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Familial hypercholesterolaemia (FH) is a dominant and highly penetrant monogenic disorder present from birth that markedly elevates plasma low-density lipoprotein (LDL)-cholesterol concentration and, if untreated, leads to premature atherosclerosis and coronary artery disease (CAD). There are approximately 100,000 people with FH in Australia. However, an overwhelming majority of those affected remain undetected and inadequately treated, consistent with FH being a leading challenge for public health genomics. To further address the unmet need, we provide an updated guidance, presented as a series of systematically collated recommendations, on the care of patients and families with FH. These recommendations have been informed by an exponential growth in published works and new evidence over the last 5 years and are compatible with a contemporary global call to action on FH. Recommendations are given on the detection, diagnosis, assessment and management of FH in adults and children. Recommendations are also made on genetic testing and risk notification of biological relatives who should undergo cascade testing for FH. Guidance on management is based on the concepts of risk re-stratification, adherence to heart healthy lifestyles, treatment of non-cholesterol risk factors, and safe and appropriate use of LDL-cholesterol lowering therapies, including statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors and lipoprotein apheresis. Broad recommendations are also provided for the organisation and development of health care services. Recommendations on best practice need to be underpinned by good clinical judgment and shared decision making with patients and families. Models of care for FH need to be adapted to local and regional health care needs and available resources. A comprehensive and realistic implementation strategy, informed by further research, including assessments of cost-benefit, will be required to ensure that this new guidance benefits

Junctional ectopic tachycardia (JET) is a tachyarrhythmia arising from the atrioventricular node and His bundle area. Enhanced normal automaticity has been postulated as the mechanism of JET in the majority of patients. It is more common in children and can be seen as congenital or in postoperative settings. It is often a narrow complex tachycardia but can present as a wide complex tachycardia as a result of aberrant conduction. Its differentiation from other arrhythmias especially atrioventricular nodal reentrant tachycardia (AVNRT) can be challenging. Medical treatment of JET is difficult, and catheter ablation remains the mainstay of treatment in refractory cases with a high risk of atrioventricular block and recurrence.Copyright © 2020 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of Japanese Heart Rhythm Society

Introduction Familial hypercholesterolaemia (FH) is a common, heritable and preventable cause of premature coronary artery disease, with significant potential for positive impact on public health and healthcare savings. New clinical practice recommendations are presented in an abridged guidance to assist practitioners in enhancing the care of all patients with FH. Main recommendations Core recommendations are made on the detection, diagnosis, assessment and management of adults, children and adolescents with FH. There is a key role for general practitioners (GPs) working in collaboration with specialists with expertise in lipidology. Advice is given on genetic and cholesterol testing and risk notification of biological relatives undergoing cascade testing for FH; all healthcare professionals should develop skills in genomic medicine. Management is under-pinned by the precepts of risk stratification, adherence to healthy lifestyles, treatment of non-cholesterol risk factors, and appropriate use of low-density lipoprotein (LDL)-cholesterol lowering therapies, including statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Recommendations on service design are provided in the full guidance. Potential impact on care of FH These recommendations need to be utilised using judicious clinical judgement and shared decision making with patients and families. Models of care need to be adapted to both local and regional needs and resources. In Australia new government funded schemes for genetic testing and use of PCSK9 inhibitors, as well as the National Health Genomics Policy Framework, will enable adoption of these recommendations. A broad implementation science strategy is, however, required to ensure that the guidance translates into benefit for all families with FH.

Familial hypercholesterolaemia (FH) is a common, heritable and preventable cause of premature coronary artery disease. New clinical practice recommendations are presented to assist practitioners in enhancing the care of all patients with FH. Core recommendations are made on the detection, diagnosis, assessment and management of adults, children and adolescents with FH. Management is under-pinned by the precepts of risk stratification, adherence to healthy lifestyles, treatment of non-cholesterol risk factors and appropriate use of low-density lipoprotein (LDL)-cholesterol-lowering therapies including statins, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. The recommendations need to be utilised using judicious clinical judgement and shared decision-making with patients and families. New government-funded schemes for genetic testing and use of PCSK9 inhibitors, as well as the National Health Genomics Policy Framework, will enable adoption of the recommendations. However, a comprehensive implementation science and practice strategy is required to ensure that the guidance translates into benefit for all families with FH.

