Suspected myocardial infarction in the emergency department: An evaluation of clinical thresholds for the Beckman Coulter Access hsTnI high-sensitivity cardiac troponin I assay

OBJECTIVE

The primary objective was to determine rapid rule-out (RRO) criteria for the outcome of myocardial infarction (MI) using the Beckman Coulter Access high-sensitivity cardiac troponin I (hs-cTnI) assay. Secondary objectives were to explore cut-points for rapid rule-in (RRI) and amount of change at 3-h (3-h delta) indicative of MI.

METHODS

A retrospective study included ED patients with suspected MI between June and September 2019. hs-cTnI levels were performed at baseline and after 3 h. The performance benchmark for RRO criteria was a negative predictive value (NPV) for MI with a lower 95% confidence limit >99%, and for RRI and 3-h delta cut-points was a positive predictive value (PPV) for MI >70%. Delta calculation required rising hs-cTnI levels, with at least one above the 99th percentile of the upper reference limit. Analyses utilised receiver operating characteristic (ROC) curves and contingency tables.

RESULTS

Baseline hs-cTnI levels from 935 patients were available for RRO analyses. Of tested criteria, baseline hs-cTnI <6 ng/L (females) or <11 ng/L (males) plus symptom onset >2 h met the performance benchmark (NPV: 100% [95% confidence interval 99-100]). hs-cTnI levels were available for RRI and 3-h delta analyses from 935 and 52 patients, respectively. A 3-h delta cut-point >35 ng/L met the performance benchmark (PPV: 81% [95% confidence interval 58-95]) but no RRI cut-point did so.

CONCLUSIONS

For the Beckman Coulter Access hs-cTnI assay, RRO criteria of baseline hs-cTnI <6 ng/L (females) or <11 ng/L (males) plus symptom onset >2 h met our performance benchmark. A 3-h delta cut-point >35 ng/L met the performance benchmark, but poor precision means further adequately powered research is required.

Socioeconomic determinants of health, traditional risk factors and cardiovascular outcomes in Australia

Background

Cardiovascular disease burden is decreasing, but these reductions have not been distributed equally amongst socioeconomic groups.

Objectives

The aim of this study was to define the relationships between different domains of socioeconomic health, traditional cardiovascular risk factors and cardiovascular events.

Methods

This was a cross-sectional study of local government areas (LGAs) in Victoria, Australia. We used data from a population health survey combined with cardiovascular event data derived from hospital and government data. Four socioeconomic domains: educational attainment, financial wellbeing, remoteness, and psychosocial health, were generated from 22 variables. The primary outcome was a composite of non-STEMI, STEMI, heart failure and cardiovascular deaths per 10,000 persons. Linear regression and cluster analysis were used to assess the relationships between risk factors and events.

Results

Across 79 LGAs there were 33,654 interviews conducted. All socioeconomic domains were associated with burden of traditional risk factors, including hypertension, smoking, poor diet, diabetes, and obesity. Financial wellbeing, educational attainment and remoteness were all correlated with cardiovascular events on univariate analysis. After multivariate adjustment for age and sex, financial wellbeing, psychosocial wellbeing, and remoteness were associated with cardiovascular events, while educational attainment was not. After including traditional risk factors only financial wellbeing and remoteness remained correlated with cardiovascular events.

Conclusions

Financial wellbeing and remoteness independently be associated with cardiovascular events, while educational attainment and psychosocial wellbeing are attenuated by traditional cardiovascular risk factors. Poor socioeconomic health is clustered in certain areas, which have high cardiovascular event rates.

Computed tomography imaging for subclinical leaflet thrombosis following surgical and transcatheter aortic valve replacement

Subclinical leaflet thrombosis (LT) may occur following surgical and transcatheter aortic valve replacement. Computed tomography (CT) has become an established imaging modality to diagnose subclinical LT following bioprosthetic aortic valve replacement. Even so, there is a limited (but growing) experience in utilizing CT imaging for this indication. This review emphasizes a systematic approach to acquiring and analysing CT imaging for subclinical LT, highlighting evidence surrounding clinical sequelae of subclinical LT and anti-thrombotic implications following diagnosis.

Left ventricular contractile reserve as a determinant of adverse clinical outcomes: a systematic review

An abnormal left ventricular contractile reserve is often seen in patients undergoing stress echocardiogram and may indicate the presence of obstructive coronary artery disease. The techniques and indexes used to identify abnormal left ventricular contractile response and its prognostic value in the absence of known causes has not been well studied. To describe the characteristics and clinical outcomes associated with an abnormal left ventricular contractile response, we performed a systematic review that identified 27 eligible studies. A diverse range of indices were utilised to measure left ventricular contractile reserve, most commonly Δleft ventricular ejection fraction in 11 studies. Dobutamine stress echocardiogram was the most commonly performed modality (19 studies) followed by exercise stress echocardiogram (4 studies), dipyridamole stress echocardiogram (2 studies), invasive hemodynamic measurement (1 study) and dobutamine stress magnetic resonance imaging (1 study). All but one study demonstrated a significant association between the absence of left ventricular contractile reserve and increased rate of cardiovascular events, cardiac death and all-cause mortality.

