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The patient is a 73-year-old female with peripheral vascular disease, coronary artery disease, and systemic lupus erythematosus, who underwent mesenteric artery bypass surgery. She suffered from a pneumonia after surgery, causing acute hypoxic respiratory failure and septic shock. Due to shock, she developed acute renal failure. She was intubated, ventilated, and received continuous veno-venous hemodialysis for renal failure. ST elevation was first observed on telemetry and subsequently confirmed on electrocardiogram. Marked ST elevation is present in the anterior leads with reciprocal ST depression in the inferior leads. A prolonged QT interval is also present. What is the most likely diagnosis?

The patient is a 73-year-old female with peripheral vascular disease, coronary artery disease, and systemic lupus erythematosus, who underwent mesenteric artery bypass surgery. She suffered from a pneumonia after surgery, causing acute hypoxic respiratory failure and septic shock. Due to shock, she developed acute renal failure. She was intubated, ventilated, and received continuous veno-venous hemodialysis for renal failure. ST elevation was first observed on telemetry and subsequently confirmed on electrocardiogram. Marked ST elevation is present in the anterior leads with reciprocal ST depression in the inferior leads. A prolonged QT interval is also present. What is the most likely diagnosis?

Acute myocardial infarction can be considered as a potential epidemic for mankind (WHO 1982). Diabetes mellitus is one of the 6 primary risk factors identified for myocardial infarction. The aim of our study was to correlate the incidence of complications with diabetes by using ST segment resolution as a tool, thereby re-enforcing the role of incomplete ST resolution as a marker of worse clinical outcome in cases of diabetes with ST-elevated myocardialinfarction in our population.

Acute myocardial infarction can be considered as a potential epidemic for mankind (WHO 1982). Diabetes mellitus is one of the 6 primary risk factors identified for myocardial infarction. The aim of our study was to correlate the incidence of complications with diabetes by using ST segment resolution as a tool, thereby re-enforcing the role of incomplete ST resolution as a marker of worse clinical outcome in cases of diabetes with ST-elevated myocardialinfarction in our population.

Acute myocardial infarction can be considered as a potential epidemic for mankind (WHO 1982). Diabetes mellitus is one of the 6 primary risk factors identified for myocardial infarction. The aim of our study was to correlate the incidence of complications with diabetes by using ST segment resolution as a tool, thereby re-enforcing the role of incomplete ST resolution as a marker of worse clinical outcome in cases of diabetes with ST-elevated myocardialinfarction in our population.

Acute myocardial infarction can be considered as a potential epidemic for mankind (WHO 1982). Diabetes mellitus is one of the 6 primary risk factors identified for myocardial infarction. The aim of our study was to correlate the incidence of complications with diabetes by using ST segment resolution as a tool, thereby re-enforcing the role of incomplete ST resolution as a marker of worse clinical outcome in cases of diabetes with ST-elevated myocardial infarction in our populationST segment elevation

Acute myocardial infarction can be considered as a potential epidemic for mankind (WHO 1982). Diabetes mellitus is one of the 6 primary risk factors identified for myocardial infarction. The aim of our study was to correlate the incidence of complications with diabetes by using ST segment resolution as a tool, thereby re-enforcing the role of incomplete ST resolution as a marker of worse clinical outcome in cases of diabetes with ST-elevated myocardial infarction in our populationST segment elevation

Acute myocardial infarction can be considered as a potential epidemic for mankind (WHO 1982). Diabetes mellitus is one of the 6 primary risk factors identified for myocardial infarction. The aim of our study was to correlate the incidence of complications with diabetes by using ST segment resolution as a tool, thereby re-enforcing the role of incomplete ST resolution as a marker of worse clinical outcome in cases of diabetes with ST-elevated myocardial infarction in our populationST segment elevation

Background: Oral squamous cell carcinoma (SCC) with cardiac metastasis is a rare antemortem finding. A case demonstrating significant right ventricular (RV) cavity obliteration due to metastatic SCC in an asymptomatic patient is presented. Case Summary: A 46-year-old gentleman underwent routine preoperative electrocardiogram which raised concern of possible anterior and inferior ST elevation (Image 1A). Clinically he had no chest pain but a 2-week history of night sweats, anorexia and weight loss. This was on a background of meta-static floor of mouth SCC treated with neoadjuvant carboplatin/paclitaxel chemotherapy and wide local excision of the floor of the mouth, subtotal glossectomy, segmental mandibulectomy, left sided selective lymph node dissection, and right modified radical neck dissection. Histopathology revealed T4aN2cM0 locally advanced SCC. Clinical examination was unremarkable except for a JVP with a prominent 'a' wave and a pericardial friction rub. Investigations revealed a normal Troponin (<0.04 ng/ml). CT Pulmonary Angiogram demonstrated a large pericardial effusion, a large filling defect (49x45mm) within the RV, multiple enlarged mediastinal and anterior pericardial lymph nodes. Several lung nodules were found bilaterally (largest 14x17mm). FDG-PET scan demonstrated an intensely avid mass involving the myocardium, the interventricular septum and floor of the ventricle (Image 1D). Nodular FDG avid pericardial disease and bilateral pulmonary metastases were noted in addition to uptake in the subcutaneous soft tissues anterior to the left oropharynx (SUV max 6). Urgent transtho-racic echocardiogram revealed moderate right ventricular (RV) dilation, with a large lobulated echodense mass invading the RV free wall, occupying most of the RV cavity (Image 1B & C). Estimated RV systolic pressure was 32 mmHg. A moderate circumferential pericardial effusion was detected, measuring 25 mm in diameter posteriorly with no tamponade physiology. Management: A pres