Familial hypercholesterolaemia (FH) is a dominant and highly penetrant monogenic disorder present from birth that markedly elevates plasma low-density lipoprotein (LDL)-cholesterol concentration and, if untreated, leads to premature atherosclerosis and coronary artery disease (CAD). There are approximately 100,000 people with FH in Australia. However, an overwhelming majority of those affected remain undetected and inadequately treated, consistent with FH being a leading challenge for public health genomics. To further address the unmet need, we provide an updated guidance, presented as a series of systematically collated recommendations, on the care of patients and families with FH. These recommendations have been informed by an exponential growth in published works and new evidence over the last 5 years and are compatible with a contemporary global call to action on FH. Recommendations are given on the detection, diagnosis, assessment and management of FH in adults and children. Recommendations are also made on genetic testing and risk notification of biological relatives who should undergo cascade testing for FH. Guidance on management is based on the concepts of risk re-stratification, adherence to heart healthy lifestyles, treatment of non-cholesterol risk factors, and safe and appropriate use of LDL-cholesterol lowering therapies, including statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors and lipoprotein apheresis. Broad recommendations are also provided for the organisation and development of health care services. Recommendations on best practice need to be underpinned by good clinical judgment and shared decision making with patients and families. Models of care for FH need to be adapted to local and regional health care needs and available resources. A comprehensive and realistic implementation strategy, informed by further research, including assessments of cost-benefit, will be required to ensure that this new guidance benefits

Background. Despite the high prevalence of coronary bifurcation lesions in routine interventional cardiology practice, the best strategy for managing this challenging lesion subset remains debatable. Due to potential for complications, the routine practice of side-branch (SB) predilation is controversial. Methods. An electronic search was performed of online databases up until April 2018 for studies reporting periprocedural angiographic outcomes comparing provisional main-branch stenting with and without SB predilation. Random-effects model odds ratios (ORs) were calculated. Results. Eight studies were selected for a qualitative review, with 47.3% (1367/2890) of included subjects having angiographic outcomes following SB predilation reported. Of these, four studies included details of periangiographic outcomes comparing two groups. Bifurcation lesions stented without SB predilation demonstrated lower odds of requiring further SB intervention compared with lesions receiving upfront SB predilation (OR, 2.44; 95% confidence interval [CI], 1.71-3.47; I2=21%; P<.001). No difference was demonstrated regarding final SB TIMI flow <3, SB dissection, or intraprocedural SB occlusion. Although the odds of performing final kissing-balloon inflation were in favor of the group without SB predilation (OR, 1.62; 95%CI, 1.11-2.37; I2=61%; P=.01), there was no statistical difference in long-term major cardiovascular outcome (MACE) between the two groups (risk ratio, 1.29; 95%CI, 0.94-1.75; I2=11%; P=.33). Conclusion. SB predilation during coronary bifurcation percutaneous coronary intervention did not alter overall procedural angiographic outcomes. However, SB predilation is associated with increased SB intervention, including increased requirement for SB stenting, without demonstrable long-term MACE benefit, compared with a standard strategy without SB predilation.Copyright © 2020 HMP Communications. All rights reserved.