The impact of hypo-attenuated leaflet thickening on haemodynamic valve deterioration following transcatheter aortic valve replacement

BACKGROUND

Hypo-attenuated leaflet thickening (HALT) may occur following transcatheter aortic valve replacement (TAVR), however, it remains unclear if HALT is a predictor of haemodynamic valve deterioration (HVD).

AIM

To determine the impact of HALT on the occurrence of HVD.

METHODS

We prospectively evaluated 186 patients for the presence of HALT at a median of 6 weeks following TAVR (Interquartile-range [IQR] 4-12 weeks). HALT depth and area were measured. HVD encompassed any of the following: mean gradient ≥20 ​mmHg with an increase in gradient ≥10 ​mmHg from baseline, Doppler velocity index reduction ≥0.1 or new moderate-to-severe valvular regurgitation. Routine echocardiograms at discharge, one month and annually, were assessed by echo-cardiologists that were blinded to the HALT status.

RESULTS

LT prevalence was 17.7% (33/186). HVD was present in 8.6% (16/186) at a median follow-up of 2 years (IQR 1-3); two required valve re-intervention and five required anticoagulation. HALT was the only independent predictor of HVD on multivariate analysis (OR 33.3, 95%CI 7.4-125). Patients with HALT were more likely to develop HVD, require repeat valve intervention and have higher trans-valvular gradients at up to 3-year follow-up. Patients with HALT had a median cumulative thickness of 2.9 ​mm (IQR 1.9-4.7) and area of 64.2 ​mm² (IQR 40.9-91.6). Thresholds for HALT in predicting HVD were a cumulative depth of 2.4 ​mm (Specificity 94.1%, Sensitivity 75.0%, AUC ​= ​0.87) and cumulative area of 28 ​mm² (Specificity 92.2%, Sensitivity 81.3%, AUC ​= ​0.86).

CONCLUSION

HALT is an independent predictor of HVD, which exhibits specific depth and area thresholds to predict HVD. CT following TAVR may determine patients at risk of HVD.

Potential impact of a novel pathway for suspected myocardial infarction utilising a new high-sensitivity cardiac troponin I assay

BACKGROUND

High-sensitivity cardiac troponin I (hs-cTnI) assays promise high diagnostic accuracy for myocardial infarction (MI). In an ED where conventional cTnI was in use, we evaluated an assessment pathway using the new Access hsTnI assay.

METHODS

This retrospective analysis recruited ED patients with suspected MI between June and September 2019. All patients received routine care with a conventional cTnI assay (AccuTnI +3: limit of detection (LoD) 10 ng/L, 99th centile upper reference limit (URL) 40 ng/L, abnormal elevation cut-point 80 ng/L). Arrival, then 90-minute or 360-minute cTnI levels for low and non-low risk patients, respectively (ED Assessment of Chest pain score) guided diagnosis and disposition which was at treating physician discretion. The same patients had arrival and 90-minute or 180-minute samples drawn for hs-cTnI levels (Access hsTnI: LoD 2 ng/L, 99th centile URL 10 ng/L (females) and 20 ng/L (males); abnormal elevation above the URL and delta >30%). Treating physicians were blinded to the hs-cTnI results. Using the hs-cTnI values, investigators retrospectively assigned likely diagnosis, disposition and likelihood of a 30-day major adverse cardiac event (MACE). Admission was recommended for significantly rising hs-cTnI elevations. The primary objective was to demonstrate an acceptable unexpected 30-day post-discharge MACE rate of <1%. cTnI elevation rates, diagnostic outcomes and ED disposition were also compared between pathways.

RESULTS

For the 935 patients, unexpected 30-day post-discharge MACE rates were 0/935 (0%, 95% CI 0% to 0.4%) with the conventional or novel pathway. For the high-sensitivity and conventional assays, respectively, abnormal elevation rates were 29% (95% CI 26% to 32%) and 19% (95% CI 17% to 22%), for MI were 9% (95% CI 8% to 11%) and 8% (95% CI 6% to 10%), and for hospital admission were 42% (95% CI 39% to 45%) and 43% (95% CI 40% to 47%).

CONCLUSION

The novel pathway using the Access hsTnI assay has an acceptably low 30-day MACE rate.

Characteristics and Clinical Outcomes in Patients With Heart Failure With Preserved Ejection Fraction Compared to Heart Failure With Reduced Ejection Fraction: Insights From the VCOR Heart Failure Snapshot

BACKGROUND

Heart failure is increasing in prevalence, creating a greater public health and economic burden on our health care system. With a rising proportion of hospitalisations for heart failure with preserved ejection fraction (HFpEF) compared to heart failure with reduced ejection fraction (HFrEF) and lack of proven therapies for HFpEF, patient characterisation and defining clinical outcomes are important in determining optimal management of heart failure patients. There is scarce Australian-specific data with regards to the burden of disease of patients with HFpEF which further limits our ability to appropriately manage this syndrome.

