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Background: Air emboli are a life-threatening diagnosis, which may form through a range of mechanisms. In this case, we describe the case of extensive multi-territory air emboli in a patient with a history of intravenous drug abuse., Case Summary: This case describes a 41-year-old male who presented with confusion following fall with long lie. He was diagnosed with hyperkalaemia, renal failure, rhabdomyolysis, and compartment syndrome, and he developed extensive multi-territory air emboli. Air embolism was identified in arterial, venous, subcutaneous, and mediastinal territories. Echocardiography demonstrated right ventricular dilation and dysfunction, consistent with air visualized in the right coronary artery on computed tomography. The patient was transferred to the intensive care unit for close cardiac and neurological monitoring and supportive organ care, and ultimately made an uneventful recovery by 6 weeks without apparent complications from the air emboli., Discussion: The presence of multi-territory air emboli has previously been described in the setting of surgery, manipulation of intravascular catheters, pulmonary barotrauma, and in sepsis with gas-forming organisms. It has not previously been reported in intravenous drug use or sterile rhabdomyolysis. Computed tomography imaging and echocardiography are useful to diagnose air emboli and their haemodynamic impact. Our patient's case provides a novel example of multi-territory air emboli in a unique scenario., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Pericardial decompression syndrome (PDS) is an uncommon complication of pericardial drainage of large pericardial effusions and cardiac tamponade characterized by paradoxical haemodynamic instability following drainage. Pericardial decompression syndrome may occur immediately, or in the days following pericardial decompression, and presents with signs and symptoms suggestive of uni-/biventricular failure or acute pulmonary oedema., Case Summary: This series describes two cases of this syndrome which demonstrates acute right ventricular failure as a mechanism of PDS and provides insights into the echocardiographic findings and clinical course of this poorly understood syndrome. Case 1 describes a patient who underwent pericardiocentesis, whilst Case 2 describes a patient who underwent surgical pericardiostomy. In both patients, acute right ventricular failure was observed following the release of tamponade and is favoured to be the cause of haemodynamic instability., Discussion: Pericardial decompression syndrome is a poorly understood, likely underreported complication of pericardial drainage for cardiac tamponade associated with high morbidity and mortality. Whilst a number of hypotheses exist as to the aetiology of PDS, this case series supports haemodynamic compromise being secondary to left ventricular compression following acute right ventricular dilatation., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objectives: Describe the incidence of cardiac complications in patients admitted to hospital with COVID-19 in Australia., Design: Observational cohort study., Setting: Twenty-one (21) Australian hospitals., Participants: Consecutive patients aged ≥18 years admitted to hospital with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection., Main Outcome Measures: Incidence of cardiac complications., Results: Six-hundred-and-forty-four (644) hospitalised patients (62.5±20.1 yo, 51.1% male) with COVID-19 were enrolled in the study. Overall in-hospital mortality was 14.3%. Twenty (20) (3.6%) patients developed new atrial fibrillation or flutter during admission and 9 (1.6%) patients were diagnosed with new heart failure or cardiomyopathy. Three (3) (0.5%) patients developed high grade atrioventricular (AV) block. Two (2) (0.3%) patients were clinically diagnosed with pericarditis or myopericarditis. Among the 295 (45.8%) patients with at least one troponin measurement, 99 (33.6%) had a peak troponin above the upper limit of normal (ULN). In-hospital mortality was higher in patients with raised troponin (32.3% vs 6.1%, p<0.001). New onset atrial fibrillation or flutter (6.4% vs 1.0%, p=0.001) and troponin elevation above the ULN (50.3% vs 16.4%, p<0.001) were more common in patients 65 years and older. There was no significant difference in the rate of cardiac complications between males and females., Conclusions: Among patients with COVID-19 requiring hospitalisation in Australia, troponin elevation was common but clinical cardiac sequelae were uncommon. The incidence of atrial arrhythmias and troponin elevation was greatest in patients 65 years and older., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: To assess whether hypertension is an independent risk factor for mortality among patients hospitalised with COVID-19, and to evaluate the impact of ACE inhibitor and angiotensin receptor blocker (ARB) use on mortality in patients with a background of hypertension., Method: This observational cohort study included all index hospitalisations with laboratory-proven COVID-19 aged ≥18 years across 21 Australian hospitals. Patients with suspected, but not laboratory-proven COVID-19, were excluded. Registry data were analysed for in-hospital mortality in patients with comorbidities including hypertension, and baseline treatment with ACE inhibitors or ARBs., Results: 546 consecutive patients (62.9±19.8 years old, 51.8% male) hospitalised with COVID-19 were enrolled. In the multivariable model, significant predictors of mortality were age (adjusted OR (aOR) 1.09, 95% CI 1.07 to 1.12, p<0.001), heart failure or cardiomyopathy (aOR 2.71, 95% CI 1.13 to 6.53, p=0.026), chronic kidney disease (aOR 2.33, 95% CI 1.02 to 5.32, p=0.044) and chronic obstructive pulmonary disease (aOR 2.27, 95% CI 1.06 to 4.85, p=0.035). Hypertension was the most prevalent comorbidity (49.5%) but was not independently associated with increased mortality (aOR 0.92, 95% CI 0.48 to 1.77, p=0.81). Among patients with hypertension, ACE inhibitor (aOR 1.37, 95% CI 0.61 to 3.08, p=0.61) and ARB (aOR 0.64, 95% CI 0.27 to 1.49, p=0.30) use was not associated with mortality., Conclusions: In patients hospitalised with COVID-19, pre-existing hypertension was the most prevalent comorbidity but was not independently associated with mortality. Similarly, the baseline use of ACE inhibitors or ARBs had no independent association with in-hospital mortality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Although it is known that patients with Type 2 Diabetes Mellitus (T2DM) are at an increased risk of coronary artery disease (CAD), the actual coronary artery burden of atherosclerotic disease in patients with and without T2DM in a real-world setting and its possible modification by preventative therapies has not been extensively documented., Methods: Merged coronary angiography and hospital discharge data between 2013 and 2019 were obtained for analysis and a random sub-sample of patient charts were reviewed for medication use. Propensity scores were estimated using logistic regression models and used to match patients, looking at the effect of severity of CAD over time in years in an ordinal logistic regression model. A separate propensity score was estimated and used to inverse probability weight the ordinal logistic regression looking at the effect of medication use on CAD severity in patients with and without T2DM., Results: From 3,016 patients in the coronary angiography database, 1421 with T2DM and 1421 without T2DM were matched on propensity score. T2DM patients had more extensive CAD in 2018 compared to 2013 ((adjusted odds ratio) adjOR: 2.06 95% C.I. 1.38, 2.07), but this risk appeared to be attenuated in 2019. In contrast, there was no effect of time on CAD burden in patients without diabetes. In the sub-sample of 760 patients who underwent a chart review of their medication use, there were 367 (48%) with T2DM. For patients with T2DM 69.8% reported taking statins, 64.0% RAS inhibitors and 64.0% anti-platelet drugs. This was significantly higher than patients without diabetes of whom 46.6% reported taking statins, 49.0% RAS inhibitors and 49.9% anti-platelet drugs. As in the full matched sample, patients with diabetes had more extensive CAD (adjOR: 1.32 95% CI: 1.01, 1.74). However, after adjustment for the use of RAS inhibitors, statins and anticoagulants there was no difference in extent of CAD between patients with and without diabetes (adjOR: 1.14 95% CI: 0.85, 1.53)., Conclusions: Although patients with diabetes have a greater extent of CAD in comparison to those without T2DM, preventative medication use decreases this CAD burden significantly., (© 2021. The Author(s).)