Background: Oral squamous cell carcinoma (SCC) with cardiac metastasis is a rare antemortem finding. A case demonstrating significant right ventricular (RV) cavity obliteration due to metastatic SCC in an asymptomatic patient is presented. Case Summary: A 46-year-old gentleman underwent routine preoperative electrocardiogram which raised concern of possible anterior and inferior ST elevation (Image 1A). Clinically he had no chest pain but a 2-week history of night sweats, anorexia and weight loss. This was on a background of meta-static floor of mouth SCC treated with neoadjuvant carboplatin/paclitaxel chemotherapy and wide local excision of the floor of the mouth, subtotal glossectomy, segmental mandibulectomy, left sided selective lymph node dissection, and right modified radical neck dissection. Histopathology revealed T4aN2cM0 locally advanced SCC. Clinical examination was unremarkable except for a JVP with a prominent 'a' wave and a pericardial friction rub. Investigations revealed a normal Troponin (<0.04 ng/ml). CT Pulmonary Angiogram demonstrated a large pericardial effusion, a large filling defect (49x45mm) within the RV, multiple enlarged mediastinal and anterior pericardial lymph nodes. Several lung nodules were found bilaterally (largest 14x17mm). FDG-PET scan demonstrated an intensely avid mass involving the myocardium, the interventricular septum and floor of the ventricle (Image 1D). Nodular FDG avid pericardial disease and bilateral pulmonary metastases were noted in addition to uptake in the subcutaneous soft tissues anterior to the left oropharynx (SUV max 6). Urgent transtho-racic echocardiogram revealed moderate right ventricular (RV) dilation, with a large lobulated echodense mass invading the RV free wall, occupying most of the RV cavity (Image 1B & C). Estimated RV systolic pressure was 32 mmHg. A moderate circumferential pericardial effusion was detected, measuring 25 mm in diameter posteriorly with no tamponade physiology. Management: A pres

Objective: To find out frequency and outcomes of undiagnosed diabetes mellitus in patients presenting with acute ST elevation myocardial infarction (STEMI). Study Design: Descriptive / Cross-Sectional Study Place and Duration of study: This study was conducted at the Cardiology Department, Lady Reading Hospital, Peshawar from November 2018 to May 2019. Materials and Methods: Patient of either gender having age ranging between 30-75 years old with acute STEMI who present within 12 hours of symptoms and with no past history of documented diabetes mellitus were included in the study. Venous blood samples for laboratory data, including random blood sugar, two fasting blood sugar and HBA1c using hitachi modular evo p800 machine was done. Results: A total of 158 patients having acute STEMI were studied. Males were 68.4% (n=108).The mean age was 59.65 ±10.80 years. Frequency of undiagnosed diabetes mellitus was 31.64 % (n = 50). In non-diabetics stress hyperglycemia was found in 51.85 % (n=56) patients. Among various types of STEMI, anterior STEMI was more common presentation 34.1 % (n=54. p= 0.85). Mean HBA1C was 6.19 ± 1.87%. Frequency of Ventricular tachycardia (VT) was 22.2 % in which undiagnosed diabetics were n=18 (p=0.004).Ventricular fibrillation was present in 13.3 % patients with undiagnosed diabetics were n=14 (p=0.001). Frequency of AF was 13.9% (n=22) with undiagnosed diabetics having AF in n=13 (p=0.003). SVT was present in 5.7% (n=9) patients with not significant difference between two groups (p=0.017). Among various mechanical complications VSR was present in 10 % (n=16) of patients (p=0.001), cardiogenic shock in 11.1 % (n=18) patients (p=0.004), acute LVF was present in 15.8 % patients (p=0.017). Conclusion: In our study we concluded that one third of patients having acute ST elevation myocardial infarction have undiagnosed diabetes mellitus (31.64 %, n = 50). The most common complication was ventricular tachycardia among electrical complication and LVF a, QC 20211011