AIM

To determine the characteristics, management practices and outcomes of patients with HFpEF compared to patients diagnosed with HFrEF.

METHOD

Data was sourced from the Victorian Cardiac Outcomes Registry-Heart Failure (VCOR-HF) snapshot of patients admitted with acute heart failure to one of 16 Victorian health services between 2014-2017 over one consecutive month annually. Outcomes measured were in-hospital mortality, and 30-day readmission and mortality.

RESULTS

Of the 1,132 HF patients, 436 patients were diagnosed with HFpEF and were more likely to be female (59%) and older (81.5±9.8 vs 73.2±14.5 years). They were also more likely to have hypertension (80%), atrial fibrillation (59.9%), chronic obstructive airways disease (36.2%) and chronic kidney disease (68.8%). Patients with HFrEF were more likely to have ischaemic heart disease with a history of previous myocardial infarction (36.6%), percutaneous coronary intervention and cardiac bypass surgery (35.2%). There were no significant differences in 30-day mortality between HFpEF and HFrEF (10.2% vs 7.8%; p=0.19, respectively) and 30-day readmission rates (22.1% vs 25.9%; p=0.15, respectively).

CONCLUSION

VCOR-HF Snapshot data provides important insight into the burden of acute heart failure. Whilst patients with HFpEF and HFrEF have differing clinical profiles, morbidity, mortality and re-admission rates are similar.

Hypo-attenuated leaflet thickening is associated with structural valve deterioration following transcatheter aortic valve replacement

Background

While hypo-attenuated leaflet thickening (HALT) has been extensively described following transcatheter aortic valve replacement (TAVR), it remains unclear if HALT impacts long-term prosthetic haemodynamics or predicts structural valve deterioration (SVD).

Purpose

To determine the role of HALT and its characteristics of depth and thickness in predicting SVD.

Methods

We prospectively evaluated 186 patients who had undergone TAVR with 320-slice CT imaging for the presence of HALT, defined as hypo-attenuation of bioprosthetic leaflets in diastole. All assessments were performed by two blinded operators on the 3Mensio workstation. HALT depth (thickness) was the greatest depth in the sagittal view and HALT area was the greatest area in the axial view. SVD was defined as at least one of mean gradient ≥20 mmHg, increase in gradient ≥10 mmHg from baseline and at least moderate valvular regurgitation. Echocardiograms at discharge, one month and annually were assessed by cardiologists blinded to HALT status.

Results

LT prevalence was 17.7% at a median CT scan of 6 weeks. SVD occurred in 8.6% at a median follow-up of 2 years (IQR 1–3); two required valve re-intervention, five required anticoagulation that reversed moderate-severe gradient and nine had mild-moderate gradients that were closely monitored. Patients with HALT were more likely to develop SVD (39.3% vs 1.9%, p&lt;0.01) and higher trans-valvular gradients throughout follow-up at up to 3-year follow-up. HALT affected one leaflet in 17 cases, two leaflets in 13 cases and three leaflets in 3 cases. Patients with HALT had a median cumulative thickness of 2.9 mm (IQR 1.9–4.7) and a median area of 64.2 mm2 (IQR 40.9–91.6). Threshold for the occurrence of SVD with HALT characteristics were cumulative depth of 2.4 mm (Specificity 94.1%, Sensitivity 75.0%, AUC=0.87) and cumulative area of 28 mm2 (Specificity 92.2%, Sensitivity 81.3%, AUC=0.86).

Conclusion

HALT was associated with SVD and higher trans-valvular gradients following TAVR. HALT depth and area were strong predictors of SVD. CT following TAVR may determine patients at-risk of SVD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Heart Foundation AustraliaNational Health and Medical Research Council Australia

SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes: a randomized controlled trial

BACKGROUND

There are well-documented treatment gaps in secondary prevention of coronary heart disease with a lack of clearly defined strategies to assist early physical activity after acute coronary syndromes (ACS). Smartphone technology may provide an innovative platform to close these gaps.

OBJECTIVES

The primary goal of this study was to assess whether a smartphone-based, early cardiac rehabilitation program improved exercise capacity in patients with ACS.

METHODS

A total of 206 patients with ACS across six tertiary Australian hospitals were included in this randomized controlled trial. Participants were randomized to usual care (UC; including referral to traditional cardiac rehabilitation), with or without an adjunctive smartphone-based cardiac rehabilitation program (S-CRP) upon hospital discharge. The primary endpoint was change in exercise capacity, measured by the change in 6-minute walk test distance at 8 weeks when compared to baseline, between groups. Secondary endpoints included uptake and adherence to cardiac rehabilitation, changes in cardiac risk factors, psychological well-being and quality of life status.

RESULTS

Of the 168 patients with complete follow-up (age 56 ± 10 years; 16% females), 83 were in the S-CRP. At 8-week follow-up, the S-CRP group had a clinically significant improvement in 6-minute walk test distance (Δ117 ± 76 vs. Δ91 ± 110 m; P = 0.02). Patients in the S-CRP were more likely to participate (87% vs. 51%, P < 0.001) and adhere (72% vs. 22%, P < 0.001) to a cardiac rehabilitation program. Compared to UC, patients receiving S-CRP had similar smoking cessation rates, LDL-cholesterol levels, blood pressure reduction, depression, anxiety and quality of life measures (all P = NS).

