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Diagnosis of acute coronary syndrome in the emergency room: the dictatorship of high-sensitivity cardiac troponin and major adverse cardiac events. Eur J Emerg Med 2020; 27:239-240. [DOI: 10.1097/mej.0000000000000733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Greenslade JH, Carlton EW, Van Hise C, Cho E, Hawkins T, Parsonage WA, Tate J, Ungerer J, Cullen L. Diagnostic Accuracy of a New High-Sensitivity Troponin I Assay and Five Accelerated Diagnostic Pathways for Ruling Out Acute Myocardial Infarction and Acute Coronary Syndrome. Ann Emerg Med 2017; 71:439-451.e3. [PMID: 29248334 DOI: 10.1016/j.annemergmed.2017.10.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/26/2017] [Accepted: 10/27/2017] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE This diagnostic accuracy study describes the performance of 5 accelerated chest pain pathways, calculated with the new Beckman's Access high-sensitivity troponin I assay. METHODS High-sensitivity troponin I was measured with presentation and 2-hour blood samples in 1,811 patients who presented to an emergency department (ED) in Australia. Patients were classified as being at low risk according to 5 rules: modified accelerated diagnostic protocol to assess patients with chest pain symptoms using troponin as the only biomarker (m-ADAPT), the Emergency Department Assessment of Chest Pain Score (EDACS) pathway, the History, ECG, Age, Risk Factors, and Troponin (HEART) pathway, the No Objective Testing Rule, and the new Vancouver Chest Pain Rule. Endpoints were 30-day acute myocardial infarction and acute coronary syndrome. Measures of diagnostic accuracy for each rule were calculated. RESULTS Data included 96 patients (5.3%) with acute myocardial infarction and 139 (7.7%) with acute coronary syndrome. The new Vancouver Chest Pain Rule and No Objective Testing Rule had high sensitivity for acute myocardial infarction (100%; 95% confidence interval [CI] 96.2% to 100% for both) and acute coronary syndrome (98.6% [95% CI 94.9% to 99.8%] and 99.3% [95% CI 96.1% to 100%]). The m-ADAPT, EDACS, and HEART pathways also yielded high sensitivity for acute myocardial infarction (96.9% [95% CI 91.1% to 99.4%] for m-ADAPT and 97.9% [95% CI 92.7% to 99.7%] for EDACS and HEART), but lower sensitivity for acute coronary syndrome (≤95.0% for all). The m-ADAPT, EDACS, and HEART rules classified more patients as being at low risk (64.3%, 62.5%, and 49.8%, respectively) than the new Vancouver Chest Pain Rule and No Objective Testing Rule (28.2% and 34.5%, respectively). CONCLUSION In this cohort with a low prevalence of acute myocardial infarction and acute coronary syndrome, using the Beckman's Access high-sensitivity troponin I assay with the new Vancouver Chest Pain Rule or No Objective Testing Rule enabled approximately one third of patients to be safely discharged after 2-hour risk stratification with no further testing. The EDACS, m-ADAPT, or HEART pathway enabled half of ED patients to be rapidly referred for objective testing.
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Affiliation(s)
- Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
| | - Edward W Carlton
- Emergency Department, South Meade Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Christopher Van Hise
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Elizabeth Cho
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Tracey Hawkins
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - William A Parsonage
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jillian Tate
- Pathology Queensland, Herston, Queensland, Australia
| | | | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
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Hancock DG, Chuang MYA, Bystrom R, Halabi A, Jones R, Horsfall M, Cullen L, Parsonage WA, Chew DP. Rational clinical evaluation of suspected acute coronary syndromes: The value of more information. Emerg Med Australas 2017; 29:664-671. [PMID: 28574204 DOI: 10.1111/1742-6723.12819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/28/2017] [Accepted: 05/09/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Many meta-analyses have provided synthesised likelihood ratio data to aid clinical decision-making. However, much less has been published on how to safely combine clinical information in practice. We aimed to explore the benefits and risks of pooling clinical information during the ED assessment of suspected acute coronary syndrome. METHODS Clinical information on 1776 patients was collected within a randomised trial conducted across five South Australian EDs between July 2011 and March 2013. Bayes theorem was used to calculate patient-specific post-test probabilities using age- and gender-specific pre-test probabilities and likelihood ratios corresponding to the presence or absence of 18 clinical factors. Model performance was assessed as the presence of adverse cardiac outcomes among patients theoretically discharged at a post-test probability less than 1%. RESULTS Bayes theorem-based models containing high-sensitivity troponin T (hs-troponin) outperformed models excluding hs-troponin, as well as models utilising TIMI and GRACE scores. In models containing hs-troponin, a plateau in improving discharge safety was observed after the inclusion of four clinical factors. Models with fewer clinical factors better approximated the true event rate, tended to be safer and resulted in a smaller standard deviation in post-test probability estimates. CONCLUSIONS We showed that there is a definable point where additional information becomes uninformative and may actually lead to less certainty. This evidence supports the concept that clinical decision-making in the assessment of suspected acute coronary syndrome should be focused on obtaining the least amount of information that provides the highest benefit for informing the decisions of admission or discharge.