Objectives: CASE: A previously well 62-year-old female presented to the emergency department with central chest pain. Initial electrocardiogram demonstrated sinus rhythm with ST-elevation in V1-V2 and she underwent emergent coronary angiography which demonstrated no obstructive coronary artery stenosis, however left ventriculography demonstrated focal dyskinesis / aneurysm of the mid anterior left ventricular (LV) wall. Contrast enhanced transthoracic echocardiography (TTE) confirmed the appearance and demonstrated a pericardial effusion, raising the suspicion of a contained LV rupture. Cardiacmagnetic resonance (CMR) imaging confirmed the presence of an anterior wall aneurysm with associated oedema on T2 weighted images (Fig 1) however there was no evidence of associated late gadolinium enhancement (LGE) in the region (Fig 1). The patient had been involved in an argument before presenting to hospital and the findings were thought to be most consistent with an atypical Takotsubo cardiomyopathy (TC), and repeat transthoracic echocardiography 1 month later demonstrated complete normalisation of LV contraction. DISCUSSION: TC is a rare syndrome characterized by transient regional systolic dysfunction of the LV, mimickingmyocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. Focal involvement of the myocardium is its rarest form. A large multi-centre study in this population found CMR can accurately identify TC through a typical pattern of LV dysfunction and demonstrates myocardial edema in 81% patients, and no significant LGE in 91%. These findings were consistent with our patient. Interestingly in this study 40% of this patient population also had a pericardial effusion. (Figure Presented).

Objectives: CASE: A previously well 62-year-old female presented to the emergency department with central chest pain. Initial electrocardiogram demonstrated sinus rhythm with ST-elevation in V1-V2 and she underwent emergent coronary angiography which demonstrated no obstructive coronary artery stenosis, however left ventriculography demonstrated focal dyskinesis / aneurysm of the mid anterior left ventricular (LV) wall. Contrast enhanced transthoracic echocardiography (TTE) confirmed the appearance and demonstrated a pericardial effusion, raising the suspicion of a contained LV rupture. Cardiacmagnetic resonance (CMR) imaging confirmed the presence of an anterior wall aneurysm with associated oedema on T2 weighted images (Fig 1) however there was no evidence of associated late gadolinium enhancement (LGE) in the region (Fig 1). The patient had been involved in an argument before presenting to hospital and the findings were thought to be most consistent with an atypical Takotsubo cardiomyopathy (TC), and repeat transthoracic echocardiography 1 month later demonstrated complete normalisation of LV contraction. DISCUSSION: TC is a rare syndrome characterized by transient regional systolic dysfunction of the LV, mimickingmyocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. Focal involvement of the myocardium is its rarest form. A large multi-centre study in this population found CMR can accurately identify TC through a typical pattern of LV dysfunction and demonstrates myocardial edema in 81% patients, and no significant LGE in 91%. These findings were consistent with our patient. Interestingly in this study 40% of this patient population also had a pericardial effusion. (Figure Presented).

A 75-year-old male presented to the Emergency Department with chest pain and anterior ST segment elevation. He had previously had a left anterior descending (LAD) stent (CYPHERTM sirolimus-eluting) implanted in 2006 for angina. Coronary angiography revealed stent fracture with thrombo-sis, displacement of the distal half of the stent, and a coronary aneurysm between fractured segments. Stent fracture in first-generation drug-eluting stents (DES) is an uncommon but recognised complication of DES implantation. Most cases are minor, but aneurysm formation at the site of fracture is rare. Image A demonstrates the stent in the LAD with the proximal (red arrow) and distal (yellow arrow) portions angulated relative to each other; the coronary wire is in the proximal LAD. Image B shows the coronary aneurysm (blue arrow) with TIMI0 flow in the LAD distal to the aneurysm; the coronary wire is seen in a septal branch. The vessel was unable to be revascularised. [Figure Presented].

Catheter induced coronary dissection is an uncommon but potentially catastrophic complication of coronary angiography. We report a case of a 48-year-old female with normal coronary arteries on angiography complicated by extensive catheter induced spiral dissection. Wiring into the true lumen was a formidable challenge as a consequence of the large false lumen obliterating the true lumen. We present management strategies and in particular, highlight the important role of intravascular ultrasound (IVUS) imaging.Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

A 75-year-old male presented to the Emergency Department with chest pain and anterior ST segment elevation. He had previously had a left anterior descending (LAD) stent (CYPHERTM sirolimus-eluting) implanted in 2006 for angina. Coronary angiography revealed stent fracture with thrombo-sis, displacement of the distal half of the stent, and a coronary aneurysm between fractured segments. Stent fracture in first-generation drug-eluting stents (DES) is an uncommon but recognised complication of DES implantation. Most cases are minor, but aneurysm formation at the site of fracture is rare. Image A demonstrates the stent in the LAD with the proximal (red arrow) and distal (yellow arrow) portions angulated relative to each other; the coronary wire is in the proximal LAD. Image B shows the coronary aneurysm (blue arrow) with TIMI0 flow in the LAD distal to the aneurysm; the coronary wire is seen in a septal branch. The vessel was unable to be revascularised. [Figure Presented].