CONCLUSION

In patients with ACS, a S-CRP, as an adjunct to UC improved exercise capacity at 8 weeks in addition to participation and adherence to cardiac rehabilitation (Australian New Zealand Clinical Trials Registry; ACTRN12616000426482).

Enhancing the appeal of cardiac rehabilitation for women: development and pilot testing of a women-only yoga cardiac rehabilitation programme

AIMS

Despite its demonstrated benefits, cardiac rehabilitation (CR) attendance, and completion is suboptimal, particularly in women. The aims of this study were (i) to develop and pilot test a women-only yoga-based CR programme (the Women's Yoga CR Programme; WYCRP); (ii) to investigate programme acceptability; and (iii) to investigate attendance and completion of the WYCRP and continuation to Phase III community-based CR.

METHODS AND RESULTS

Women eligible for CR at a tertiary hospital in Melbourne, Australia were recruited. Over a 6-month period in 2019, they were offered the WYCRP or usual CR. The WYCRP involved attendance at a 1-h yoga session following the usual 1-h mixed-sex education session, over a 7-week period. Participants completed pre- and post-programme questionnaires and attended focus groups to assess programme acceptability. Rates of attendance, completion, and continuation for the WYCRP were recorded and compared to those for the standard CR programme offered in 2018. In total, 27 women were eligible for the study and attended the initial CR assessment. Of those, 22 (81%) attended the WYCRP, 1 (4%) attended usual CR, and 4 (15%) did not attend CR. Ratings of programme acceptability were consistently positive; qualitative comments highlighted both physical and emotional benefits. While attendance at the WYCRP was not significantly higher than for usual CR the previous year (81% vs. 76%; P = 0.40), CR completion, and continuation were (95% vs. 56%; P = 0.02, and 72% vs. 12%; P < 0.001, respectively).

CONCLUSION

This pilot study has demonstrated that women-only yoga-based CR is appealing to women and can improve women's CR completion and continuation. These preliminary findings support further development of women-only and yoga-based CR options.

Predictive utility of left heart catheterization indices for left ventricular thrombus formation after anterior ST-elevation myocardial infarction

BACKGROUND

Left ventricular thrombus (LVT) has a 5% incidence after anterior ST-elevation myocardial infarction (STEMI). Multiple risk factors predispose to LVT formation, including left ventricular systolic dysfunction and infarct size, however measurable predictors during index left heart catheterization (LHC) have not been determined.

METHODS

We performed a retrospective analysis of patients presenting between January 2010 and September 2017 with anterior STEMI who had in-hospital transthoracic echocardiography (TTE). LHC variables that were assessed included coronary anatomy, location of culprit stenosis, presence of diffuse stenosis, number of severely diseased vessels, apical akinesis on left ventriculogram (LVG), left ventricular end diastolic pressure, and success of percutaneous coronary intervention (PCI).

RESULTS

Of 598 consecutive anterior STEMI patients, records and inpatient TTE results were available in 425 patients. The incidence of LVT was 6.8% (n = 29). After multivariate adjustment, severe triple vessel coronary disease (OR = 8.27, CI = 2.97-23.00, p ≤0.001), apical akinesis on LVG (OR = 6.74, CI = 1.48-30.73, p = 0.014), wrap-around left anterior descending (LAD) anatomy (OR = 5.10, CI = 1.97-13.23, p = 0.001), and failure of recanalization after PCI (OR = 3.94, CI = 1.06-14.66, p = 0.04) were predictors for LVT formation. The combined negative predictive value (NPV) for the absence of these four indices was 99.2%.

CONCLUSION

Severe triple vessel disease, apical akinesis on LVG during index admission, wrap-around LAD, and failure of recanalization after PCI are associated with increased risk of LVT formation after anterior STEMI. The high NPV for the absence of these indices could serve as a risk stratification tool for LVT risk to guide early TTE utilization.

Colchicine in Patients With Acute Coronary Syndrome

Background:

Inflammation plays a crucial role in clinical manifestations and complications of acute coronary syndromes (ACS). Colchicine, a commonly used treatment for gout, has recently emerged as a novel therapeutic option in cardiovascular medicine owing to its anti-inflammatory properties. We sought to determine the potential usefulness of colchicine treatment in patients with ACS.

Methods:

This was a multicenter, randomized, double-blind, placebo-controlled trial involving 17 hospitals in Australia that provide acute cardiac care service. Eligible participants were adults (18–85 years) who presented with ACS and had evidence of coronary artery disease on coronary angiography managed with either percutaneous coronary intervention or medical therapy. Patients were assigned to receive either colchicine (0.5 mg twice daily for the first month, then 0.5 mg daily for 11 months) or placebo, in addition to standard secondary prevention pharmacotherapy, and were followed up for a minimum of 12 months. The primary outcome was a composite of all-cause mortality, ACS, ischemia-driven (unplanned) urgent revascularization, and noncardioembolic ischemic stroke in a time to event analysis.