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Affiliation(s)
- David G Hancock
- School of Medicine, Flinders University, Adelaide, South Australia, Australia.,Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Ming-Yu Anthony Chuang
- School of Medicine, Flinders University, Adelaide, South Australia, Australia.,Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Rebecca Bystrom
- School of Medicine, Flinders University, Adelaide, South Australia, Australia.,Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Amera Halabi
- School of Medicine, Flinders University, Adelaide, South Australia, Australia.,Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Rachel Jones
- School of Medicine, Flinders University, Adelaide, South Australia, Australia.,Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Matthew Horsfall
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Louise Cullen
- Australian Centre for Health Service Innovation, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | | | - Derek P Chew
- School of Medicine, Flinders University, Adelaide, South Australia, Australia.,Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
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Quelle place pour la biologie délocalisée aux urgences ? ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-016-0691-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Roche T, Gardner G, Lewis P. Retrospective observational study of patients who present to Australian rural emergency departments with undifferentiated chest pain. Aust J Rural Health 2016; 22:229-34. [PMID: 25303414 DOI: 10.1111/ajr.12134] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2014] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To identify the demographic and clinical characteristics of patients who present to Australian rural emergency departments (EDs) with chest pain. DESIGN Retrospective, observational study. SETTING Rural EDs in Queensland, Australia. PARTICIPANTS Three hundred thirty-seven consecutive adult patients with undifferentiated chest pain who presented between 1 September 2013 and 30 November 2013. MAIN OUTCOME MEASURES Service indicators, discharge diagnoses and disposition. RESULTS Presentations for undifferentiated chest pain represented 3.5% of all patient presentations during the sampling period. The mean age of patients was 48 years and 54% were male. Overall, 92% of patients left the ED within the 4-hour NEAT target. The majority of presentations were related to cardiac concerns (39%), followed by non-cardiac chest pain (17%), musculoskeletal (15%) and respiratory (10%) conditions. More than half of these patients were discharged at the completion of the ED service (52.8%), 40.6% were admitted, 3.3% left at own risk, 2.4% did not wait and less than 1% of patients required transfer to another hospital directly from the ED. CONCLUSIONS This study has provided information on the characteristics and processes of care for patients presenting to Australian rural EDs with undifferentiated chest pain that will inform service planning and further research to evaluate the effectiveness of care for these patients.