Catheter induced coronary dissection is an uncommon but potentially catastrophic complication of coronary angiography. We report a case of a 48-year-old female with normal coronary arteries on angiography complicated by extensive catheter induced spiral dissection. Wiring into the true lumen was a formidable challenge as a consequence of the large false lumen obliterating the true lumen. We present management strategies and in particular, highlight the important role of intravascular ultrasound (IVUS) imaging.Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Objective: Clonidine is a central alpha(2)-agonist antihypertensive used widely for indications such as opioid/alcohol withdrawal, Attention Deficit Hyperactivity Disorder and the management of chronic pain. In recent times, clonidine withdrawal has not been commonly reported. We describe an unusual case of clonidine withdrawal causing life-threatening sympathetic storm and takotsubo cardiomyopathy. Case report: A 47-year-old man with chronic back pain, treated with clonidine for many years via intrathecal pump (550 mcg/24hours), presented to our emergency department following collapse and complaining of sudden worsening of back pain, severe headache, diaphoresis, malaise, nausea and vomiting. A few hours prior to presentation, his subcutaneous pump beeped, suggesting malfunction. On presentation his vital signs were pulse 100 bpm, BP 176/103, temperature 37.8degreeC and O2 saturations 100% (room air). Acute clonidine withdrawal with hypertensive crisis was suspected. An intravenous clonidine loading-dose of 150 mcg was given, followed by 150 mcg/hour infusion. Despite this, 5 hours later, severe chest pain, dyspnoea, tachycardia (150 bpm), hypoxia (SpO2 82%), with BP 180/120 ensued. CXR showed pulmonary oedema. ECG showed sinus tachycardia with no ST elevation. The toxicology service was consulted and advised repeated boluses of clonidine 25 mcg every 5-10 minutes, with ongoing clonidine infusion to control his blood pressure with addition of glyceryl trinitrate (GTN) infusion, positive pressure ventilation and intravenous benzodiazepines. Bedside echocardiogram showed takotsubo-type stress-induced cardiomyopathy pattern. Serum troponin-I was markedly elevated. Subsequent in-patient coronary angiography showed minor irregularities in the major vessels. Over the next 3 days in ICU, GTN and clonidine infusions were weaned. Discharge was 12-days later on oral clonidine, metoprolol, perindopril, aspirin and oxycodone SR. Two months later an echocardiogram was normal. T

Aim: To determine the characteristics and outcomes of patients transferred froma rural hospital for coronary angiography. Method(s): Retrospective audit of medical records of patients transferred from Mildura Base Hospital from 1st January to 31st December 2013 for coronary angiography. Demographic data, medical insurance, primary diagnosis, illness severity score, and transfer costs were recorded. Details regarding inpatient stay at the receiving hospitals were obtained from discharge summaries. Result(s): There were 114 transfers for coronary angiography which represented 41% of all medical inter-hospital transfers fromthis centre. Median age was 64 years, 36.9% were female. 42.9% had private insurance with 39.5% being transferred to private hospitals. The median Charlson comorbidity score was 1 and median Simple Clinical Score was 5 suggesting haemodynamically stable patients with low 24-hour and 30- day mortality risk, suitable for transfer and advanced care. The principle diagnosis included non ST elevation (64%) and ST elevation myocardial infarction (14.9%), angina (11.4%), arrhythmias (6.1%), other chest pain (1.7%) and heart failure (1.7%). Angiography, performed in 95.6% of transfers (n=109), revealed significant coronary disease in 78 (71.5%) and resulted in revascularisation in 56 cases (coronary artery stenting in 40 and bypass grafting in 16), evidencing that transfer was clinically reasonable. In-hospital mortality was 2.6%. The cost of air ambulance transfer of 114 patients was $AU558,000. Conclusion(s): Coronary angiography is a common and appropriate reason for inter-hospital patient transfer. The cost of air transfer is significant and our study supports the development of cardiac catheterisation laboratories in selected large rural centres.

Objective: Clonidine is a central alpha(2)-agonist antihypertensive used widely for indications such as opioid/alcohol withdrawal, Attention Deficit Hyperactivity Disorder and the management of chronic pain. In recent times, clonidine withdrawal has not been commonly reported. We describe an unusual case of clonidine withdrawal causing life-threatening sympathetic storm and takotsubo cardiomyopathy. Case report: A 47-year-old man with chronic back pain, treated with clonidine for many years via intrathecal pump (550 mcg/24hours), presented to our emergency department following collapse and complaining of sudden worsening of back pain, severe headache, diaphoresis, malaise, nausea and vomiting. A few hours prior to presentation, his subcutaneous pump beeped, suggesting malfunction. On presentation his vital signs were pulse 100 bpm, BP 176/103, temperature 37.8degreeC and O2 saturations 100% (room air). Acute clonidine withdrawal with hypertensive crisis was suspected. An intravenous clonidine loading-dose of 150 mcg was given, followed by 150 mcg/hour infusion. Despite this, 5 hours later, severe chest pain, dyspnoea, tachycardia (150 bpm), hypoxia (SpO2 82%), with BP 180/120 ensued. CXR showed pulmonary oedema. ECG showed sinus tachycardia with no ST elevation. The toxicology service was consulted and advised repeated boluses of clonidine 25 mcg every 5-10 minutes, with ongoing clonidine infusion to control his blood pressure with addition of glyceryl trinitrate (GTN) infusion, positive pressure ventilation and intravenous benzodiazepines. Bedside echocardiogram showed takotsubo-type stress-induced cardiomyopathy pattern. Serum troponin-I was markedly elevated. Subsequent in-patient coronary angiography showed minor irregularities in the major vessels. Over the next 3 days in ICU, GTN and clonidine infusions were weaned. Discharge was 12-days later on oral clonidine, metoprolol, perindopril, aspirin and oxycodone SR. Two months later an echocardiogram was normal. T