Results:

A total of 795 patients were recruited between December 2015 and September 2018 (mean age, 59.8±10.3 years; 21% female), with 396 assigned to the colchicine group and 399 to the placebo group. Over the 12-month follow-up, there were 24 events in the colchicine group compared with 38 events in the placebo group ( P =0.09, log-rank). There was a higher rate of total death (8 versus 1; P =0.017, log-rank) and, in particular, noncardiovascular death in the colchicine group (5 versus 0; P =0.024, log-rank). The rates of reported adverse effects were not different (colchicine 23.0% versus placebo 24.3%), and they were predominantly gastrointestinal symptoms (colchicine, 23.0% versus placebo, 20.8%).

Conclusions:

The addition of colchicine to standard medical therapy did not significantly affect cardiovascular outcomes at 12 months in patients with ACS and was associated with a higher rate of mortality.

Registration:

URL: https://www.anzctr.org.au ; Unique identifier: ACTRN12615000861550.

Association between prosthesis geometry and leaflet thrombosis following transcatheter aortic valve replacement

Introduction

Leaflet thrombosis (LT) following transcatheter aortic valve replacement (TAVR) is a recognised condition. The association between prosthesis geometry [expansion, implant depth and commissural alignment (CA)] and LT is unclear.

Methods

Patients that received intra-annular TAVR prosthesis and post-procedure computed tomography (CT) with a 320-slice scanner were included. LT, defined as at least 50% restricted leaflet motion, was assessed with a dedicated 3Mensio workstation by two experienced CT readers. Prosthesis expansion was defined as actual divided by expected prosthesis area as a percentage of expected area whilst eccentricity was [(maximum diameter − minimum diameter) / maximum diameter) × 100%], both measured at prosthesis inflow, annulus and outflow. Implant depth was the average distance between prosthesis inflow and nadir of each cusp. CA was the average angle between each native and prosthesis leaflet coaptations. Significant commissural misalignment (CMA) was defined as CA greater than 30 degrees. To exclude anticoagulation bias, similar analysis was also performed in the cohort of non-anticoagulated patients.

Results

117 patients were included; the prevalence of LT was 13.7% [13/93 cases (14.0%) of Lotus valves and 3/24 cases (12.5%) of Sapien 3 valves]. Baseline demographics (age, STS score, cardiac risk factors) and procedural characteristics (access site, post-dilation, repositioning) were similar in both groups. None of the patients with LT were discharged on anticoagulation therapy (0.0% vs 22.8%, p&lt;0.01). There were no differences in actual prosthesis area, perimeter or eccentricity at the three prosthesis levels. Patients with LT had reduced annulus expansion (89.3±9.8% vs 94.6±8.3%, p=0.02), lower implant depth (6.9±1.5mm vs 4.9±1.5mm, p&lt;0.01) and more significant CMA (81.3% vs 48.5%, p=0.02). These findings were similar in patients that were not anticoagulated (94/117 patients).

Conclusion

Patients with LT had reduced annulus expansion, lower implant depth and greater CMA. These findings were not affected by presence or absence of anticoagulation. These factors may be important considerations during procedural planning for TAVR.

Graphical abstract

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Health and Medical Research Council (NHMRC). National Heart Foundation (NHF) Australia.

Evidence-practice gaps in P2Y12 inhibitor use after hospitalisation for acute myocardial infarction: findings from a new population-level data linkage in Australia

Background

P2Y₁₂ inhibitor therapy is recommended for 12 months in patients hospitalised for acute myocardial infarction (AMI) unless the bleeding risk is high.

Aims

To describe real‐world use of P2Y₁₂ inhibitor therapy following AMI hospitalisation.

Methods

We used population‐level linked hospital data to identify all patients discharged from a public hospital with a primary diagnosis of AMI between July 2011 and June 2013 in New South Wales and Victoria, Australia. We used dispensing claims to examine dispensing of a P2Y₁₂ inhibitor (clopidogrel, prasugrel or ticagrelor) within 30 days of discharge and multilevel models to identify predictors of post‐discharge dispensing and persistence of therapy to 1 year.

Results

We identified 31 848 patients hospitalised for AMI, of whom 56.8% were dispensed a P2Y₁₂ inhibitor within 30 days of discharge. The proportion of patients with post‐discharge dispensing varied between hospitals (interquartile range: 25.0–56.5%), and significant between‐hospital variation remained after adjusting for patient characteristics. Patient factors associated with the lowest likelihood of post‐discharge dispensing were: having undergone coronary artery bypass grafting (odds ratio (OR): 0.17; 95% confidence intervals (CI): 0.15–0.20); having oral anticoagulants dispensed 180 days before or 30 days after discharge (OR: 0.39, 95% CI: 0.35–0.44); major bleeding (OR: 0.68, 95% CI: 0.61–0.76); or being aged ≥85 years (OR: 0.68, 95% CI: 0.62–0.75). A total of 26.8% of patients who were dispensed a P2Y₁₂ inhibitor post‐discharge discontinued therapy within 1 year.