Purpose: Since the introduction of the Biotronik Linox S/SD leads in 2006, there have been multiple reports of premature lead failure. The purpose of this study was to investigate the longevity of the Linox S/SD leads and to identify the possible predictors of lead failure in a single tertiary implant center. Method(s): We retrospectively reviewed patients who underwent implantation of Linox S/SD leads or Sorin Vigila 1CR/2CR leads (the same Linox S/SD leads marketed by Sorin) at our center. The cumulative lead survival was estimated using the Kaplan-Meier curve, and variables associated with lead failure were assessed by Cox proportional hazard model. Result(s): A total of 187 patients (154 (82%) male) underwent Linox S/SD or Vigila 1CR/2CR implantation between 2007 and 2013. During follow-up with a median time of 75 months, nine lead failures were identified (4.8%). The mean and median times from lead implantation to lead failure were 70.7 +/- 21 months and 64 (45-111) months, respectively. The cumulative survival probability for the Linox S/SD at 5 years was 97.1% and at 12 years was 90.3%. Non-physiological high-rate sensing was the most common type of lead failure in patients. In two-thirds of these patients, this led to inappropriate shock. We did not find any significant relationships between patients' clinical and procedural characteristics and lead failure. Conclusion(s): At our center, the 5-year lead survival of the Linox S/SD has been better than reports from other centers. The majority of lead failures presented as non-physiological high-rate sensing with subsequent inappropriate therapy.Copyright © 2020, Springer Science+Business Media, LLC, part of Springer Nature.

Introduction: The global disease burden of atrial fibrillation in geriatric population is increasing. Frailty and atrial fibrillation(AF) commonly coexist and share risk factors however the association between these two clinical conditions has not been well studied. Hypothesis: We hypothesised that atrial fibrillation is independently predictive of frailty in geriatric patients requiring inpatient rehabilitation. Method(s): Hospitalised patients requiring subacute hospital admissions were recruited between August and December 2016. AF diagnosis was confirmed on an electrocardiogram(ECG) by a cardiologist in addition to a documented history of AF. Demographics and echocardiographic data were collected and frailty, nutritional status and oral health were assessed utilising Reported- Edmonton-Frailty-Scale(REFS), Mini-Nutrition-Assessment(MNA) and Geriatric-Oral-Health- Assessment-Index(GOHAI). Patients with mini-mental-state-examination score of <24, non-English speaking background, visual impairment or delirium were excluded. Result(s): Of 168 eligible patients, 65(38%) were moderately or severely frail and 103(62%) were either not frail or mildly frail based on REFS. The former group, compared to the latter had comparable age distribution(mean age of 82+/-7.7vs.80+/-7.3 years(P=0.109)) and were mostly male 68%vs.55%(P=0.111). Prevalence of cardiovascular risk factors were: hypertension 73%vs.73% (P=0.998), dyslipidemia 43%vs.35%(P=0.314), diabetes 38%vs.26%(P=0.112) and smoking 37%vs.29%(P=0.308). On multivariable analysis, AF (odds ratio(OR) =2.76, P=0.036, 95% confidence interval(CI)=1.07-7.16), abnormal regional wall motion on transthoracic echocardiography (OR= 3.12, P=0.03, 95%CI=1.11-8.8), dental health(OR=0.93,P=0.041,95%CI =0.86-0.997) and older age(OR=1.12,P=0.003, 95%CI=1.04-1.2) were independent predictors of frailty after adjusting for each other. Conclusion(s): Our study suggests the identification of AF on subacute hospital admission, known segmental h

Background: Familial hypercholesterolemia (FH) is a common underdiagnosed autosomal dominant lipid disorder carrying a significant risk of premature coronary artery disease. The aim of this study was to evaluate the awareness and knowledge of heterozygous FH of healthcare providers in coronary care units (CCUs). Method(s): Medical staff working in CCUs in 4 sizable metropolitan health networks in Melbourne, Australia, were requested to complete a structured anonymised questionnaire with regard to FH. The results were tabulated and analysed with the Statistical Package for the Social Sciences version 23 (IBM, New York, NY). Result(s): A total of 121 participants (67% response rate) completed the survey. Some 76% claimed to be at least modestly familiar with FH, and more than half of them adequately described FH; however, only 16% and 43%, respectively, were aware of the prevalence of FH and existence of lipid guidelines. In regard to epidemiological knowledge and update in the management of FH in CCUs, knowledge was suboptimal. In regard to FH care, General Practitioners were rated by 72% of participants as the first most efficient healthcare provider in the management of FH, and cardiologists were rated by 54% of participants as the second most efficient healthcare provider in the management of FH. Some 36% of respondents advocated a form of alert system in laboratory reports to facilitate the diagnosis of FH. Conclusion(s): This survey identified substantial gaps in the knowledge and awareness of FH among healthcare providers involved in the management of acute coronary syndrome. Focused education and clinical training are warranted to raise awareness of FH among healthcare providers working in CCUs.Copyright © 2019