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Affiliation(s)
- Tina Roche
- Institute of Health and Biomedical Innovation, School of Nursing, Queensland University of Technology, Stanthorpe, Queensland, Australia; Stanthorpe Health Services, Emergency Department, Stanthorpe, Queensland, Australia
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Diagnostic Yield of Routine Stress Testing in Low and Intermediate Risk Chest Pain Patients Under 40 Years: A Systematic Review. Crit Pathw Cardiol 2016; 15:114-20. [PMID: 27465008 DOI: 10.1097/hpc.0000000000000081] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Chest pain is one of the most frequent causes for presentation to emergency departments (EDs). The majority of patients will undergo diagnostic workup including stress testing to rule out an acute coronary syndrome, but very few patients will be diagnosed with a cardiac cause for their pain. Patients under 40 years represent a lower risk group in which routine stress testing may be of little benefit. This systematic review sought to determine the diagnostic yield of routine stress testing in low- and intermediate-risk chest pain patients under 40 years. METHODS Electronic databases were searched for relevant studies. The quality of the included primary studies was assessed using the National Health and Medical Research Council evidence hierarchy and the McMaster Critical Appraisal Tool for Quantitative Studies. Descriptive statistics summarized the findings. RESULTS Five primary studies were included in the review (all level III-3 evidence); 7 additional sources of relevant data were also included. Diagnostic yield of routine stress testing in low- and intermediate-risk patients under 40 years is reported between 0% and 1.1%. Combined data from included primary studies demonstrated just 4 out of 1683 true positive stress tests (0.24%), only one of which was definitively confirmed by coronary angiogram; additional data sources identified just 1 out of 310 true positive stress tests (0.32%). CONCLUSIONS Diagnostic yield of routine stress testing in low- and intermediate-risk chest pain patients under 40 years is low. However, better quality studies are required to be able to draw definitive conclusions.
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Cheng Q, Greenslade JH, Parsonage WA, Barnett AG, Merollini K, Graves N, Peacock WF, Cullen L. Change to costs and lengths of stay in the emergency department and the Brisbane protocol: an observational study. BMJ Open 2016; 6:e009746. [PMID: 26916691 PMCID: PMC4769416 DOI: 10.1136/bmjopen-2015-009746] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To compare health service cost and length of stay between a traditional and an accelerated diagnostic approach to assess acute coronary syndromes (ACS) among patients who presented to the emergency department (ED) of a large tertiary hospital in Australia. DESIGN, SETTING AND PARTICIPANTS This historically controlled study analysed data collected from two independent patient cohorts presenting to the ED with potential ACS. The first cohort of 938 patients was recruited in 2008-2010, and these patients were assessed using the traditional diagnostic approach detailed in the national guideline. The second cohort of 921 patients was recruited in 2011-2013 and was assessed with the accelerated diagnostic approach named the Brisbane protocol. The Brisbane protocol applied early serial troponin testing for patients at 0 and 2 h after presentation to ED, in comparison with 0 and 6 h testing in traditional assessment process. The Brisbane protocol also defined a low-risk group of patients in whom no objective testing was performed. A decision tree model was used to compare the expected cost and length of stay in hospital between two approaches. Probabilistic sensitivity analysis was used to account for model uncertainty. RESULTS Compared with the traditional diagnostic approach, the Brisbane protocol was associated with reduced expected cost of $1229 (95% CI -$1266 to $5122) and reduced expected length of stay of 26 h (95% CI -14 to 136 h). The Brisbane protocol allowed physicians to discharge a higher proportion of low-risk and intermediate-risk patients from ED within 4 h (72% vs 51%). Results from sensitivity analysis suggested the Brisbane protocol had a high chance of being cost-saving and time-saving. CONCLUSIONS This study provides some evidence of cost savings from a decision to adopt the Brisbane protocol. Benefits would arise for the hospital and for patients and their families.
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Affiliation(s)
- Qinglu Cheng
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jaimi H Greenslade
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
| | - William A Parsonage
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
| | - Adrian G Barnett
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Katharina Merollini
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Louise Cullen
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- The University of Queensland, Brisbane, Queensland, Australia
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Cullen L, Greenslade J, Merollini K, Graves N, Hammett CJ, Hawkins T, Than MP, Brown AF, Huang CB, Panahi SE, Dalton E, Parsonage WA. Cost and outcomes of assessing patients with chest pain in an Australian emergency department. Med J Aust 2015; 202:427-32. [DOI: 10.5694/mja14.00472] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 02/05/2015] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Emily Dalton
- Royal Brisbane and Women's Hospital, Brisbane, QLD
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Cullen L, Greenslade J, Than M, Tate J, Ungerer JPJ, Pretorius C, Hammett CJ, Lamanna A, Chu K, Brown AFT, Parsonage WA. Performance of risk stratification for acute coronary syndrome with two-hour sensitive troponin assay results. Heart Lung Circ 2013; 23:428-34. [PMID: 24321648 DOI: 10.1016/j.hlc.2013.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 10/30/2013] [Accepted: 11/12/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Risk stratification processes for patients with possible acute coronary syndrome (ACS) recommend the use of serial sensitive troponin testing over at least 6h. Troponin assays vary in their analytical performance. Utility in accurate risk stratification at 2h post-presentation is unknown. METHODS A diagnostic accuracy study of patients presenting to the emergency department (ED) with symptoms of ACS was performed. Troponin was measured at 0, 2 and 6h post-presentation. Acute myocardial infarction (AMI) was adjudicated by cardiologists and incorporated the 0 and 6h troponin values measured by a sensitive troponin assay. Results were described using standard measures of test accuracy. RESULTS Of the 685 patients, 51 (7.4%) had 30-day AMI or cardiac death, and 76 (11.1%) had secondary outcomes (all cause death, ACS and revascularisation procedures). There was no significant difference in the diagnostic accuracy of early versus late biomarker strategies when used with the current risk stratification processes. Incorporation of a significant delta did not improve the stratification at 2h post-presentation. CONCLUSIONS Accelerated risk stratification of patients with ACS symptoms may occur at 2h post-presentation using troponin results measured by a sensitive assay. Incorporation of such a strategy could support improvements in patient flow within EDs.