Conclusion

Post‐hospitalisation use of P2Y₁₂ inhibitor therapy in AMI patients is low and varies substantially by hospital of discharge. Our findings suggest strategies addressing both health system (hospital and physician) and patient factors are needed to close this evidence‐practice gap.

CSANZ Position Statement on the Evaluation of Patients Presenting With Suspected Acute Coronary Syndromes During the COVID-19 Pandemic

A pandemic of Coronavirus-19 disease was declared by the World Health Organization on March 11, 2020. The pandemic is expected to place unprecedented demand on health service delivery. This position statement has been developed by the Cardiac Society of Australia and New Zealand to assist clinicians to continue to deliver rapid and safe evaluation of patients presenting with suspected acute cardiac syndrome at this time. The position statement complements, and should be read in conjunction with, the National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016: Section 2 'Assessment of Possible Cardiac Chest Pain'.

Predictors of acute hospital mortality and length of stay in patients with new-onset atrial fibrillation: a first-hand experience from a medical emergency team response provider

BACKGROUND

Atrial fibrillation (AF) occurs frequently following cardiothoracic surgery and treatment decisions are informed by evidence-based clinical guidelines. Outside this setting there are few data to guide clinical management.

AIM

To describe the characteristics, management and outcomes of hospitalised adult patients with new-onset AF.

METHODS

The medical emergency team (MET) database was utilised to identify patients who had a 'MET call' activated for tachycardia between 2015 and 2016. Patients with sinus tachycardia, pre-existing AF/atrial flutter or other known tachyarrhythmia were excluded. Primary outcomes were length of hospital stay and in-hospital mortality.

RESULTS

New-onset AF was identified in 137 patients: 68 medically managed; 38 non-cardiothoracic post-operative; and 31 cardiothoracic post-operative. Mean age was 74 ± 11.6 years and 72 (53%) were male. Of 79 patients who underwent echocardiography, 80% had left atrial dilatation and 14% had reduced left ventricular ejection fraction (LVEF). Mean length of stay (LOS) was 12 days and in-hospital mortality rate was 11%. On multivariable analysis, the odds of death during acute hospitalisation was 7.4 times higher in patients with heart failure with reduced LVEF (odds ratio 7.4, 95% confidence interval (CI) 1.23-44.8, P = 0.028). Length of acute hospital stay increased by 36% if the duration of AF was longer than 48 h (beta coefficient 0.36, 95% CI -0.015 to 0.74, P = 0.059).

CONCLUSION

Left ventricular systolic dysfunction in hospitalised patients with new-onset AF is associated with increased all-cause mortality whereas lower serum potassium levels are associated with an increased LOS. A prospective study is planned to compare outcomes based on in-hospital treatment strategies.

Evidence-Practice Gaps in Postdischarge Initiation With Oral Anticoagulants in Patients With Atrial Fibrillation

Background

Oral anticoagulant (OAC) therapy reduces the risk of stroke in people with atrial fibrillation (AF), and is considered best practice; however, there is little Australian evidence around the uptake of OACs in this population.

Methods and Results

We used linked hospital admissions, pharmaceutical dispensing claims, medical services, and mortality data for people in Australia's 2 most populous states (July 2010 to June 2015). Among OAC‐naïve people hospitalized with AF, we estimated initiation of OAC therapy within 30 days of discharge, and persistence with therapy in the first year. We analyzed both outcomes using multivariable Cox regression. In 71 184 people with AF (median age 78 years, 49% female), 22.7% initiated OAC therapy. Initiation was lowest in July to December 2011 (17.0%) and highest in July to December 2014 (30.1%) after subsidy of the direct OACs. In adjusted analyses, initiation was most likely in people with a CHA₂DS₂‐VA score ≥7 (versus 0) (hazard ratio=6.25, 95% CI 5.08–7.69), and a history of venous thromboembolism (hazard ratio=2.65, 95% CI 2.49–2.83). Of the people who initiated OAC therapy, 39.9% discontinued within 1 year; a lower risk of discontinuation was associated with a CHA₂DS₂‐VA score ≥7 (versus 0) (hazard ratio=0.22, 95% CI 0.14–0.35), or initiation on a direct OAC (versus warfarin) (hazard ratio=0.55, 95% CI 0.50–0.60).

Conclusions

We found that OAC therapy was severely underutilized in people hospitalized with AF, even among high‐risk individuals. Reasons for this underuse, whether patient, prescriber, or hospital related, should be identified and addressed to reduce stroke‐related morbidity and mortality in people with AF.

Awareness of Familial Hypercholesterolemia Among Healthcare Providers Involved in the Management of Acute Coronary Syndrome in Victoria, Australia

Background

Familial hypercholesterolemia (FH) is a common underdiagnosed autosomal dominant lipid disorder carrying a significant risk of premature coronary artery disease. The aim of this study was to evaluate the awareness and knowledge of heterozygous FH of healthcare providers in coronary care units (CCUs).

