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Objective: International guidelines provide increasing support for computed tomography coronary angiography (CTCA) in investigating chest pain. A pathway utilising CTCA first‐line for outpatient stable chest pain evaluation was implemented in an Australian ED. Methods: In pre‐post design, the impact of the pathway was prospectively assessed over 6 months (August 2021 to January 2022) and compared with a 6‐month pre‐implementation group (February 2021 to July 2021). CTCA was recommended first‐line in suspected stable cardiac chest pain, followed by chest pain clinic review. Predefined criteria were provided recommending functional testing in select patients. The impact of CTCA versus functional testing was evaluated. Data were obtained from digital medical records. Results: Three hundred and fifteen patients were included, 143 pre‐implementation and 172 post‐implementation. Characteristics were similar except age (pre‐implementation: 58.9 ± 12.0 vs post‐implementation: 62.8 ± 12.3 years, P = 0.004). Pathway‐guided management resulted in higher first‐line CTCA (73.3% vs 46.2%, P < 0.001), lower functional testing (30.2% vs 56.6%, P < 0.001) and lower proportion undergoing two non‐invasive tests (4.7% vs 10.5%, P = 0.047), without increasing investigation costs or invasive coronary angiography (ICA) (pre‐implementation: 13.3% vs post‐implementation: 9.3%, P = 0.263). In patients undergoing CTCA, 40.7% had normal coronaries and 36.2% minimal/mild disease, with no difference in disease burden post‐implementation. More medication changes occurred following CTCA compared with functional testing (aspirin: P = 0.005, statin: P < 0.001). In patients undergoing ICA, revascularisation to ICA ratio was higher following CTCA compared with functional testing (91.7% vs 18.2%, P < 0.001). No 30‐day myocardial infarction or death occurred. Conclusions: The pathway increased CTCA utilisation and reduced downstream investigations. CTCA was associated with medication changes and improved ICA efficiency. [ABSTRACT FROM AUTHOR]

Familial hypercholesterolaemia (FH) is a common genetic disorder of LDL-cholesterol, that, if untreated, leads to premature atherosclerotic cardiovascular disease (ASCVD). With early diagnosis and initiation of cholesterol-lowering treatment, the risk of ASCVD can be substantially reduced. Yet, many people with FH remain undiagnosed and undertreated. GPs can play an important role in the care of patients and families with FH. [ABSTRACT FROM AUTHOR]

Computed tomography coronary angiography (CTCA) is a non-invasive diagnostic modality that provides a comprehensive anatomical assessment of the coronary arteries and coronary atherosclerosis, including plaque burden, composition and morphology. The past decade has witnessed an increase in the role of CTCA for evaluating patients with both stable and acute chest pain, and recent international guidelines have provided increasing support for a first line CTCA diagnostic strategy in select patients. CTCA offers some advantages over current functional tests in the detection of obstructive and non-obstructive coronary artery disease, as well as for ruling out obstructive coronary artery disease. Recent randomised trials have also shown that CTCA improves prognostication and guides the use of guideline-directed preventive therapies, leading to improved clinical outcomes. CTCA technology advances such as fractional flow reserve, plaque quantification and perivascular fat inflammation potentially allow for more personalised risk assessment and targeted therapies. Further studies evaluating demand, supply, and cost-effectiveness of CTCA for evaluating chest pain are required in Australia. This discussion paper revisits the evidence supporting the use of CTCA, provides an overview of its implications and limitations, and considers its potential role for chest pain evaluation pathways in Australia. [ABSTRACT FROM AUTHOR]

Background: Lipoprotein(a) (Lp[a]) is a risk factor for cardiovascular disease. The burden of thrombus in ST-segment elevation myocardial infarction (STEMI) has implications on treatment and outcomes. However, the association between Lp(a) and atherothrombosis in STEMI remains unclear. Objectives: The aim of the study was to determine the association between Lp(a) and culprit artery thrombus burden in younger patients with STEMI. Methods: This was a single-center study of 83 patients aged <65 years with STEMI between 2016–2018 who underwent percutaneous coronary intervention and measurement of Lp(a); those receiving thrombolytic therapy were excluded. Thrombus burden in the culprit artery was determined angiographically using the Thrombolysis In Myocardial Infarction score and classified as absent-to-small, moderate, or large. Elevated Lp(a) was defined as plasma mass concentration >30 mg/dL. Multivariate analysis was performed adjusting for cardiovascular risk factors. Results: The mean age was 48.0 ± 8.4 years, and 78.3% were male. Thirteen (16%), 9 (11%), and 61 (73%) patients had small, moderate, or large thrombus burden, respectively, and 34 (41%) had elevated Lp(a). Elevated Lp(a) was associated with greater thrombus burden compared to normal Lp(a) (large burden 85% vs. 65%; p = 0.024). Elevated Lp(a) was associated with moderate or large thrombus in univariate (OR 10.70 [95% CI 1.32–86.82]; p = 0.026) and multivariate analysis (OR 10.33 [95% CI 1.19–89.52]; p = 0.034). Lp(a) was not associated with culprit artery or stenosis location according to culprit artery. Conclusions: Elevated Lp(a) is associated with greater thrombus burden in younger patients with STEMI. The finding of this observational study accords with the thrombotic and anti-fibrinolytic properties of Lp(a). A causal relationship requires verification. [ABSTRACT FROM AUTHOR]