Background: Impaired postprandial remnant cholesterol (RC) metabolism results in high triglyceride (TG) in plasma and may intensify the risk of atherosclerotic cardiovascular disease (ASCVD) in familial hypercholesterolaemia (FH). However, routine assessment of postprandial lipaemia in FH has not been previously investigated. Objective(s): We aimed to assess postprandial lipaemia and chylomicron metabolism by implicating a simplified oral fat tolerance test (OFTT). Method(s): Thirty consecutive subjects with phenotypical FH (N1 = 20 with ASCVD and N2 = 10 without ASCVD) prospectively underwent a simplified OFTT (0,4 h) using a dietary supplement containing 75.0 g monosaturated fat, 41.9 g carbohydrate and 7.2 g protein. FH was diagnosed using the Dutch Lipid Clinic Network criteria. Total cholesterol, TG and high-density lipoprotein (HDL)-cholesterol were measured with enzymatic, colorimetric assays on a Beckman Coulter AU 5800 analyser. RC was calculated as (Total cholesterol-LDL cholesterol-HDL cholesterol). Result(s): Delta plasma TG for cases [mean age 49.9 +/- 11.6yr, median LDL 2.3 (1.7-4.4), median TG 1.2 (0.95-1.40) mmol/L], and 10 FH patients without ASCVD [mean age 46.4 +/- 13.8 yr, LDL 3.5 (2.4-4.5), TG 1.0 (0.60-1.30)] was measured. In cases with ASCVD, there was significant increased postprandial delta TG [1.50 (0.75-2.0) vs 0.35 (0.18-1.56), p = 0.01] and RC [1.2 (0.85-1.55) vs 0.35 (0.18-1.56), p = 0.01]. Postprandial dyslipidaemia in FH with and without ASCVD was independent to conventional risk factors, lipoprotein (a) level [0.18 (0.06-1.14) vs 0.23 (0.15-0.40) p = 0.54], body mass index [(27.3 (3.7) vs 24.4 (4.2), p = 0.06], HbA1C [5.8 (0.4) vs 5.6 (0.8), p = 0.29] and insulin plasma level [(11.5 (6.3) vs 7.0 (2.4), P = 0.06]. Conclusion(s): Our results suggest that postprandial lipaemia is significantly higher in FH subjects with ASCVD. Further trial is required to evaluate implications for additional lipid lowering therapy for further reduction

Introduction: Familial hypercholesterolaemia (FH) is a common hereditary lipid disorder which causes premature coronary artery disease. Pericoronary adipose tissue (PCAT) attenuation is a novel computed tomography coronary angiography (CTCA) biomarker of coronary inflammation with prognostic validation. We sought to compare PCAT attenuation in FH patients with and without significant coronary artery disease (CAD). Method(s): Patients with probable/definite FH as per Dutch Lipid Clinical Network Criteria who underwent 320-detector CTCA were included in this cross-sectional study. More than 50% coronary stenoses in CTCA were defined as significant CAD. Using semi-automated software (Autoplaque version 2.0), PCAT attenuation was measured around the proximal 10-50 mm of the right coronary artery (RCA). In patients with significant CAD, PCAT attenuation was measured around the lesion with highest-grade stenosis. Result(s): Sixty patients with phenotypic FH (40 with significant CAD and 20 with no CAD) were included. Median low-density lipoprotein cholesterol (LDL-C) was higher in patients without CAD compared to those with significant CAD (5.3 [IQR 3.85-6.7] vs. 3.3 [2.65-4.55] mmol/L, p < 0.001]. PCAT attenuation was significantly higher in patients with significant CAD compared to those without CAD (-80.9 +/- 12.2 vs. -90.6 +/- 7.6 HU, p = 0.004). PCAT attenuation around the proximal RCA was not statistically significant between the two groups (-85.3 +/- 11.9 vs. -90.6 +/- 7.6, p = 0.09). PCAT attenuation did not correlate with plasma LDL-C levels. Conclusion(s): FH patients with significant CAD had a higher PCAT attenuation than those without CAD, perhaps reflecting a greater degree of coronary inflammation. Future studies are required to assess whether PCAT attenuation can enhance risk stratification and guide therapy in FH patients.Copyright © 2019

