Determinants and Outcomes of Invasive Coronary Angiography in Unselected Patients Presenting With Chest Pain to Emergency Departments in Western Australian Teaching Hospitals.

Background: Chest pain is a common cause of presentation to the emergency department (ED), and its outcomes are affected by various diagnostic tests and timely management. Our aim was to identify determinants of invasive coronary angiography (ICA) in a chest pain cohort following ED presentation, and to compare outcomes by time to ICA.

Methods: We identified all adults aged ≥20 years presenting with chest pain to public teaching hospital EDs in Perth, Western Australia, from 1 January 2016 to 31 March 2017.

rimary care dherence o eart ailure guidelines iagnosis, valuation and outine management (PATHFINDER): a randomised controlled trial protocol.

Introduction: General practitioners (GPs) routinely provide care for patients with heart failure (HF); however, adherence to management guidelines, including titrating medication to optimal dose, can be challenging in this setting. This study will evaluate the effectiveness of a multifaceted intervention to support adherence to HF management guidelines in primary care.

Methods And Analysis: We will undertake a multicentre, parallel-group, randomised controlled trial of 200 participants with HF with reduced ejection fraction.

Galactic Cosmic Rays Throughout the Heliosphere and in the Very Local Interstellar Medium.

We review recent observations and modeling developments on the subject of galactic cosmic rays through the heliosphere and in the Very Local Interstellar Medium, emphasizing knowledge that has accumulated over the past decade. We begin by highlighting key measurements of cosmic-ray spectra by Voyager, PAMELA, and AMS and discuss advances in global models of solar modulation. Next, we survey recent works related to large-scale, long-term spatial and temporal variations of cosmic rays in different regimes of the solar wind.

Q Fever Endocarditis: A Review of Local and all Reported Cases in the Literature.

Background: Q fever endocarditis by Coxiella burnetii is rare and presents a diagnostic challenge. With limited data available, the aim of this study was to review all reported cases together with unpublished local cases to understand risk factor profiles, diagnostic methods, clinical features, treatments and outcomes.

Methods: A search of the PubMed database using the term 'Q fever endocarditis' identified cases between 1950-2019.

Invasive Coronary Angiography after Chest Pain Presentations to Emergency Departments.

We investigated patients presenting to emergency departments (EDs) with chest pain to identify factors that influence the use of invasive coronary angiography (ICA). Using linked ED, hospitalisations, death and cardiac biomarker data, we identified people aged 20 years and over who presented with chest pain to tertiary public hospital EDs in Western Australia from 1 January 2016 to 31 March 2017 (ED chest pain cohort). We report patient characteristics, ED discharge diagnosis, pathways to ICA, ICA within 90 days, troponin test results, and gender differences.

Cardioprotective medication adherence in Western Australians in the first year after myocardial infarction: restricted cubic spline analysis of adherence-outcome relationships.

Adherence to cardioprotective medications following myocardial infarction (MI) is commonly assessed using a binary threshold of 80%. We investigated the relationship between medication adherence as a continuous measure and outcomes in MI survivors using restricted cubic splines (RCS). We identified all patients aged ≥65 years hospitalised for MI from 2003-2008 who survived one-year post-discharge (n = 5938).

Operationalization and validation of a novel method to calculate adherence to polypharmacy with refill data from the Australian pharmaceutical benefits scheme (PBS) database.

Background: Electronic health care data contain rich information on medicine use from which adherence can be estimated. Various measures developed with medication claims data called for transparency of the equations used, predominantly because they may overestimate adherence, and even more when used with multiple medications. We aimed to operationalize a novel calculation of adherence with polypharmacy, the daily polypharmacy possession ratio (DPPR), and validate it against the common measure of adherence, the medication possession ratio (MPR) and a modified version (MPR).

A Practical Guide for Fractional Flow Reserve Guided Revascularisation.

The presence and extent of myocardial ischaemia is a major determinant of prognosis and benefit from revascularisation in patients with stable coronary artery disease. Fractional Flow Reserve (FFR) is accepted as the reference standard for invasive assessment of ischaemia. Its ability to detect lesion specific ischaemia makes it a useful test in a wide range of patient and lesion subsets, with FFR guided intervention improving clinical outcomes and reducing health care costs compared to assessment with coronary angiography alone.

Has invasive management for acute coronary syndromes become more 'risk-appropriate': pooled results of five Australian registries.

Background: Despite being recommended in acute coronary syndrome (ACS) guidelines, the use of invasive management within specific risk groups continues to be debated. This study examines the change in the use of invasive management in ACS by patient risk and the associated change in mortality within Australia over the last 17 years.