Introduction: Icosapent ethyl reduces cardiovascular events in high-risk patients with hypertriglyceridaemia on statin therapy. However, it is not widely available and the potential application following coronary artery bypass graft (CABG) surgery is not well-established. We aimed to determine the real-world percentage of CABG surgery patients who may be eligible for the therapy.Methods: A retrospective analysis was performed between February 2015 and August 2020 in an Australian hospital. Patients were included if a lipid profile was performed at least three weeks following CABG surgery. Data was extracted from electronic medical records. Eligibility for icosapent ethyl was defined according to inclusion criteria from the REDUCE-IT trial.Results: Of 484 patients with follow-up lipid profiles, 21 (4.3%) were not eligible for icosapent ethyl based on age and 39 (8.1%) were not prescribed statin therapy or were prescribed a fibrate. After applying triglyceride and low-density lipoprotein cholesterol level criteria, 124 (25.6%) patients were potentially eligible for icosapent ethyl therapy. Of those eligible, high-intensity statin therapy were prescribed in 108 (87.1%).Discussion: A substantial percentage of CABG surgery patients may be eligible for icosapent ethyl and could potentially benefit from its cardiovascular protection. Further research should evaluate the additional cardiovascular benefits of icosapent ethyl in this very high-risk group of patients who are already treated with high-intensity statins. [ABSTRACT FROM AUTHOR]

Introduction: The role of intra-aortic balloon pumps (IABP) in high-risk patients undergoing coronary artery bypass graft (CABG) surgery remains controversial. We report the 5-year experience from a new Australian centre.Methods: We retrospectively analysed 690 patients undergoing urgent isolated CABG surgery at a Western Australian tertiary centre from February 2015 to May 2020. De-identified data was obtained from the Australia & New Zealand Society of Cardiothoracic Surgeons database. Patients were stratified according to preoperative IABP use. A propensity score was created for the probability of IABP use and a propensity adjusted analysis was performed using logistic regression. The primary outcome was 30-day mortality. Secondary outcomes were postoperative inhospital outcomes.Results: Preoperative IABP was used in 78 patients (11.3%). After propensity score adjustment, in a subgroup of patients with reduced ejection fraction or left main disease, 30-day mortality (7.0% vs 2.0%, OR 6.03, 95% CI 1.89-19.28, p=0.002) was significantly higher in the IABP group. Red blood cell transfusions (19.7% vs 12.6%, OR 1.86, 95% CI 1.02-3.35, p=0.039), prolonged inotrope use (78.9% vs 50.9%, OR 6.11, 95% CI 2.77-13.48, p<0.001), prolonged invasive ventilation (28.2% vs 3.4%, OR 20.2, 95% CI 8.24-49.74, p<0.001), mesenteric ischaemia (2.8% vs 0%, OR 4.52, 95% CI 1.15-17.77, p=0.031) and multisystem organ failure (1.3% vs 0.7%, OR 25.68, 95% CI 2.55-258.34, p=0.006) were significantly higher in the IABP group.Conclusion: In patients undergoing isolated CABG surgery, preoperative IABP use was associated with increased 30-day mortality and adverse outcomes. Large randomised controlled trials are required to confirm our findings. [ABSTRACT FROM AUTHOR]

Introduction: Lipoprotein(a) [Lp(a)] and diabetes are independently associated with premature coronary artery disease (pCAD). However, there is an inverse relationship between Lp(a) concentration and type 2 diabetes (T2D) risk. We examine whether Lp(a) distribution in patients with pCAD differs between those with or without T2D, and whether elevated Lp(a) is associated with pCAD in patients with T2D.Methods: Lp(a) concentration was measured in consecutive acute coronary syndrome (ACS) patients in two coronary care units (study one: ACS with or without diabetes, study two: ACS and diabetes). Elevated Lp(a) mass concentration was defined as ≥0.5 g/L and pCAD where CAD was diagnosed age <60 years. The association between elevated Lp(a) and pCAD was assessed using logistic regression.Results: Of 449 patients, 233 (51.9%) had pCAD and 278 (61.9%) had T2D. In patients with pCAD, those with T2D had a significantly lower median Lp(a) concentration (0.13 g/L versus 0.27 g/L, p=0.004). In patients with T2D, elevated Lp(a) was significantly associated with pCAD (OR 2.419, 95% CI 1.513-3.867, p<0.001). After adjusting for gender, smoking, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglycerides, elevated Lp(a) remained significantly associated with pCAD (OR 2.895, 95% CI 1.427-5.876, p=0.003) in patients with T2D.Conclusions: In coronary care patients with pCAD, patients with T2D had lower Lp(a) concentrations than those without T2D. Despite this, elevated Lp(a) remained predictive of pCAD in patients with T2D. Measurement of Lp(a) should be considered in younger adults with T2D to identify who may benefit from earlier preventative therapies to reduce pCAD burden. [ABSTRACT FROM AUTHOR]