Background: Familial hypercholesterolaemia (FH) is a common inherited disease which causes premature acute coronary syndrome (ACS). Fatal ventricular arrhythmias are the leading cause of mortality in ACS patients worldwide. However, there are limited data on the association of FH and cardiac arrhythmias. Objective(s): This study aimed to examine the association of cardiac arrhythmia profile and FH in the setting of ACS. Method(s): We included 231 patients with early onset ACS out of 997 total admissions to coronary care unit in a large tertiary centre between January-December 2015. FH was diagnosed using the Dutch Lipid Clinic Network Criteria. Fatal ventricular arrhythmias (FVA), defined as primary ventricular fibrillation (VF) or sustained ventricular tachycardia (VT), were confirmed by reviewing rhythm strips and 12-lead electrocardiograms. Result(s): Among all subjects with premature ACS incidence of fatal arrhythmia was 4.7%. 26 patients (11.2%) with early-onset ACS had probable/definite FH, with mean age 46.8 +/- 7.4 years and mean low density lipoprotein-cholesterol 5.6 +/- 1.9 mmol/L. There was no significant difference in the prevalence of diabetes (25.9% vs 24.7% vs 23.0%, p = 0.94), hypertension (46.1% vs 49.5% vs 50.0%, p = 0.87) or smoking (69.2% vs 61.3% vs 76.9%, p = 0.24) among all groups [Unlikely (n = 104), Possible (n = 101), Probable/Definite (n = 26)]. When compared to patients with no FH, patients with FH had significantly lower rates of FVA (4.3%, 0.9%, 0%, p = 0.007). Left ventricular ejection fraction (LVEF) was not significantly different between the groups (p = 0.11). On multivariable analysis, FH was independently associated with lower frequency of FVA, adjusted for age, LVEF <40% and type of ACS (p = 0.04). Conclusion(s): This study suggests FH is associated with lower incidence of FVA in the setting of ACS. Further investigation via multicentre prospective studies with larger populations is warranted.Copyright © 2019

Familial hypercholesterolemia (FH) is a common hereditary lipid disorder associated with substantial risk of premature atherosclerotic cardiovascular disease. We report an interesting newly diagnosed index case of FH in a 31-year-old man who presented to the hospital with an ST-elevated myocardial infarction. He had a background of inadequately treated hypertension and hypercholesterolemia. Further investigations raised the possibility of secondary hypertension after the identification of renal artery stenosis, in addition to other areas of mesenteric arterial stenoses. Our patient's case highlights that early-onset hypertension and hypercholesterolemia in a young individual may be an early manifestation of FH requiring high clinical vigilance and awareness.Copyright © American Journal of Hypertension, Ltd 2019. All rights reserved.