Background: The use of telehealth has increased dramatically in Australia in 2020 as a pragmatic response to the COVID-19 pandemic; however, differences between telehealth modalities have not been established., Aim: To identify characteristics contributing to choosing telephone (TP) versus video consultation (VC) and assess patient outcomes between telehealth modalities., Methods: We conducted an observational study of cardiology outpatients at a tertiary hospital with appointments from 17 March 2020 to 12 August 2020. Demographic variables and appointment modality were compared between each group. Outcomes assessed were mortality, emergency department (ED) presentations and cross over between appointment modalities., Results: There were 1754 telemedicine encounters with 1188 patients seen by TP and 327 patients by VC. Consulting volume increased from previous years. Cardiac mortality was low (0.3%). There were no differences in mortality or ED presentations between telehealth modalities. Patients choosing TP over VC were older (P < 0.001), more likely to be female (P = 0.005), non-English-speaking (P = 0.041), living in metropolitan Melbourne (P < 0.0001), undertaking a first appointment (P = 0.002) and seeing particular cardiologists (P < 0.001). VC patients were more likely to have early review (P = 0.015), and this was likely to be TP (P < 0.0001). TP patients were more likely to follow up in person (P < 0.0001)., Conclusion: During COVID-19, we increased consultation volumes without adverse patient outcomes. We identified factors influencing the choice of telemedicine modality which did not translate into differences in mortality or ED presentations. Telemedicine is a growing platform with an important role of facilitating access to healthcare for diverse patient groups., (© 2021 Royal Australasian College of Physicians.)

Introduction: The coronavirus 2019 disease (COVID-19) pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Pre-existing cardiovascular disease (CVD) increases the morbidity and mortality of COVID-19, and COVID-19 itself causes serious cardiac sequelae. Strategies to minimise the risk of viral transmission to health care workers and uninfected cardiac patients while prioritising high quality cardiac care are urgently needed. We conducted a rapid literature appraisal and review of key documents identified by the Cardiac Society of Australia and New Zealand Board and Council members, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, and key cardiology, surgical and public health opinion leaders., Main Recommendations: Common acute cardiac manifestations of COVID-19 include left ventricular dysfunction, heart failure, arrhythmias and acute coronary syndromes. The presence of underlying CVD confers a five- to tenfold higher case fatality rate with COVID-19 disease. Special precautions are needed to avoid viral transmission to this population at risk. Adaptive health care delivery models and resource allocation are required throughout the health care system to address this need., Changes in Management as a Result of This Statement: Cardiovascular health services and cardiovascular health care providers need to recognise the increased risk of COVID-19 among CVD patients, upskill in the management of COVID-19 cardiac manifestations, and reorganise and innovate in service delivery models to meet demands. This consensus statement, endorsed by the Cardiac Society of Australia and New Zealand, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, the National Heart Foundation of Australia and the High Blood Pressure Research Council of Australia summarises important issues and proposes practical approaches to cardiovascular health care delivery to patients with and without SARS-CoV-2 infection., (© 2020 AMPCo Pty Ltd.)

Background: Transcatheter aortic valve implantation (TAVI) is an established therapy for patients with severe aortic stenosis (AS). There is limited data exploring differences in outcomes post-TAVI SEV vs. BEV. This study compared procedural success and 30-d clinical outcomes self-expandable valves (SEV), vs. balloon-expandable valves (BEV) for patients with severe AS. Methods: Retrospective analysis was undertaken of patients receiving TAVI at St Vincent's Hospital, Melbourne between August 2009 and May 2018. The primary endpoints included procedural success, clinical outcomes and complication rates at 30-d. Results: Out of 151 patients undergoing TAVI, 70 received (46.3%) SEV (Medtronic CoreValve & Evolut-R) and 81 (53.6%) BEV (Edwards SAPIEN-XT & S3). The mean Society of Thoracic Surgery (STS) risk score did not differ between the groups, SEV (83.6 ± 4.9 years, STS 4.4 ± 3.8) compared to BEV (82.3 ± 5.8 years, STS 4.9 ± 4.9). Procedural success was similar SEV 67 (95.7%) vs. BEV 78 (96.3%). Rates of ≥ moderate paravalvular aortic regurgitation (PAR) at 30-d were significantly higher in SEV compared to BEV (6.7 vs. 0.0%; p =  .02). SEV patients had higher rates of pacemaker insertion (36.4 vs. 9.5%; p =  .001) and stroke rates (12.4 vs. 1.4%; p =  .04) compared to BEV patients. The difference in 30-d mortality between the two groups was similar (SEV 4.6% vs. BEV 1.3%; p  = .23). Conclusions: This real-world retrospective analysis demonstrates higher rates of ≥ moderate PAR, stroke and pacemaker insertion with SEV compared to BEV at 30 d post-TAVI for severe symptomatic AS.