Methods

Medical staff working in CCUs in 4 sizable metropolitan health networks in Melbourne, Australia, were requested to complete a structured anonymised questionnaire with regard to FH. The results were tabulated and analysed with the Statistical Package for the Social Sciences version 23 (IBM, New York, NY).

Results

A total of 121 participants (67% response rate) completed the survey. Some 76% claimed to be at least modestly familiar with FH, and more than half of them adequately described FH; however, only 16% and 43%, respectively, were aware of the prevalence of FH and existence of lipid guidelines. In regard to epidemiological knowledge and update in the management of FH in CCUs, knowledge was suboptimal. In regard to FH care, General Practitioners were rated by 72% of participants as the first most efficient healthcare provider in the management of FH, and cardiologists were rated by 54% of participants as the second most efficient healthcare provider in the management of FH. Some 36% of respondents advocated a form of alert system in laboratory reports to facilitate the diagnosis of FH.

Conclusions

This survey identified substantial gaps in the knowledge and awareness of FH among healthcare providers involved in the management of acute coronary syndrome. Focused education and clinical training are warranted to raise awareness of FH among healthcare providers working in CCUs.

The tertiary hospital laboratory; a novel avenue of opportunistic screening of familial hypercholesterolemia

Background

Familial hypercholesterolemia (FH) is a common monogenic hereditary lipid disorder characterised by increased serum low-density lipoprotein cholesterol (LDL-cholesterol) concentrations and high risk of premature atherosclerotic cardiovascular disease. The prevalence of FH identified in a tertiary hospital laboratory was investigated by performing an opportunistic screen for index cases.

Methods

The prevalence of likely FH based on LDL-cholesterol thresholds >4.9 mmol/L as employed by the Dutch Lipid Clinic Network Criteria (DLCNC) score was evaluated retrospectively in a single tertiary hospital laboratory over a six-month period (July to December 2016).

Results

4943 lipid profiles screened, 106 patients (mean age 53.2 ± 12.9 and 41% male) had LDL-cholesterol of >4.9 mmol/L after exclusion of 5 patients (0.1%) with secondary causes. Possible (n = 90) and probable/definite (n = 16) FH according to DLCNC score was seen in 1.8% and 0.4% of the overall screened population, respectively.

Conclusions

Point prevalence of screening for FH in patients undergoing lipid profile testing in a tertiary hospital laboratory was comparable with prevalence of FH in general population (based on 1 in 200-250). This supports the benefit of establishing an efficient "alert system" in conjunction with a trigger "reflex testing" to facilitate further formal FH scoring and exclusion of possible secondary causes of hyperlipidemia in potential index FH.

Texture analysis of cardiovascular magnetic resonance cine images differentiates aetiologies of left ventricular hypertrophy

AIM

To investigate whether unenhanced cardiovascular magnetic resonance (CMR) balanced steady state free precession (bSSFP) cine images could be analysed using textural analysis (TA) software to differentiate different aetiologies of disease causing increased myocardial wall thickness (left ventricular hypertrophy [LVH]) and indicate the severity of myocardial tissue abnormality.

MATERIALS AND METHODS

A mid short axis unenhanced cine frame of 216 patients comprising 50 cases of hypertrophic cardiomyopathy (HCM; predominantly Left ventricular outflow tract obstruction [LVOTO] subtype), 52 cases of cardiac amyloid (CA; predominantly AL: light chain subtype), 68 cases of aortic stenosis (AS), 15 hypertensive patients with LVH (HTN+LVH), and 31 healthy volunteers (HV) underwent TA of the CMR cine images (CMRTA) using TexRAD (TexRAD Ltd, Cambridge, UK). Among the HV, 16/31 were scanned twice to form a test-retest reproducibility cohort. CMRTA comprised a filtration-histogram technique to extract and quantify features using six parameters.

RESULTS

Test-retest analysis in the HV showed a medium filter (3 mm) was the most reproducible (intra-class correlation of 0.9 for kurtosis and skewness and 0.8 for mean and SD). Disease cohorts were statistically different (p<0.001) to HV for all parameters. Pairwise comparisons of CMRTA parameters showed kurtosis and skewness was consistently significant in ranking the degree of difference from HV (greatest to least): CA, HCM, LVH+HTN, AS (p<0.001). Similarly, mean, standard deviation, entropy, and mean positive pixel (MPP) were consistent in ranking degree of difference from HV: HCM, CA, AS and HTN+LVH.

CONCLUSION

Radiomic features of bSSFP CMR data sets derived using TA show promise in discriminating between the aetiologies of LVH.