Familial hypercholesterolaemia (FH) is a common autosomal semi-dominant and highly penetrant disorder of the low-density lipoprotein (LDL) receptor pathway, characterised by lifelong elevated levels of low-density lipoprotein cholesterol (LDL-C) and increased risk of atherosclerotic cardiovascular disease (ASCVD). However, many patients with FH are not diagnosed and do not attain recommended LDL-C goals despite maximally tolerated doses of potent statin and ezetimibe. Over the past decade, several cholesterol-lowering therapies such as those targeting proprotein convertase subtilisin/kexin type 9 (PCSK9) or angiopoietin-like 3 (ANGPTL3) with monoclonal antibody or ribonucleic acid (RNA) approaches have been developed that promise to close the treatment gap. The availability of new therapies with complementary modes of action of lipid metabolism has enabled many patients with FH to attain guideline-recommended LDL-C goals. Emerging therapies for FH include liver-directed gene transfer of the LDLR , vaccines targeting key proteins involved in cholesterol metabolism, and CRISPR-based gene editing of PCSK9 and ANGPTL3 , but further clinical trials are required. In this review, current and emerging treatment strategies for lowering LDL-C, and ASCVD risk-stratification, as well as implementation strategies for the care of patients with FH are reviewed. [Display omitted] [ABSTRACT FROM AUTHOR]

Coronary artery calcium (CAC) is a marker of atherosclerotic cardiovascular disease (CVD). However, for patients with type 1 diabetes (T1D), its relationship with T1D-specific cardiovascular (CV) risk-stratification tools is unknown. Assess prevalence of CAC and evaluate relationship between CAC and T1D-specific CV risk-stratification methods in T1D. Cross-sectional study of adults with T1D age 20–60 years, statin-naïve and no history of CVD. Data was obtained from electronic medical records and by interview. Presence of CAC was assessed using non-contrast cardiac computed tomography and quantified by Agatston Units (AU). CV risk-stratification was assessed using the 2019 European Society of Cardiology (ESC) Guidelines and the Steno T1 Risk Engine (ST1RE). 85 patients were included with mean age 35.4 ± 10.3 years, HbA1c 8.3 ± 1.5 % and T1D duration 17.0 ± 10.1 years. 67 patients (78.9 %) had a CAC score of 0 AU, 17 (20.0 %) >0–100 AU, and one (1.2 %) >100 AU. Duration of T1D (p = 0.009), body mass index (p = 0.029), neuropathy (p = 0.016) and low-density lipoprotein cholesterol levels (p = 0.016) were independently associated with a positive CAC score on multivariate analysis. Positive predictive value for a positive CAC score was 85.7 % for the ST1RE high risk category and 31.3 % for the 2019 ESC Guidelines very high risk category. One-fifth of this T1D cohort had a positive CAC score. The ST1RE was superior in identifying positive CAC compared to the 2019 ESC Guidelines. Further studies are required to elucidate the role of CAC in personalising CV risk-stratification and statin initiation in T1D. • One-fifth of asymptomatic, statin-naïve patients with types 1 diabetes had a positive coronary artery calcium score. • Positive coronary artery calcium was significantly associated with duration of type 1 diabetes, BMI, neuropathy, and LDL-C. • Steno T1 Risk Engine was superior in identifying positive coronary artery calcium compared to ESC Guidelines. [ABSTRACT FROM AUTHOR]

Significant advances have been made in artificial intelligence technology in recent years. Many health care applications have been investigated to assist clinicians and the technology is close to being integrated into routine clinical practice. The high prevalence of cardiac disease in Australia places overwhelming demands on the existing health care system, challenging its capacity to provide quality patient care. Artificial intelligence has emerged as a promising solution. This discussion paper provides an Australian perspective on the current state of artificial intelligence in cardiology, including the benefits and challenges of implementation. This paper highlights some current artificial intelligence applications in cardiology, while also detailing challenges such as data privacy, ethical considerations, and integration within existing health infrastructures. Overall, this paper aims to provide insights into the potential benefits of artificial intelligence in cardiology, while also acknowledging the barriers that need to be addressed to ensure safe and effective implementation into an Australian health system. [ABSTRACT FROM AUTHOR]