Background: Exercise capacity is frequently reduced in people with diabetes mellitus (DM) and may be due to subclinical cardiac dysfunction. Speckle-tracking echocardiography is now widely available; however, the clinical utility and significance of left ventricular (LV) strain and twist parameters remain uncertain. We hypothesized that LV strain and twist would be reduced in DM subjects during exercise., Methods: Adults with type 1 or type 2 DM and age- and sex-matched controls performed cardiopulmonary exercise testing (VO 2 peak) and supine bicycle exercise echocardiography. Detailed echocardiographic assessment of biventricular function was performed at baseline and repeated during incremental exercise to maximal intensity., Results: Of the 60 participants completing the study protocol, 51 (34 DM, 17 controls; mean age, 42 ± 13 years; 69% male; DM duration, 16 ± 10 years) had sufficient image quality to assess LV deformation and twist mechanics at rest. Of these, 38 (25 DM, 13 controls) were able to be assessed immediately after exercise. Baseline LV systolic and diastolic function using standard echocardiography measurements were similar between groups. Resting LV global longitudinal strain, twist, twist rate and untwist rate, and the corresponding peak exercise and reserve measures did not differ significantly. As compared with the control subjects, exercise capacity was reduced in the DM cohort (VO 2 peak 33 ± 10 vs 41 ± 12 mL/minute/kg; P = .02); however, no correlation was observed between VO 2 peak and LV twist reserve (R = 0.28, P = .09), LV twist rate reserve (R = 0.14, P = .39), or LV untwist rate reserve (R = 0.24, P = .14)., Conclusions: Despite reduced VO 2 peak, LV twist mechanics at rest and after maximal intensity exercise did not differ significantly in a cohort of asymptomatic DM subjects with normal resting LV systolic and diastolic function compared with age- and sex-matched controls. This would suggest that exercise capacity can be reduced in the absence of subclinical cardiac dysfunction and that noncardiac factors should be considered as alternative explanations., (Copyright © 2019 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Exercise capacity is frequently reduced in people with diabetes mellitus (DM), and the contribution of pulmonary microvascular dysfunction remains undefined. We hypothesized that pulmonary microvascular disease, measured by a novel exercise echocardiography technique termed pulmonary transit of agitated contrast (PTAC), would be greater in subjects with DM and that the use of pulmonary vasodilator agent sildenafil would improve exercise performance by reducing right ventricular afterload. Forty subjects with DM and 20 matched controls performed cardiopulmonary exercise testing and semisupine exercise echocardiography 1 h after placebo or sildenafil ingestion in a double-blind randomized crossover design. The primary efficacy end point was exercise capacity (V̇o 2peak ) while secondary measures included pulmonary vascular resistance, cardiac output, and change in PTAC. DM subjects were aged 44 ± 13 yr, 73% male, with 16 ± 10 yr DM history. Sildenafil caused marginal improvements in echocardiographic measures of biventricular systolic function in DM subjects. Exercise-induced increases in pulmonary artery systolic pressure and pulmonary vascular resistance were attenuated with sildenafil, while heart rate (+2.4 ±1.2 beats/min, P = 0.04) and cardiac output (+322 ± 21 ml, P = 0.03) improved. However, the degree of PTAC did not change ( P = 0.93) and V̇o 2peak did not increase following sildenafil as compared with placebo (V̇o 2peak : 31.8 ± 9.7 vs. 32.1 ± 9.5 ml·min -1 ·kg -1 , P = 0.42). We conclude that sildenafil administration causes modest acute improvements in central hemodynamics but does not improve exercise capacity. This may be due to the mismatch in action of sildenafil on the pulmonary arteries rather than the distal pulmonary microvasculature and potential adverse effects on peripheral oxygen extraction. NEW & NOTEWORTHY This is one of the largest and most comprehensive studies of cardiopulmonary exercise performance in people with diabetes mellitus and to our knowledge the first to assess the effect of sildenafil using detailed echocardiographic measures during incremental exercise. Sildenafil attenuated the rise in pulmonary vascular resistance while augmenting cardiac output and intriguingly heart rate, without conferring any improvement in exercise capacity. The enhanced central hemodynamic indexes may have been offset by reduced peripheral O 2 extraction.

Severe aortic stenosis (AS) is the most common form of valvular heart disease in the developed world, with a rising prevalence due to an ageing Australian population. Transcatheter aortic valve implantation (TAVI) offers a less invasive option for the treatment of severe AS, with evidence supporting TAVI compared with medical therapy in inoperable patients and superior with surgical aortic valve replacement (SAVR) in high-risk patients. Equal outcomes have been observed in all-comer intermediate-risk populations. The Heart Team utilises a shared decision-making approach between physicians and surgeons in risk-stratifying patients and reduces the intrinsic bias that may occur if decisions are made in isolation. Geriatric assessment is useful for identifying preoperative frailty, a major risk factor for death post-aortic valve intervention. In severe AS, a decision can be made collaboratively to pursue TAVI, SAVR, a Ross Procedure or conservative management. The learning curve associated with TAVI has improved markedly, with overall complication rates decreasing around the world. Contemporary changes in practice, such as conscious sedation without general anaesthesia, expedited recovery and early discharge, will likely improve cost-effectiveness. In 2018, TAVI is a well-established procedure in Australia that has revolutionised the management of severe AS. In the future, with an expanding elderly population, the number of patients to benefit from transcatheter therapies for severe AS is hypothesised to increase 4-10-fold. Heart Team assessment is crucial in patients with severe AS to direct appropriate management., (© 2018 Royal Australasian College of Physicians.)