Artificial FLOwering plants in Reducing Anxiety and depressive symptoms following Acute Coronary Syndromes (A-FLORA-ACS): a randomised controlled trial

Patients often experience emotional distress after acute coronary syndrome (ACS). These may lead to symptoms of depression or anxiety and greater morbidity/mortality. We sought to determine whether flowering plants in the coronary care ward reduced depressive and anxiety symptoms in these patients. Patients with ACS were randomly allocated to flowering plants (intervention) or no plants (control) in their room during index hospitalisation. Baseline data were collected. The primary outcome was the Hospital Anxiety and Depression Scale (HADS) depressive and anxiety symptom scores at discharge. Secondary outcomes were HADS depression and anxiety scores at 3 months. Both modified intention-to-treat (mITT) and per-protocol (PP) analysis were performed. 122 patients were included in the analysis after case exclusion, with all completing the HADS questionnaire at discharge and 89/122 (73%) patients completing the 3-month post-discharge HADS. At discharge, mean depressive symptom scores were lower in the intervention group, but only significantly so in the PP analysis (mITT 3.6/21 vs 4.6/21, p = 0.11; PP 3.5/21 vs 4.9/21, p = 0.04). There were no significant changes in between-group anxiety symptom scores (mITT 6.4/21 vs 6.1/21, p = 0.51; PP 3.3/21 vs 3.6/21, p = 0.67). The mean increase in depressive symptom scores at 3 months was smaller in the intervention group in both analyses (mITT 0.6 ± 3.6 vs 2.2 ± 2.6, p = 0.02; PP 0.8 ± 3.6 vs 2.4 ± 2.7, p = 0.03). Mean increase in anxiety symptom scores was not significantly different between groups (mITT 2.8/21 vs 2.5/21, p = 0.86; PP 3.3/21 vs 3.6/21, p = 0.67). Flowering plants during index hospitalisation for ACS reduced depressive symptoms in a per-protocol analysis but did not have a significant impact on anxiety symptoms. Increases in depression symptom scores were significantly smaller at 3 months post exposure to flowers compared to anxiety symptom scores.

The effect of combined ezetimibe and statin therapy versus statin therapy alone on coronary plaque volume assessed by intravascular ultrasound: A systematic review and meta-analysis

BACKGROUND

Current guidelines recommend an intensive lipid-lowering therapy to achieve the low-density lipoprotein cholesterol (LDL-C) target in patients with high risk of cardiovascular disease. Former studies suggested adding ezetimibe to statin therapy in the above setting may promote plaque changes; however, this effect has not been consistently reported.

METHODS

Electronic searches were performed in MEDLINE, EMBASE, and Cochrane library on November 30, 2017 to identify prospective trials assessing the effects of combined ezetimibe and statin therapy versus statin therapy alone on atheroma volume using intravascular ultrasound. The effect size between treatment groups within individual studies was assessed by weighted mean difference (MD) using a random-effects model.

RESULTS

Eight studies were obtained for systematic review and 6 of them compromising total of 583 subjects that meet the criteria were meta-analyzed. There was a significant reduction from baseline to follow-up in total atheroma volume with an MD of -3.71 mm³ (95% confidence interval: -5.98 to -1.44, P < .001), whereas analysis for percent atheroma volume demonstrated weighted MD of - 0.77% (-1.68 to 0.14, P = .10). A substantial decrease in LDL-C was observed with MD -16.75 mg/dL (-20.89 to -12.60, P < .00001).

CONCLUSION

The addition of ezetimibe to statin therapy is effective in reducing total atheroma volume assessed by intravascular ultrasound and also resulted in effective reduction of plasma LDL-C levels.

Using Australia’s National Data Linkage Demonstration Project (NDLDP) to improve cardiac care: Towards a national, whole-of-population linked data resource for evidence-informed health policy

IntroductionIn Australia, the Commonwealth, State and Territory governments are each responsible for specific aspects of health care. Historically, cross-jurisdictional health data have not been linked routinely, resulting in significant blind spots in our understanding of the interplay between hospital and primary care, a major impediment to evidence-informed health policy. Objectives and ApproachIn December 2016, the Australian Health Ministers’ Advisory Council approved the NDLDP, to establish the value of national linked data to inform health planning and policy. The Australian Institute of Health and Welfare (AIHW) linked five years of hospital, emergency department, pharmaceutical dispensing, medical services claims and mortality data for Australia’s two most populous states (New South Wales and Victoria). The Victorian Agency for Health Innovation (VAHI) is leading the ‘Delivering better cardiac outcomes: Primary, specialist and hospital care’ project to demonstrate the value of the collection in identifying evidence-practice gaps and driving change in cardiac care. ResultsThe NDLDP combined data for over 10 million individuals with over 7 billion records of health transactions, utilising a new strategy for confidentialising dates to protect patient privacy. The NDLDP is governed by a Steering Committee; the AIHW is the data custodian approving outputs from analyses within a secure host environment. VAHI established a Project Steering Committee to oversee roll-out, governance and capacity building of the approved cardiac project. The VAHI project was instigated by evidence that best-practice pharmacological treatments for cardiac care are underutilised in Australia, but with no quantification of the population-level extent of this gap. The project quantified significant variations and underuse of post-discharge pharmacological care for patients admitted to hospital with key cardiac conditions, including atrial fibrillation and acute myocardial infarction. Conclusion/ImplicationsThis collaboration between government, clinical networks and academic researchers demonstrated this novel data linkage can enable evaluation of patient care pathways across both hospital and community-based services. These linked data resources provide essential information to investigate variation in care in Australia and improve care integration in cardiac care and beyond.