p = 0.008) and LV ejection fraction (r = -0.39, p = 0.008). In conclusion, TTC is associated with marked and persistent elevation of NT-proBNP/BNP levels, which correlated with both the extent of catecholamine increase and the severity of LV systolic dysfunction.