Background: In this prospective study, we compared the invasive measures of microvascular function in two subsets: patients with pharmacoinvasive thrombolysis for STEMI, and patients undergoing percutaneous coronary intervention (PCI) for NSTEMI., Methods: The study consisted of 17 patients with STEMI referred for cardiac catheterisation post thrombolysis, and 20 patients with NSTEMI. Coronary physiological indexes were measured in each patient before and after PCI., Results: The median pre-PCI index of microcirculatory function (IMR) at baseline was significantly higher in the STEMI group than the NSTEMI group (26 units vs. 15 units, p = 0.02). Following PCI, IMR decreased in both groups (STEMI 20 units vs. NSTEMI 14 units, p = 0.10). There was an inverse correlation between post PCI IMR and left ventricular ejection fraction (LVEF) (r = -0.52, p = 0.001). Furthermore, post PCI IMR was an independent predictor of index admission LVEF in the total population (β = -0.388, p = 0.02)., Conclusion: Invasive measures of microvascular function are inferior in a pharmacoinvasive STEMI group compared to a clinically stable NSTEMI group. In the STEMI population, the IMR following coronary intervention appears to predict LVEF., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The risks of percutaneous coronary intervention (PCI) in obese and particularly morbidly obese patients remain uncertain., Methods: 1082 consecutive patients were categorised as non-obese (NO, body mass index (BMI) <30kg/m 2 , n=688), obese (O, BMI 30-40kg/m 2 , n=354) or morbidly obese (MO, BMI ≥40kg/m 2 , n=40). Demographic and procedural information was collated. Monte Carlo simulations modelled radiation dosimetric data., Results: Obese and morbidly obese patients were younger (p=0.016), more frequently female (p=0.036), more frequently diabetic (p<0.0001), with better renal function (p<0.0001), and prior PCI (p=0.01). There was no difference in major adverse cardiovascular or cerebrovascular events (MACCE) (NO=1.2%, O=0.8%, MO=2.5%, p=NS), acute kidney injury, bleeding, length of stay, 30-day readmission or 30-day mortality. Obese and morbidly obese patients received increased contrast (NO=180 [150-230]mL, O=190 [160-250]mL, MO=200 [165-225]mL, p=0.016), dose area product (NO=75.56 [50.61-113.69]Gycm 2 , O=116.4 [76.11-157.82]Gycm 2 , MO=125.62 [92.22-158.81]Gycm 2 , p<0.0001), entrance air kerma (NO=1439.42 [977.0-2075.5]mGy, O=2111.63 [1492.0-3011.0]mGy, MO=2376.0 [1700.0-3234.42]mGy, p<0.0001), and peak skin dose (NO=1439.42 [977.0-2075.5], O=2111.63 [1492.0-3011.0], MO=2376.0 [1700.0-3234.42], p<0.0001). Effective radiation dose increased in obese patients (NO=20.9±14.9mSv, O=27.4±17.1mSv, MO=24.1±12.6mSv, p<0.0001 for NO vs O, p=0.449 for NO vs MO)., Conclusions: Percutaneous coronary intervention can be performed in obese and morbidly obese patients without elevated risk for most clinical outcomes. However, radiation increases above levels that could cause both transient and late effects. Strategies should be pursued to minimise radiation dose., (Copyright © 2017. Published by Elsevier B.V.)

Objective: To determine whether pulmonary microvascular disease is detectable in subjects with diabetes and associated with diminished exercise capacity using a novel echocardiographic marker quantifying the pulmonary transit of agitated contrast bubbles (PTAC)., Research Design and Methods: Sixty participants (40 with diabetes and 20 control subjects) performed cardiopulmonary (maximal oxygen consumption [VO 2 peak]) and semisupine bicycle echocardiography exercise tests within a 1-week period. Pulmonary microvascular disease was assessed using PTAC (the number of bubbles traversing the pulmonary circulation to reach the left ventricle, categorized as low PTAC or high PTAC). Echocardiographic measures of cardiac output, pulmonary artery pressures, and biventricular function were obtained during exercise., Results: Subjects with diabetes and control subjects were of similar age (44 ± 13 vs. 43 ± 13 years, P = 0.87) and sex composition (70% vs. 65% male, P = 0.7). At peak exercise, low PTAC was present in more participants with diabetes than control subjects (41% vs. 12.5%, χ 2 P = 0.041) and, in particular, in more subjects with diabetes with microvascular complications compared with both those without complications and control subjects (55% vs. 26% vs. 13%, χ 2 P = 0.02). When compared with high PTAC, low PTAC was associated with a 24% lower VO 2 peak ( P = 0.006), reduced right ventricular function ( P = 0.015), and greater pulmonary artery pressures during exercise ( P = 0.02)., Conclusions: PTAC is reduced in diabetes, particularly in the presence of microvascular pathology in other vascular beds, suggesting that it may be a meaningful indicator of pulmonary microvascular disease with important consequences for cardiovascular function and exercise capacity., (© 2018 by the American Diabetes Association.)