Aim: To determine the characteristics and outcomes of patients transferred froma rural hospital for coronary angiography. Method(s): Retrospective audit of medical records of patients transferred from Mildura Base Hospital from 1st January to 31st December 2013 for coronary angiography. Demographic data, medical insurance, primary diagnosis, illness severity score, and transfer costs were recorded. Details regarding inpatient stay at the receiving hospitals were obtained from discharge summaries. Result(s): There were 114 transfers for coronary angiography which represented 41% of all medical inter-hospital transfers fromthis centre. Median age was 64 years, 36.9% were female. 42.9% had private insurance with 39.5% being transferred to private hospitals. The median Charlson comorbidity score was 1 and median Simple Clinical Score was 5 suggesting haemodynamically stable patients with low 24-hour and 30- day mortality risk, suitable for transfer and advanced care. The principle diagnosis included non ST elevation (64%) and ST elevation myocardial infarction (14.9%), angina (11.4%), arrhythmias (6.1%), other chest pain (1.7%) and heart failure (1.7%). Angiography, performed in 95.6% of transfers (n=109), revealed significant coronary disease in 78 (71.5%) and resulted in revascularisation in 56 cases (coronary artery stenting in 40 and bypass grafting in 16), evidencing that transfer was clinically reasonable. In-hospital mortality was 2.6%. The cost of air ambulance transfer of 114 patients was $AU558,000. Conclusion(s): Coronary angiography is a common and appropriate reason for inter-hospital patient transfer. The cost of air transfer is significant and our study supports the development of cardiac catheterisation laboratories in selected large rural centres.

Introduction: Historically female sex has been associated with worse prognosis after ST elevation myocardial infarction (STEMI). Equivalent door to balloon times (D2BT) in females and males with STEMI has been extensively reported in the literature. Total ischaemic time is recognised as equally important in determining outcome. Objective(s): To determine if sex related differences in total ischaemic time exist in a contemporary cohort of patients presenting with STEMI to a major primary percutaneous coronary intervention (PPCI) centre. Method(s): A total of 1314 consecutive patients presented with ST elevation to our hospital network comprising a STEMI receiving centre and two non-PCI capable STEMI referral hospitals, between December 2007 and December 2012. Patients were excluded from the analysis if there was a resolution of pain and ST elevation in the ED (threatened STEMI), if they received treatment with thrombolysis, if they were current inpatients or if data regarding onset of pain was incomplete. We report here median [Interquartile Range] total ischaemic time and D2BT in the remaining patients (84%). Result(s): Of 1086 patients in the cohort, 20% (218) were female. Females experienced a longer total ischaemic time (209[181] minutes) compared to males (194 [136] minutes), P=0.03, whilst D2BT was similar (72[62] and 77[55] minutes, females and males respectively, P=0.72). Mean catheter laboratory door to balloon time was identical in the sexes (31 minutes). There was no statistically significant correlation between age and total ischaemic time. (Figure Presented) Conclusion(s): In this prospectively collected cohort, women with STEMI exhibited longer total ischaemic times despite similar D2BTs. Further research is required to determine the causes for longer pain to door times in women. This may be a contributing factor to worse outcomes in women with STEMI.

Introduction: Historically female sex has been associated with worse prognosis after ST elevation myocardial infarction (STEMI). Equivalent door to balloon times (D2BT) in females and males with STEMI has been extensively reported in the literature. Total ischaemic time is recognised as equally important in determining outcome. Objective(s): To determine if sex related differences in total ischaemic time exist in a contemporary cohort of patients presenting with STEMI to a major primary percutaneous coronary intervention (PPCI) centre. Method(s): A total of 1314 consecutive patients presented with ST elevation to our hospital network comprising a STEMI receiving centre and two non-PCI capable STEMI referral hospitals, between December 2007 and December 2012. Patients were excluded from the analysis if there was a resolution of pain and ST elevation in the ED (threatened STEMI), if they received treatment with thrombolysis, if they were current inpatients or if data regarding onset of pain was incomplete. We report here median [Interquartile Range] total ischaemic time and D2BT in the remaining patients (84%). Result(s): Of 1086 patients in the cohort, 20% (218) were female. Females experienced a longer total ischaemic time (209[181] minutes) compared to males (194 [136] minutes), P=0.03, whilst D2BT was similar (72[62] and 77[55] minutes, females and males respectively, P=0.72). Mean catheter laboratory door to balloon time was identical in the sexes (31 minutes). There was no statistically significant correlation between age and total ischaemic time. (Figure Presented) Conclusion(s): In this prospectively collected cohort, women with STEMI exhibited longer total ischaemic times despite similar D2BTs. Further research is required to determine the causes for longer pain to door times in women. This may be a contributing factor to worse outcomes in women with STEMI.