Aims: This study explored characteristics and outcomes of patients with type 1 diabetes mellitus (T1DM) and acute coronary syndromes (ACS).Methods: A retrospective analysis of patients with T1DM admitted with ACS to an Australian hospital was conducted. Risk factor targets were defined by 2021 European Society of Cardiology Guidelines. Outcomes were defined as an adverse cardiovascular event (ACS, unplanned revascularisation, heart failure, stroke, or cardiovascular death) or all-cause mortality within six-months after discharge.Results: 61 patients were included [age 58.5 ± 12.8 years, 39 % female]. Dyslipidaemia (85 %), hypertension (75 %), smoking (28 %), prior coronary artery disease (CAD) (44 %), and microvascular complications (62 %) were common. HbA1c, low-density lipoprotein cholesterol, and blood pressure targets were attained in 12 %, 36 % and 47 %, respectively. ST-elevation myocardial infarction (65 % versus 7 %, p < 0.001) and revascularisation (77 % versus 41 %, p = 0.008) were more common in those without prior CAD. Peak inpatient blood glucose correlated directly with peak troponin (p = 0.011) and inversely with left ventricular ejection fraction (p = 0.027). Nineteen patients experienced an adverse six-month outcome, with peripheral neuropathy (p = 0.039) and in-hospital hypoglycaemia (p = 0.012) being independent predictors.Conclusions: Patients with T1DM and ACS often do not meet guideline targets for cardiovascular risk factors, and frequently present with transmural infarctions. Dysglycemia and microvascular complications predict poorer outcomes. [ABSTRACT FROM AUTHOR]

In this real-world study, the main barriers for not initiating SGLT2 inhibitor therapy early after an acute cardiac event are prescribing criteria around glycated haemoglobin and renal function. Initiation of SGLT2 inhibitors near to, or at, hospital discharge following the cardiac event was not associated with 30-day diabetic ketoacidosis readmissions. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) is associated with significant morbidity and mortality. Non-adherence to IE guidelines and recommendations is frequent, and may adversely impact patient outcomes. To assess the impact of non-adherence to components of existing IE guidelines and recommendations on a composite outcome consisting of any of the following: mortality, unplanned cardiac surgery, embolic event or relapse of positive blood culture within six months of diagnosis. A single centre, retrospective cohort study. Amongst 157 patients, there was inconsistent adherence to: initial diagnosis of an infective condition (87%), timely administration of antimicrobial therapy (82%), appropriateness of predominant antimicrobial regime (94%), appropriate management of the portal of entry (86%), multidisciplinary input (75%), end of antimicrobial therapy repeat echocardiography (60%) and adherence to indications for surgery (76%). Inpatient mortality was 12.1% (n = 19) and the composite adverse outcome occurred in 36 (22.9%) patients. In multivariate logistic regression analysis, infection of prosthetic device (adjusted odds ratio [95% confidence interval]; 2.43 [1.07–5.50]) and non-adherence to surgical guidelines (aOR 3.67 [1.60–8.47]) were significantly associated with an adverse outcome. Our data suggests that adherence to differing components of IE management guidelines and recommendations varies and that non-adherence to surgical aspects of guidelines has the biggest impact in determining outcomes. [ABSTRACT FROM AUTHOR]

Background: Patent foramen ovale (PFO) is a potential mechanism for paradoxical embolism in cryptogenic ischaemic stroke or transient ischaemic attack (TIA). PFO is typically demonstrated with agitated saline ("bubble study", BS) during echocardiography. We hypothesised that the BS is frequently requested in patients that have a readily identifiable cause of stroke, that any PFO detected is likely incidental, and its detection often does not alter management.Methods: This was a retrospective observational study of patients with recent ischaemic stroke/TIA referred for a BS. Patient demographics, stroke risk factors, vascular/cerebral imaging results and transoesophageal echocardiogram (TOE) reports were recorded. A "modified" Risk of Paradoxical Embolism (RoPE) score was calculated. Change in management was defined as antiplatelet/anticoagulant therapy alteration or referral for PFO closure. Bubble Study complications were recorded.Results: Among 715 patients with ischaemic stroke/TIA referred for a BS, 8.7% had atrial fibrillation and 9.2% had carotid stenosis ≥70%. At least three stroke risk factors were present in 39.3% and only 47.1% of patients screened had a "modified" RoPE score of >5. A PFO was detected in 248 patients of whom only 31% (77/248) had a subsequent change in management. Of BS performed, 1/924 patients (0.1%) suffered a TIA as a complication.Conclusions: The echocardiographic BS is frequently performed in patients that have a readily identifiable cause of stroke and whose PFO unlikely relates to the stroke/TIA. Bubble Study findings resulted in a change in management in the minority. The procedure is safe but the complication rate warrants informed consent. [ABSTRACT FROM AUTHOR]