Background: The reasons for reduced exercise capacity in diabetes mellitus (DM) remains incompletely understood, although diastolic dysfunction and diabetic cardiomyopathy are often favored explanations. However, there is a paucity of literature detailing cardiac function and reserve during incremental exercise to evaluate its significance and contribution. We sought to determine associations between comprehensive measures of cardiac function during exercise and maximal oxygen consumption ([Formula: see text]peak), with the hypothesis that the reduction in exercise capacity and cardiac function would be associated with co-morbidities and sedentary behavior rather than diabetes itself., Methods: This case-control study involved 60 subjects [20 with type 1 DM (T1DM), 20 T2DM, and 10 healthy controls age/sex-matched to each diabetes subtype] performing cardiopulmonary exercise testing and bicycle ergometer echocardiography studies. Measures of biventricular function were assessed during incremental exercise to maximal intensity., Results: T2DM subjects were middle-aged (52 ± 11 years) with a mean T2DM diagnosis of 12 ± 7 years and modest glycemic control (HbA 1c 57 ± 12 mmol/mol). T1DM participants were younger (35 ± 8 years), with a 19 ± 10 year history of T1DM and suboptimal glycemic control (HbA 1c 65 ± 16 mmol/mol). Participants with T2DM were heavier than their controls (body mass index 29.3 ± 3.4 kg/m 2 vs. 24.7 ± 2.9, P = 0.001), performed less exercise (10 ± 12 vs. 28 ± 30 MET hours/week, P = 0.031) and had lower exercise capacity ([Formula: see text]peak = 26 ± 6 vs. 38 ± 8 ml/min/kg, P < 0.0001). These differences were not associated with biventricular systolic or left ventricular (LV) diastolic dysfunction at rest or during exercise. There was no difference in weight, exercise participation or [Formula: see text]peak in T1DM subjects as compared to their controls. After accounting for age, sex and body surface area in a multivariate analysis, significant positive predictors of [Formula: see text]peak were cardiac size (LV end-diastolic volume, LVEDV) and estimated MET-hours, while T2DM was a negative predictor. These combined factors accounted for 80% of the variance in [Formula: see text]peak (P < 0.0001)., Conclusions: Exercise capacity is reduced in T2DM subjects relative to matched controls, whereas exercise capacity is preserved in T1DM. There was no evidence of sub-clinical cardiac dysfunction but, rather, there was an association between impaired exercise capacity, small LV volumes and sedentary behavior.

Background: Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is defined as SCAD occurring during pregnancy or within 3 months post-partum. Earlier systematic reviews have suggested a high maternal and foetal mortality rate. We undertook a structured systematic review of P-SCAD demographics, management and maternal and foetal outcomes., Methods: Case study identification was conducted according to PRISMA guidelines, with screening of all published P-SCAD cases not meeting pre-defined exclusion criteria. Of two hundred and seventy-three publications screened, one hundred and thirty-eight cases met inclusion criteria. Cases were allocated to one of three time periods; 1960-85 (twenty cases) reflecting early management of P-SCAD, 1986-2005 (forty-two cases) reflecting recent management, and 2006-16 (seventy-six cases), reflecting contemporary management., Results: The only significant demographic change in women experiencing P-SCAD over the last 50 years was an increasing proportion of primigravidas ( p  = 0.02). Management and outcomes, however, have altered significantly. Emergent angiography ( p  < 0.0001), reduced thrombolysis ( p  = 0.006) and increasingly conservative or percutaneous management ( p  < 0.0001) are associated with dramatic reductions in maternal mortality (85% in earliest reports to 4% in the last decade, p  < 0.0001) and foetal mortality (50% in earliest reports to 0.0% in the last decade, p  = 0.023)., Conclusion: This systematic review of temporal changes in presentation, management and outcomes of P-SCAD represents the widest range of variables analysed in the largest cohort of P-SCAD patients to date. In the setting of earlier coronary angiography and increasingly conservative management, maternal and foetal survival rates continue to improve.

Background: Methamphetamine use is escalating in Australia and New Zealand, with increasing emergency department attendance and mortality. Cardiac complications play a large role in methamphetamine-related mortality, and it would be informative to assess the frequency of abnormal electrocardiograms (ECGs) amongst methamphetamine users., Objective: To determine the frequency and severity of ECG abnormalities amongst methamphetamine users compared to a control group., Methods: We conducted a retrospective cohort analysis on 212 patients admitted to a tertiary hospital (106 patients with methamphetamine use, 106 age and gender-matched control patients). Electrocardiograms were analysed according to American College of Cardiology guidelines., Results: Mean age was 33.4 years, with 73.6% male gender, with no significant differences between groups in smoking status, ECG indication, or coronary angiography rates. Methamphetamine users were more likely to have psychiatric admissions (22.6% vs 1.9%, p<0.0001). Overall, ECG abnormalities were significantly more common (71.7% vs 32.1%, p<0.0001) in methamphetamine users, particularly tachyarrhythmias (38.7% vs 26.4%, p<0.0001), right axis deviation (7.5% vs 0.0%, p=0.004), left ventricular hypertrophy (26.4% vs 4.7%, p<0.0001), P pulmonale pattern (7.5% vs 0.9%, p=0.017), inferior Q waves (10.4% vs 0.0%, p=0.001), lateral T wave inversion (3.8% vs 0.0%, p=0.043), and longer QTc interval (436.41±31.61ms vs 407.28±24.38ms, p<0.0001). Transthoracic echocardiogram (n=24) demonstrated left ventricular dysfunction (38%), thrombus (8%), valvular lesions (17%), infective endocarditis (17%), and pulmonary hypertension (13%). Electrocardiograms were only moderately sensitive at predicting abnormal TTE., Conclusion: Electrocardiographic abnormalities are more common in methamphetamine users than age and gender-matched controls. Due to the high frequency of abnormalities, ECGs should be performed in all methamphetamine users who present to hospital. Methamphetamine users with abnormal ECGs should undergo further cardiac investigations., (Copyright © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.)