Guidelines report that the optimal treatment for ST-elevation myocardial infarction (STEMI) is a primary percutaneous coronary intervention (PPCI) when performed timely by trained operators. Yet, the reopening of the infarct-related artery (IRA) is not always followed by myocardial reperfusion. This phenomenon is most commonly called "no-reflow", is caused by microvascular obstruction (MVO) and is associated to a worse outcome. Electrocardiogram (ECG) is crucial for the diagnosis of STEMI, but is also useful for the assessment of MVO. In this review we summarize ECG-derived parameters associated to MVO and their prognostic relevance.

Objectives: Prompt reperfusion is essential for patients who have myocardial infarction with ST-segment elevation. The objective of the study is estimation of door to needle/balloon time and onset to needle/balloon time. Material(s) and Method(s): Our study is a Hospital based retrospective audit of patients who were admitted as a case of ST Elevation Myocardial Infarction conducted in Rashid hospital as well as Dubai hospital (Department of Health and Medical Services-DOHMS) simultaneously from November 2005 to May 2006. One hundred and sixty patients were included in our final analysis. 80 patients were from Rashid Hospital and 80 patients were from Dubai Hospital. Result(s): In Rashid Hospital the mean door to needle time was 42.8 minutes and the mean door to balloon time was 72 minutes. 31% of the patients were thrombolysed in less than 30 minutes. In Dubai Hospital the mean door to needle time was 35 minutes and the door to balloon time was 71.4 minutes. 43% were thrombolysed in less than 30 minutes Only 10% of patients were taken for primary PCI as the catheterization laboratories in both hospitals function only till 14:30 hrs. Conclusion(s): Although most guidelines recommend a door to needle time of less than 30 minutes and door to balloon time of less than 90 minutes, most of the hospitals do not achieve this in most of their patients. The Door to Needle time and Door to Balloon time in Department of Health and Medical Services (which includes Rashid and Dubai Hospital) is shorter than many other centers.

Objectives: Prompt reperfusion is essential for patients who have myocardial infarction with ST-segment elevation. The objective of the study is estimation of door to needle/balloon time and onset to needle/balloon time. Material(s) and Method(s): Our study is a Hospital based retrospective audit of patients who were admitted as a case of ST Elevation Myocardial Infarction conducted in Rashid hospital as well as Dubai hospital (Department of Health and Medical Services-DOHMS) simultaneously from November 2005 to May 2006. One hundred and sixty patients were included in our final analysis. 80 patients were from Rashid Hospital and 80 patients were from Dubai Hospital. Result(s): In Rashid Hospital the mean door to needle time was 42.8 minutes and the mean door to balloon time was 72 minutes. 31% of the patients were thrombolysed in less than 30 minutes. In Dubai Hospital the mean door to needle time was 35 minutes and the door to balloon time was 71.4 minutes. 43% were thrombolysed in less than 30 minutes Only 10% of patients were taken for primary PCI as the catheterization laboratories in both hospitals function only till 14:30 hrs. Conclusion(s): Although most guidelines recommend a door to needle time of less than 30 minutes and door to balloon time of less than 90 minutes, most of the hospitals do not achieve this in most of their patients. The Door to Needle time and Door to Balloon time in Department of Health and Medical Services (which includes Rashid and Dubai Hospital) is shorter than many other centers.

Using Australian guidelines for management of acute coronary syndromes, we investigated the proportion of high-risk patients enrolled in the Acute Coronary Syndromes Prospective Audit registry who received a coronary angiogram. A prospective nationwide multicentre registry involving 39 Australian hospitals was used. The study cohort were patients with high-risk clinical features without ST segment elevation (n = 1948) admitted from emergency departments between 1 November 2005 and 31 July 2007. Eighty nine per cent of patients with ST segment elevation myocardial infarction and only 53% of eligible patients with high-risk acute coronary syndromes with no ST elevation received a diagnostic angiogram. Increasing age was associated with lower rates of angiography; a high-risk patient at the age of ≥70 years was 19% less likely to receive an angiogram than one at the age of <70 years (risk ratio (RR) = 0.81 95% confidence interval (CI) 0.76, 0.76). Women were 26% less likely than men to receive an angiogram (RR = 0.74; 95% CI = 0.65, 0.83). The adjusted RR from the multivariate analysis suggests that a patient at the age of ≥70 years was 35% less likely to receive an angiogram than one at the age of <70 years (RR = 0.65, 95% CI = 0.60, 0.73), and that women were 13% less likely than men to receive an angiogram (RR = 0.87, 95% CI = 0.80, 0.96). Indigenous patients were as likely to access angiography as eligible non-indigenous patients (RR = 1.03, 95% CI 0.85, 1.25). There is underinvestigation of high-risk patients without ST segment elevation in Australian hospitals, particularly for women and older patients. Indigenous patients are younger and have poorer risk profiles, and represent a group that would benefit from greater investment in prevention strategies. © 2013 Royal Australasian College of Physicians.