Methods: Pooled cohorts derived from five ACS registries (ACACIA, CONCORDANCE, GRACE, Snapshot-ACS, and Predict) spanned from 1999 to 2015.

Impact of the Australian gender specific thresholds using the Abbott high sensitivity troponin I assay in clinical care.

The aim of this study was to ascertain the impact of gender specific hs-TnI thresholds in a clinical setting and determine the clinical characteristics and discharge diagnosis for individuals presenting to the Emergency Department (ED) with elevated troponin I with the Abbott high-sensitivity troponin I (hs-TnI) assay, but non-elevated troponin I on the previous generation assay (STAT TnI-II). Medical records of individuals presenting to the Royal Perth Hospital ED with elevated hs-TnI between 12 November 2013 and 24 December 2013 were retrospectively reviewed. The 99th percentile hs-TnI thresholds were ≥26 ng/L for males and ≥16 ng/L for females.

The underutilisation of dual antiplatelet therapy in acute coronary syndrome.

Background: Despite guideline recommendation of dual antiplatelet therapy (DAPT) in treating ACS, DAPT is underutilized. Our objective was to determine independent predictors of DAPT non-prescription in ACS and describe pattern of DAPT prescription over time.

Methods: Patients presenting to 41 Australian hospitals with an ACS diagnosis between 2009 and 2016 were stratified according to discharge prescription with DAPT and single antiplatelet therapy (SAPT) or no antiplatelet therapy.

A Comparison of Radial and Femoral Coronary Angiography in Patients From SNAPSHOT ACS, a Prospective Acute Coronary Syndrome Audit in Australia and New Zealand.

Background: There is wide variation in the use of radial over femoral access for patients with ACS. This study evaluates the factors associated with the selection of radial versus femoral angiography in Australia and New Zealand and the effect of access site on clinical events in acute coronary syndrome (ACS) patients.

Methods: An analysis of the SNAPSHOT ACS audit was conducted during May 2012 across 286 hospitals in Australia and New Zealand.

Secondary preventive medication use in a prevalent population-based cohort of acute coronary syndrome survivors.

Aim: Describe the dispensing patterns for guideline-recommended medications during 2008 in people with acute coronary syndrome (ACS) and how dispensing varies by gender and time since last ACS hospitalization.

Method: A descriptive cohort spanning 20 years of people alive post-ACS in 2008. We extracted all ACS hospitalizations and deaths in Western Australia (1989-2008), and all person-linked Pharmaceutical Benefits Scheme claims nationally for 2008.

Characteristics and Clinical Course of STEMI Patients who Received no Reperfusion in the Australia and New Zealand SNAPSHOT ACS Registry.

Background: Cohort studies of STEMI patients have reported that over 30% receive no reperfusion. Barriers to greater use of reperfusion in STEMI patients require further elucidation.

Methods: We collected data on STEMI patients with no reperfusion as part of the SNAPSHOT ACS Registry, which recruited consecutive ACS patients in 478 hospitals throughout Australia and New Zealand during 14-27 May 2012.

Kounis syndrome with Samter-Beer triad treated with intracoronary adrenaline.

Kounis syndrome is a well-described clinical condition characterized by the simultaneous occurrence of chest pain and an allergic reaction accompanied by clinical and laboratory findings of angina caused by inflammatory mediators released during an allergic insult. We present the case of a 50-year-old male with the Samter-Beer triad of asthma, nasal polyps, and salicylate intolerance with an ST elevation myocardial infarction complicated with cardiac arrest due to multi-vessel coronary artery spasm secondary to aspirin anaphylaxis. Adrenaline is recommended during anaphylaxis but is controversial in Kounis syndrome as it may worsen coronary spasm.

Age-specific gender differences in long-term recurrence and mortality following incident myocardial infarction: a population-based study.

Background: Higher mortality following myocardial infarction (MI) is reported in women compared with men with short-term follow-up. Our study aim was to compare long-term gender- and age-specific outcomes following incident MI.

Methods: 30-day survivors of incident MI from 2003-2009 were identified from linked administrative data in Western Australia.

Long-term use and cost-effectiveness of secondary prevention drugs for heart disease in Western Australian seniors (WAMACH): a study protocol.