Background: This paper presents a protocol for a randomised controlled trial of the Cardiac-Diabetes Transcare program which is a transitional care, multi-modal self-management program for patients with acute coronary syndrome comorbid with type 2 diabetes. Prior research has indicated people hospitalised with dual cardiac and diabetes diagnoses are at an elevated risk of hospital readmissions, morbidity and mortality. The primary aim of this study is to evaluate the effectiveness (and cost-effectiveness) of a Cardiac-Diabetes Transcare intervention program on 6-month readmission rate in comparison to usual care., Methods/design: A two-armed, randomised controlled trial with blinded outcome assessment will be conducted to evaluate the comparative effectiveness of two modes of care, including a Usual Care Group and a Cardiac-Diabetes Transcare Intervention (in addition to usual care) Group. The primary outcome is 6-month readmission rate, although a range of secondary outcomes will be collected (including self-efficacy) at baseline, 1, 3 and 6 month reassessments. The intervention group will receive in-hospital education tailored for people recovering from an acute coronary syndrome-related hospital admission who have comorbid diabetes, and they will also receive home visits and telephone follow-up by a trained Research Nurse to reinforce and facilitate disease-management-related behaviour change. Both groups will receive usual care interventions offered or referred from participating hospital facilities. A sample size of 432 participants from participating hospitals in the Australian states of Queensland and Victoria will be recruited for 90% power based on the most conservative scenarios modelled for sample size estimates., Discussion: The study outlined in this protocol will provide valuable insight into the effectiveness of a transitional care intervention targeted for people admitted to hospital with cardiac-related presentations commencing in the inpatient hospital setting and transition to the home environment. The purpose of theory-based intervention comprising face-to-face sessions and telephone follow up for patients with acute coronary syndrome and type 2 diabetes is to increase self-efficacy to enhance self-management behaviours and thus improve health outcomes and reduce hospital readmissions., Trial Registration: This study has been registered with the Australian New Zealand Clinical Trials Registry dated 16/12/2014: ACTRN12614001317684 .

Background: Variation in the provision of coronary angiography is associated with health care inefficiency and inequity. We explored geographic, socio-economic, health service and disease indicators associated with variation in angiography rates across Australia., Methods: Australian census and National Health Survey data were used to determine socio-economic, health workforce and service indicators. Hospital separations and coronary deaths during 2011 were identified in the National Hospital Morbidity and Mortality databases. All 61 Medicare Locals responsible for primary care were included, and age- and sex-standardised rates of acute coronary syndrome (ACS) incidence, coronary angiography, revascularisation and mortality were tested for correlations, and adjusted by Bayesian regression., Results: There were 3.7-fold and 2.3-fold differences between individual Medicare Locals in the lowest and highest ACS and coronary artery disease mortality rates respectively, whereas angiography rates varied 5.3-fold. ACS and death rates within Medicare Locals were correlated (partial correlation coefficient [CC], 0.52; P < 0.001). There was modest correlation between ACS and angiography rates (CC, 0.31; P = 0.018). The proportion of patients undergoing angiography who proceeded to revascularisation was inversely correlated with the total angiogram rate (CC, -0.71; P < 0.001). Socio-economic disadvantage and remoteness were correlated with disease burden, ACS incidence and mortality, but not with angiography rate. In the adjusted analysis, the strongest association with local angiography rates was with admissions to private hospitals (71 additional angiograms [95% CI, 47-93] for every 1000 admissions)., Conclusion: Variation in rates of coronary angiography, not related to clinical need, occurs across Australia. A greater focus on clinical care standards and better distribution of health services will be required if these variations are to be attenuated.

Methamphetamines are increasingly popular drugs of abuse in Australia, and are rising in purity. The rising popularity and purity of methamphetamines has notably increased demands upon Australian medical services. Methamphetamines are sympathomimetic amines with a range of adverse effects upon multiple organ systems. Cardiovascular complications are the second leading cause of death in methamphetamine abusers, and there appears to be a high prevalence of cardiac pathology. Cardiovascular pathology frequently seen in methamphetamine abusers includes hypertension, aortic dissection, acute coronary syndromes, pulmonary arterial hypertension and methamphetamine-associated cardiomyopathy. The rising prevalence of methamphetamine abuse is likely to increase the burden of cardiovascular pathology in Australians. A National Parliamentary Enquiry was opened in March 2015 to address concerns regarding the medical and social impacts of methamphetamine abuse. From April 2015, a National 'Ice Taskforce' was also created in parallel. Reversal of cardiac pathology appears to be achievable with abstinence from methamphetamines and initiation of appropriate treatment. It is key to appreciate that the pathogenesis of methamphetamine-induced cardiac complications arises as a result of the specific toxic effects of methamphetamines. Clinical management is hence individualised; suggested management approaches for methamphetamine-induced cardiac complications are detailed within this article., (Crown Copyright © 2015. Published by Elsevier B.V. All rights reserved.)

Background: The index of microcirculatory resistance (IMR), an invasive measure of microvascular function, has been shown to correlate with clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study is to evaluate the predictive value of IMR on left ventricular recovery in patients undergoing a pharmacoinvasive strategy for STEMI., Methods: The index of microcirculatory resistance was assessed following percutaneous coronary intervention (PCI) in 31 patients with STEMI who were initially managed with thrombolysis. Other markers of microvascular function such as coronary flow reserve (CFR), TIMI flow grade, corrected TIMI frame count (cTFC), and ST-segment resolution were also recorded. All indices were evaluated against measures of left ventricular function and recovery 3 months postindex event., Results: The IMR correlated with left ventricular function, as assessed by wall motion score and ejection fraction at 3-month follow-up (r = 0.652, P = 0.005; r = -0.452, P = 0.011, respectively). The traditional methods of assessing microvascular function, such as CFR, TIMI flow grade, cTFC, and ST-segment resolution did not correlate with wall motion score and ejection fraction at 3 months. Post-PCI IMR was significantly lower in those patients with left ventricular recovery at 3 months (18 U vs 39 U, P < 0.001). The optimal cut-off value for post-PCI IMR and left ventricular recovery was 32 U. In patients in whom the IMR was greater than 32 U, the percent change in ejection fraction was significantly lower than in those patients in whom the IMR was less than 32 U (2 ± 11 vs 12 ± 8, P = 0.012)., Conclusions: In patients presenting with STEMI initially managed with thrombolysis and subsequently undergoing PCI, IMR correlates with measures of left ventricular function and has the potential to predict left ventricular recovery at 3 months., (© 2016, Wiley Periodicals, Inc.)