Background The efficacy of statin drugs after an acute coronary event is now well established, but the evidence for statin use in the early treatment of acute coronary events remains unclear. Methods We tested the effects of administering pravastatin within 24 hours of the onset of symptoms in patients with unstable angina, non-ST-segment elevation myocardial infarction, or ST-segment elevation myocardial infarction. Patient recruitment of 10,000 with 1200 end points was planned, but the trial was stopped early. A total of 3408 patients were randomly assigned to treatment with pravastatin (1710 patients) or matching placebo (1698 patients). Treatment was continued for 4 weeks. The primary end point of the study was a composite of death, recurrence of myocardial infarction, or readmission to hospital for unstable angina within 30 days of random assignment. Results The primary end point occurred in 199 of patients allocated to pravastatin (11.6%) and in 211 patients allocated to placebo (12.4%). A relative risk reduction of 6.4% favored allocation to pravastatin but was not statistically significant (95% CI, -13.2% to 27.6%). No adverse effects were seen. Conclusions We conclude that 20 to 40 mg of pravastatin can be safely administered within 24 hours of the onset of symptoms of an acute coronary event, with a favorable but not significant trend in outcome at 30 days compared with placebo.

We report a case of spontaneous coronary artery dissection occurring in a young female who had been diagnosed with antiphospholipid syndrome. Coronary angiography revealed extensive dissection in the proximal to mid LAD. She was treated conservatively with an excellent result. Follow-up coronary angiography at two months failed to reveal any evidence of the previous dissection. © 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand.

Drug-eluting stents (DES) offer an attractive option for the treatment of acute thrombotic lesions during acute ST-elevation myocardial infarction (STEMI) due to their ability to inhibit restenosis. Several randomised trials have demonstrated the efficacy of DES in reducing target vessel revascularisation (TVR) in this setting. However, several registries of real-world patients receiving DES for STEMI have raised long-term safety concerns about DES use in this patient subset. Given the inherent limitations of registry data, this issue is likely to remain unresolved until further data is made available from large-scale ongoing trials with long-term follow-up such as the HORIZONS-AMI trial. Crown Copyright © 2009.

Late stent thrombosis has emerged as an infrequent but serious complication of drug-eluting stent (DES) implantation. Premature cessation of dual antiplatelet therapy is the most common risk factor for its occurrence. In the era of multivessel stenting with DES, there is a potential for multivessel late stent thrombosis following cessation of dual antiplatelet therapy. We present a rare case of a patient who sustained simultaneous late stent thromboses in DESs implanted in two coronary arteries as a result of premature cessation of dual antiplatelet therapy. Crown Copyright © 2009.

The pathogenesis of ST-elevation myocardial infarction (STEMI) involves plaque disruption, platelet aggregation and intracoronary artery thrombus formation. Aspirin is the cornerstone of antiplatelet therapy in patients with STEMI, reducing the risk of recurrent myocardial infarction or death during the acute phase and long term by about one-quarter. Recent large randomized trials have demonstrated that the addition of clopidogrel to aspirin reduces the risk of major ischemic events by up to a further one-third in patients with STEMI treated with fibrinolytic therapy and undergoing percutaneous coronary intervention, with no significant increase in bleeding. Thus, dual antiplatelet therapy with the combination of elopidogrel and aspirin is becoming the new standard of care for the management of patients with STEMI. © 2006 Dove Medical Press Limited. All rights reserved.

Background - American College of Cardiology/American Heart Association guidelines recommend >75% of patients with an ST-elevation myocardial infarction receive primary percutaneous coronary interventions (PPCI) within 90 minutes. Despite these recommendations, this goal has been difficult to achieve. Methods and Results - We conducted a prospective interventional study involving 349 patients undergoing PPCI at a single tertiary referral institution to determine the impact of prehospital 12-lead ECG triage and emergency department activation of the infarct team on door-to-balloon time (D2BT). The median D2BT of all patients (n=107) who underwent PPCI after field ECG and emergency department activation of the infarct team (MonashHEART Acute Myocardial Infarction [MonAMI] group) was 56 minutes (interquartile range, 36.5 to 70) compared with the median time of a contemporary group (n=122) undergoing PPCI during the same period but not receiving field triage (non-MonAMI group) of 98 minutes (73 to 126.45). The median D2BT time of 120 consecutive patients who underwent PPCI before initiation of the project (pre-MonAMI group) was 101.5 minutes (72.5 to 134; P=0.001). The proportion of patients who achieved a D2BT of <=90 minutes increased from 39% in the pre-MonAMI group and 45% in the non-MonAMI group to 93% in the MonAMI group (P=0.001). Conclusions - The performance of prehospital 12-lead ECG triage and emergency department activation of the infarct team significantly improves D2BT and results in a greater proportion of patients achieving guideline recommendations. Copyright © 2009 American Heart Association, Inc.

Drug-eluting stents (DES) offer an attractive option for the treatment of acute thrombotic lesions during acute ST-elevation myocardial infarction (STEMI) due to their ability to inhibit restenosis. Several randomised trials have demonstrated the efficacy of DES in reducing target vessel revascularisation (TVR) in this setting. However, several registries of real-world patients receiving DES for STEMI have raised long-term safety concerns about DES use in this patient subset. Given the inherent limitations of registry data, this issue is likely to remain unresolved until further data is made available from large-scale ongoing trials with long-term follow-up such as the HORIZONS-AMI trial. Crown Copyright © 2009.