Introduction: Secondary prevention drugs for cardiac disease have been demonstrated by clinical trials to be effective in reducing future cardiovascular and mortality events (WAMACH is the Western Australian Medication Adherence and Costs in Heart disease study). Hence, most countries have adopted health policies and guidelines for the use of these drugs, and included them in government subsidised drug lists to encourage their use. However, suboptimal prescribing and non-adherence to these drugs remains a universal problem.

Intra-aortic balloon pump: indications, efficacy, guidelines and future directions.

Purpose Of Review: The intra-aortic balloon pump (IABP) has been used as a cardiac assist device in various clinical situations since 1968 on the basis of the physiological principles and observational data, with little randomized data until recently.

Recent Findings: Recently published randomized controlled trials (RCTs) and meta-analyses have demonstrated acceptable safety for IABP but have raised doubt over efficacy in acute myocardial infarction (MI) both with and without cardiogenic shock. RCTs and meta-analyses have provided limited and qualified support for the efficacy of IABP in high-risk percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG).

Impact of the introduction of drug eluting stents on clinical outcomes in patients undergoing percutaneous and surgical coronary artery revascularisation procedures in Western Australia.

Background: Increasing rates of percutaneous coronary intervention (PCI) and decreasing rates of coronary artery bypass graft (CABG) surgery followed the introduction of drug eluting stents in Western Australia in 2002. We assessed the impact of these changes on one-year outcomes for the total population of patients undergoing coronary artery revascularisation procedures (CARP) in Western Australia between 2000-2004.

Methods: Clinical and linked administrative data (inpatient admissions and death) were merged for all patients who had their first CARP with stent or CABG in Western Australia between 2000-2004.

Strategies for multivessel revascularization in patients with diabetes.

Background: In some randomized trials comparing revascularization strategies for patients with diabetes, coronary-artery bypass grafting (CABG) has had a better outcome than percutaneous coronary intervention (PCI). We sought to discover whether aggressive medical therapy and the use of drug-eluting stents could alter the revascularization approach for patients with diabetes and multivessel coronary artery disease.

Methods: In this randomized trial, we assigned patients with diabetes and multivessel coronary artery disease to undergo either PCI with drug-eluting stents or CABG.

Acute gastrointestinal bleeding after percutaneous coronary intervention.

Bleeding from the GI tract is a commonly encountered clinical problem after percutaneous coronary intervention. The GI tract is likely to become the most commonly encountered site of bleeding as cardiologists adopt smaller access sheath sizes, percutaneous closure devices and a radial artery approach, further reducing access-site bleeding. To appropriately manage gastrointestinal bleeding in this setting, the clinician must strike a balance between arresting hemorrhage and preventing ischemic coronary complications.

Can we monitor heart attack in the troponin era? Evidence from a population-based cohort study.

Background: Troponins (highly sensitive biomarkers of myocardial damage) increase counts of myocardial infarction (MI) in clinical practice, but their impact on trends in admission rates for MI in National statistics is uncertain.

Methods: Cases coded as MI or other cardiac diagnoses in the Hospital Morbidity Data Collection (MI-HMDC) in Western Australia in 1998 and 2003 were classified using revised criteria for MI developed by an International panel convened by the American Heart Association (AHA criteria) using information on symptoms, ECGs and cardiac biomarkers abstracted from samples of medical notes. Age-sex standardized rates of MI-HMDC were compared with rates of MI based on AHA criteria including troponins (MI-AHA) or traditional biomarkers only (MI-AHAck).

Reperfusion therapy in the acute management of ST-segment-elevation myocardial infarction in Australia: findings from the ACACIA registry.

Objective: To describe the contemporary management and outcomes of patients presenting with ST-segment-elevation myocardial infarction (STEMI) in Australia.

Design, Participants And Setting: Observational analysis of data for patients who presented with suspected STEMI and enrolled in the Australian Acute Coronary Syndrome Prospective Audit from 1 November 2005 to 31 July 2007.

Main Outcome Measures: Factors associated with use of reperfusion therapy and timely use of reperfusion therapy, and the effects of reperfusion on mortality.

Percutaneous coronary intervention in the Occluded Artery Trial: procedural success, hazard, and outcomes over 5 years.

Background: The Occluded Artery Trial (OAT) was a 2,201-patient randomized clinical trial comparing routine stent-based percutaneous coronary intervention (PCI) versus optimal medical therapy alone in stable myocardial infarction (MI) survivors with persistent infarct-related artery occlusion identified day 3 to 28 post MI. Intent-to-treat analysis showed no difference between strategies with respect to the incidence of new class IV congestive heart failure, MI, or death. The influence of PCI failure, procedural hazard, and crossover on trial results has not been reported.