Objective: The aim of the present study was to explore the association of health insurance status on the provision of guideline-advocated acute coronary syndrome (ACS) care in Australia., Methods: Consecutive hospitalisations of suspected ACS from 14 to 27 May 2012 enrolled in the Snapshot study of Australian and New Zealand patients were evaluated. Descriptive and logistic regression analysis was performed to evaluate the association of patient risk and insurance status with the receipt of care., Results: In all, 3391 patients with suspected ACS from 247 hospitals (23 private) were enrolled in the present study. One-third of patients declared private insurance coverage; of these, 27.9% (304/1088) presented to private facilities. Compared with public patients, privately insured patients were more likely to undergo in-patient echocardiography and receive early angiography; furthermore, in those with a discharge diagnosis of ACS, there was a higher rate of revascularisation (P < 0.001). Each of these attracts potential fee-for-service. In contrast, proportionately fewer privately insured ACS patients were discharged on selected guideline therapies and were referred to a secondary prevention program (P = 0.056), neither of which directly attracts a fee. Typically, as GRACE (the Global Registry of Acute Coronary Events) risk score rose, so did the level of ACS care; however, propensity-adjusted analyses showed lower in-hospital adverse events among the insured group (odds ratio 0.68; 95% confidence interval 0.52-0.88; P = 0.004)., Conclusion: Fee-for-service reimbursement may explain differences in the provision of selected guideline-advocated components of ACS care between privately insured and public patients.

Left ventricular diastolic dysfunction is a well-described complication of systemic hypertension. However, less is known regarding the effect of chronic pressure overload on right ventricular (RV) diastolic function. We hypothesized that pulmonary hypertension (PHT) is associated with abnormal RV early relaxation and that this would be best shown by invasive pressure measurement. Twenty-five patients undergoing right heart catheterization for investigation of breathlessness and/or suspected PHT were studied. In addition to standard measurements, RV pressure was sampled with a high-fidelity micromanometer, and RV pressure/time curves were analyzed. Patients were divided into a PHT group and a non-PHT group on the basis of a derived mean pulmonary artery systolic pressure of 25 mmHg. Eleven patients were classified to the PHT group. This group had significantly higher RV minimum diastolic pressure ([Formula: see text] vs. [Formula: see text] mmHg, [Formula: see text]) and RV end-diastolic pressure (RVEDP; [Formula: see text] vs. [Formula: see text] mmHg, [Formula: see text]), and RV τ was significantly prolonged ([Formula: see text] vs. [Formula: see text] ms, [Formula: see text]). There were strong correlations between RV τ and RV minimum diastolic pressure ([Formula: see text], [Formula: see text]) and between RV τ and RVEDP ([Formula: see text], [Formula: see text]). There was a trend toward increased RV contractility (end-systolic elastance) in the PHT group ([Formula: see text] vs. [Formula: see text] mmHg/mL, [Formula: see text]) and a correlation between RV systolic pressure and first derivative of maximum pressure change ([Formula: see text], [Formula: see text]). Stroke volumes were similar. Invasive measures of RV early relaxation are abnormal in patients with PHT, whereas measured contractility is static or increasing, which suggests that diastolic dysfunction may precede systolic dysfunction. Furthermore, there is a strong association between measures of RV relaxation and RV filling pressures.

The health burden of type 2 diabetes mellitus (T2DM) is increasing worldwide, with a substantial portion of this burden being due to the development of cardiovascular (CV) disease. Multiple individual randomised clinical trials of intensive versus conventional glucose control, based on the use of traditional oral hypoglycaemic agents, have failed to convincingly show that intensive glucose control significantly reduces CV disease outcomes. In recent times, two new approaches to lowering glucose levels have become available. One targets the "incretin effect" which involves the modulation of peptide hormones that normally regulate glucose levels when nutrients are given orally. The other approach is based on inhibiting the sodium-glucose co-transporter 2 (SGLT-2) in the tubules of the kidney to promote glycosuria. Incretin-based therapies, especially glucagon-like peptide-1 receptor analogues, reduce glucose levels, with a low risk of hypoglycaemia, by increasing insulin secretion, inhibiting glucagon release and increasing satiety. Clinical and experimental studies have also shown favourable effects on CV disease risk factors such as dyslipidaemia, blood pressure, and improvements in endothelial function and cardiac contractility. Similarly, SGLT-2 inhibitors reduce glucose levels with a low risk for hypoglycaemia and have positive effects on multiple CV disease risk factors. Whether the beneficial effects of these new glucose lowering approaches on surrogate markers of CV disease risk translates to an improvement in CV events remains unknown. Several CV outcome trials are currently being performed to show that at a minimum, these novel glucose lowering agents are safe, but also have positive CV benefits., (Copyright © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: We undertook a prospective study to assess the impact of routine incorporation of right atrial pressure into the calculation of FFR in a real world elective PCI cohort., Methods: 42 patients with stenoses in 2 separate epicardial vessels at coronary angiography were studied. Using a temperature and pressure sensing guidewire (TPSG) FFR and FFRRAP were performed in the target vessel pre and post PCI and in a non-target vessel. FFR was defined as Pd/Pa, FFRRAP as Pd-Pv/Pa-Pv where Pv was right atrial pressure and Pd/Pa were the hyperemic distal and proximal arterial pressures respectively., Results: Mean RAP was 9.1 ± 0.7 mmHg. Mean FFR was significantly lower when RAP was included in the calculation (FFRRAP 0.77 ± 0.19 vs. FFR 0.80 ± 0.16, p<0.001). In the target vessel pre PCI, incorporating RAP into the calculation of FFR resulted in a significant difference in the FFR value (FFR Pre-PCI 0.69 ± 0.02 vs. FFRRAP Pre-PCI 0.63 ± 0.03, p<0.0001). 21 patients had an FFR ≤ 0.8 in the group. If right atrial pressure were utilized to calculate FFR prior to PCI, an additional 9 patients would have been re-categorised to an FFR ≤ 0.8. Following PCI, mean FFR was lower when RAP was incorporated (Post PCI FFRRAP 0.93±0.05 vs. Post PCI FFR 0.95 ± 0.06, p<0.001)., Conclusion: Incorporation of right atrial pressure into the calculation of FFR significantly alters FFR values and may potentially reclassify lesions below ischaemic thresholds., (Crown Copyright © 2012. Published by Elsevier Ireland Ltd. All rights reserved.)