Background The efficacy of statin drugs after an acute coronary event is now well established, but the evidence for statin use in the early treatment of acute coronary events remains unclear. Methods We tested the effects of administering pravastatin within 24 hours of the onset of symptoms in patients with unstable angina, non-ST-segment elevation myocardial infarction, or ST-segment elevation myocardial infarction. Patient recruitment of 10,000 with 1200 end points was planned, but the trial was stopped early. A total of 3408 patients were randomly assigned to treatment with pravastatin (1710 patients) or matching placebo (1698 patients). Treatment was continued for 4 weeks. The primary end point of the study was a composite of death, recurrence of myocardial infarction, or readmission to hospital for unstable angina within 30 days of random assignment. Results The primary end point occurred in 199 of patients allocated to pravastatin (11.6%) and in 211 patients allocated to placebo (12.4%). A relative risk reduction of 6.4% favored allocation to pravastatin but was not statistically significant (95% CI, -13.2% to 27.6%). No adverse effects were seen. Conclusions We conclude that 20 to 40 mg of pravastatin can be safely administered within 24 hours of the onset of symptoms of an acute coronary event, with a favorable but not significant trend in outcome at 30 days compared with placebo.

We report a case of spontaneous coronary artery dissection occurring in a young female who had been diagnosed with antiphospholipid syndrome. Coronary angiography revealed extensive dissection in the proximal to mid LAD. She was treated conservatively with an excellent result. Follow-up coronary angiography at two months failed to reveal any evidence of the previous dissection. © 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand.

Late stent thrombosis has emerged as an infrequent but serious complication of drug-eluting stent (DES) implantation. Premature cessation of dual antiplatelet therapy is the most common risk factor for its occurrence. In the era of multivessel stenting with DES, there is a potential for multivessel late stent thrombosis following cessation of dual antiplatelet therapy. We present a rare case of a patient who sustained simultaneous late stent thromboses in DESs implanted in two coronary arteries as a result of premature cessation of dual antiplatelet therapy. Crown Copyright © 2009.

The pathogenesis of ST-elevation myocardial infarction (STEMI) involves plaque disruption, platelet aggregation and intracoronary artery thrombus formation. Aspirin is the cornerstone of antiplatelet therapy in patients with STEMI, reducing the risk of recurrent myocardial infarction or death during the acute phase and long term by about one-quarter. Recent large randomized trials have demonstrated that the addition of clopidogrel to aspirin reduces the risk of major ischemic events by up to a further one-third in patients with STEMI treated with fibrinolytic therapy and undergoing percutaneous coronary intervention, with no significant increase in bleeding. Thus, dual antiplatelet therapy with the combination of elopidogrel and aspirin is becoming the new standard of care for the management of patients with STEMI. © 2006 Dove Medical Press Limited. All rights reserved.

Background - American College of Cardiology/American Heart Association guidelines recommend >75% of patients with an ST-elevation myocardial infarction receive primary percutaneous coronary interventions (PPCI) within 90 minutes. Despite these recommendations, this goal has been difficult to achieve. Methods and Results - We conducted a prospective interventional study involving 349 patients undergoing PPCI at a single tertiary referral institution to determine the impact of prehospital 12-lead ECG triage and emergency department activation of the infarct team on door-to-balloon time (D2BT). The median D2BT of all patients (n=107) who underwent PPCI after field ECG and emergency department activation of the infarct team (MonashHEART Acute Myocardial Infarction [MonAMI] group) was 56 minutes (interquartile range, 36.5 to 70) compared with the median time of a contemporary group (n=122) undergoing PPCI during the same period but not receiving field triage (non-MonAMI group) of 98 minutes (73 to 126.45). The median D2BT time of 120 consecutive patients who underwent PPCI before initiation of the project (pre-MonAMI group) was 101.5 minutes (72.5 to 134; P=0.001). The proportion of patients who achieved a D2BT of <=90 minutes increased from 39% in the pre-MonAMI group and 45% in the non-MonAMI group to 93% in the MonAMI group (P=0.001). Conclusions - The performance of prehospital 12-lead ECG triage and emergency department activation of the infarct team significantly improves D2BT and results in a greater proportion of patients achieving guideline recommendations. Copyright © 2009 American Heart Association, Inc.

Three articles discussing guidelines for the treatment of acute coronary syndromes have led to an ongoing debate about the value of surgical versus medical treatment.

Three articles discussing guidelines for the treatment of acute coronary syndromes have led to an ongoing debate about the value of surgical versus medical treatment.

We describe the case of a 54-year-old male with recurrent chest pain, ST segment elevation, and bradycardia. Coronary vasospasm was confirmed by acetylcholine challenge. After failing medical therapy, stenting of an extensive segment of the right coronary artery has been clinically successful after 24-months follow-up. © 2007 Wiley-Liss, Inc.

We describe the case of a 54-year-old male with recurrent chest pain, ST segment elevation, and bradycardia. Coronary vasospasm was confirmed by acetylcholine challenge. After failing medical therapy, stenting of an extensive segment of the right coronary artery has been clinically successful after 24-months follow-up. © 2007 Wiley-Liss, Inc.