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Affiliation(s)
- Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia.
| | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia
| | - Martin Than
- Department of Emergency Medicine, Christchurch Hospital, New Zealand
| | | | | | | | - Christopher J Hammett
- School of Medicine, The University of Queensland, Brisbane, Australia; Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Arvin Lamanna
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Kevin Chu
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia
| | - Anthony F T Brown
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia
| | - William A Parsonage
- School of Medicine, The University of Queensland, Brisbane, Australia; Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Comparison of Three Risk Stratification Rules for Predicting Patients With Acute Coronary Syndrome Presenting to an Australian Emergency Department. Heart Lung Circ 2013; 22:844-51. [DOI: 10.1016/j.hlc.2013.03.074] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 03/15/2013] [Accepted: 03/18/2013] [Indexed: 11/21/2022]
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Parsonage WA, Cullen L, Younger JF. The approach to patients with possible cardiac chest pain. Med J Aust 2013; 199:30-4. [PMID: 23829259 DOI: 10.5694/mja12.11171] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 06/02/2013] [Indexed: 11/17/2022]
Abstract
Chest pain is a common reason for presentation in hospital emergency departments and general practice. Some patients presenting with chest pain to emergency departments and, to a lesser extent, general practice will be found to have a life-threatening cause, but most will not. The challenge is to identify those who do in a safe, timely and cost-effective manner. An acute coronary syndrome cannot be excluded on clinical grounds alone. In patients with ongoing symptoms of chest pain, without an obvious other cause, ST-segment-elevation myocardial infarction should be excluded with a 12-lead electrocardiogram at the first available opportunity. Significant recent advances in the clinical approach to patients with acute chest pain, including better understanding of risk stratification, increasingly sensitive cardiac biomarkers and new non-invasive tests for coronary disease, can help clinicians minimise the risk of unexpected short-term adverse cardiac events. An approach that integrates these advances is needed to deliver the best outcomes for patients with chest pain. All hospital emergency departments should adopt such a strategic approach, and general practitioners should be aware of when and how to access these facilities.
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George T, Ashover S, Cullen L, Larsen P, Gibson J, Bilesky J, Coverdale S, Parsonage W. Introduction of an accelerated diagnostic protocol in the assessment of emergency department patients with possible acute coronary syndrome: The Nambour Short Low-Intermediate Chest pain project. Emerg Med Australas 2013; 25:340-4. [DOI: 10.1111/1742-6723.12091] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Terry George
- Department of Emergency Medicine; Nambour General Hospital; Nambour; Queensland; Australia
| | - Sarah Ashover
- ACRE Project; Royal Brisbane and Women's Hospital; Brisbane; Queensland; Australia
| | | | | | - Jason Gibson
- Department of Cardiology; Nambour General Hospital; Nambour; Queensland; Australia
| | - Jennifer Bilesky
- ACRE Project; Royal Brisbane and Women's Hospital; Brisbane; Queensland; Australia
| | - Steven Coverdale
- Sunshine Coast Clinical School, School of Medicine; University of Queensland; Brisbane; Queensland; Australia
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