Background: Myocardial infarction has a high rate of morbidity and mortality. There are major social, psychological and legal implications associated with the diagnosis of myocardial infarction (MI)., Objective: We present three case studies of different chest pain syndromes presenting with serum troponin elevation, and use these cases to form the basis of a review of the updated definition of MI. A practical approach to the diagnosis of myocardial infarction is also discussed., Discussion: The measurement of serum troponin levels was a great diagnostic advance and provided powerful prognostic information. Although elevated serum troponin levels were originally considered pathognomonic of MI, it has become clear that highly sensitive troponin assays detected the presence of elevated troponin levels in the absence of MI. This has led to the recent 'Third universal definition of myocardial infarction' consensus document.

Background: This study was designed to assess whether measurement of the index of microvascular resistance (IMR) could help prospectively identify patients who develop periprocedural myocardial infarction (PPMI)., Methods and Results: IMR was measured in 54 patients before and following percutaneous coronary intervention (PCI) in a culprit vessel with a PressureWire using the equation IMR = Pa(Hyp) × Tmn(Hyp) (Pd(Hyp)-Pw/Pa(Hyp)-Pw). IMR was also measured in an angiographically normal reference vessel. The relative pre-IMR ratio (rPIMR) defined as IMR Culprit divided by IMR Non-Culprit was also calculated. Troponin was sequentially sampled up to 24 h following PCI. Mean troponin post-PCI was 0.37±0.8 ng/ml. 33 (61%) patients fulfilled the criteria for PPMI. IMR pre-PCI was the most significant correlate of post-PCI troponin (r=0.43 p=0.001), however, the number of balloon inflations (r=0.3, p=0.02) and rPIMR (r=0.33 p=0.017) were also correlated. IMR pre-PCI was higher in patients with periprocedural myocardial infarction compared with patients without PPMI (IMR pre-PCI 21.2±2.1 PPMI vs 15.6±1.8 No PPMI, p=0.02). The strongest predictor of troponin post-PCI was IMR pre-PCI (β 0.7, p=0.02). Both IMR pre- and rPIMR were predictive of PPMI (OR 11 (1.3 to 90.5) p=0.026, OR 1.09 (1 to 1.19) p=0.03, respectively)., Conclusion: Microvascular function prior to PCI is an important determinant of PPMI. Measuring IMR pre-PCI and rPIMR may allow prospective identification of patients at risk of periprocedural myocardial infarction. Future studies in a larger cohort are required to establish the predictive ability of IMR in PPMI.

Training induces changes in cardiac structure and function which improves cardiac output (CO) and oxygen delivery during exercise. It is unclear whether it is cardiac structure or function which is of greatest importance in determining maximal oxygen consumption (VO(2max)). In 55 subjects (15 non-athletes, 32 amateur and 8 elite athletes), left and right ventricular (LV and RV) volumes and mass were assessed by magnetic resonance imaging (CMR). Comprehensive traditional and novel echocardiographic measures included colour-coded Doppler echocardiography to assess myocardial velocities, strain and strain rate at rest and maximal exercise in both ventricles. Measures of cardiac size and function were assessed as univariate and multivariate predictors of VO(2max). LV and RV mass correlated strongly with VO(2max) (r = 0.79 and r = 0.65, respectively, p < 0.0001), as did LV and RV end-diastolic volumes (r = 0.68 and r = 0.75, p < 0.0001) and heart rate reserve (r = 0.60, p < 0.0001). Measures of myocardial function were not predictive of VO(2max) with the exception of RV diastolic velocities (r = 0.32 and r = 0.36 for rest and exercise, respectively, p < 0.05). On multivariate analysis, only RV end-diastolic volume, LV mass and heart rate reserve were independent predictors (beta = 0.28, 0.45 and 0.27 respectively, p < 0.0001) and together explained 73% of the variance in VO(2max). Measures of cardiac morphology are strongly associated with VO(2max) in healthy adults and well-trained athletes. A combination of ventricular volume, mass and heart rate reserve explains much of the variance in VO(2max), whilst measures of myocardial function do not further strengthen predictive models.

Aims: Endurance training may be associated with arrhythmogenic cardiac remodelling of the right ventricle (RV). We examined whether myocardial dysfunction following intense endurance exercise affects the RV more than the left ventricle (LV) and whether cumulative exposure to endurance competition influences cardiac remodelling (including fibrosis) in well-trained athletes., Methods and Results: Forty athletes were studied at baseline, immediately following an endurance race (3-11 h duration) and 1-week post-race. Evaluation included cardiac troponin (cTnI), B-type natriuretic peptide, and echocardiography [including three-dimensional volumes, ejection fraction (EF), and systolic strain rate]. Delayed gadolinium enhancement (DGE) on cardiac magnetic resonance imaging (CMR) was assessed as a marker of myocardial fibrosis. Relative to baseline, RV volumes increased and all functional measures decreased post-race, whereas LV volumes reduced and function was preserved. B-type natriuretic peptide (13.1 ± 14.0 vs. 25.4 ± 21.4 ng/L, P = 0.003) and cTnI (0.01 ± .03 vs. 0.14 ± .17 μg/L, P < 0.0001) increased post-race and correlated with reductions in RVEF (r = 0.52, P = 0.001 and r = 0.49, P = 0.002, respectively), but not LVEF. Right ventricular ejection fraction decreased with increasing race duration (r = -0.501, P < 0.0001) and VO(2)max (r = -0.359, P = 0.011). Right ventricular function mostly recovered by 1 week. On CMR, DGE localized to the interventricular septum was identified in 5 of 39 athletes who had greater cumulative exercise exposure and lower RVEF (47.1 ± 5.9 vs. 51.1 ± 3.7%, P = 0.042) than those with normal CMR., Conclusion: Intense endurance exercise causes acute dysfunction of the RV, but not the LV. Although short-term recovery appears complete, chronic structural changes and reduced RV function are evident in some of the most practiced athletes, the long-term clinical significance of which warrants further study.