Background and aims: There remains a substantial residual risk of ischaemic heart disease (IHD) despite optimal low-density lipoprotein cholesterol (LDLC) reduction. Part of this risk may be attributable to remnant cholesterol, which is carried in triglyceride-rich lipoproteins. We evaluated the relationship between remnant cholesterol and coronary atherosclerotic plaque burden assessed non-invasively by computed tomography coronary angiography (CTCA) in patients with suspected coronary artery disease (CAD). Methods and Results: This was a multicentre study of 587 patients who had a CTCA and fasting lipid profile within 3 months. Calculated remnant cholesterol was total cholesterol minus LDLC minus high-density lipoprotein cholesterol (HDLC). Significant coronary atherosclerotic burden was defined as CT-Leaman score >5 (CT-LeSc), an established predictor of cardiac events. Mean age was 61 +/- 12 years and mean pretest probability of CAD was 23.2 +/- 19.8%. LDLC levels were <1.8 mmol/L in 134 patients (23%), of whom 82% were statin-treated. Patients with CT-LeSc >5 had higher mean remnant cholesterol than those with CT-LeSc <=5 (0.76 +/- 0.36 mmol/L vs. 0.58 +/- 0.33 mmol/L, p = 0.01). On univariable analysis, remnant cholesterol (p = 0.01), LDLC (p = 0.002) and HDLC (p < 0.001) levels predicted CT-LeSc >5, whilst triglycerides (p = 0.79) had no association with CT-LeSc >5. On multivariable analysis in the subset of patients with optimal LDLC levels, remnant cholesterol levels remained predictive of CT-LeSc >5 (OR 3.87, 95% confidence interval 1.34-7.55, p = 0.004), adjusted for HDLC and traditional risk factors. Conclusion(s): Remnant cholesterol levels are associated with significant coronary atherosclerotic burden as assessed by CTCA, even in patients with optimal LDLC levels. Future studies examining whether lowering of remnant cholesterol can reduce residual IHD risk are warranted.Copyright © 2019 Elsevier B.V.

Introduction: New-onset atrial fibrillation with rapid ventricular rate(AFRVR) and sinus tachycardia(ST) commonly require medical emergency team(MET) response in a hospital setting, but the association between these tachyarrhythmias and long-term mortality after hospital discharge is unknown. Hypothesis: We hypothesised that new onset AFRVR predicts long-term mortality among patients with new-onset AFRVR or ST during an index hospital admission. Method(s): Consecutive inpatients requiring a MET-response for new-onset AFRVR(n=137) or ST(heart rate>130bpm, n=137) between 2015 and 2016 at 5 hospitals in Melbourne were analysed. AFRVR and ST were confirmed on electrocardiogram by a cardiologist. Patients with pre-existing AF/flutter or other known tachyarrhythmias were excluded. The primary endpoint was all-cause mortality at 24 months. Result(s): Compared with ST, new-onset AFRVR subjects were older (74+/-12vs.58+/-20years,P<0.001) with comparable gender distribution(male 49%vs52%,P=0.546) but greater prevalence of cardiovascular risk factors: hypertension(63%vs.47%,P=0.005); dyslipidemia(42%vs.26%,P=0.006); smoking history(62%vs.31%,P<0.001), and diabetes(28%vs.20%,P=0.158). The primary endpoint was reached in 72 of 274(26%) patients: 35(25%) in the AFRVR group and 37(27%) in the ST group(P=0.784). AF on discharge was an independent positive predictor of all-cause mortality in the AFRVR group(OR=7.9,95% confidence interval(CI)=3.1-20.1,P<0.001) while anticoagulant therapy was associated with reduced mortality rate(OR=0.31,CI=0.11-0.91,P=0.033). In the ST group, older age(OR=1.05,CI=1.02-1.09,P=0.002) and fever at the time of MET-response(OR=1.67,CI=1.11- 2.52,P=0.014) were independent predictors of all-cause mortality. Conclusion(s): All-cause mortality is high at 24-month follow-up in patients with newly diagnosed AFRVR or ST requiring in-hospital MET-response. In patients with AFRVR, AF on discharge and anticoagulant therapy were independent predictors of all-cause

Background: Mortality rate of atrial fibrillation(AF) is high in hospitalised populations. Medical Emergency Team (MET) response is frequently activated in the context of care for patients with AF with rapid ventricular response (AFRVR). Incidence of long-term mortality and predictors of mortality in patients with either pre-existing or new-onset AF have not been extensively compared. Aim(s): To study long-term mortality in patients with new-onset AF diagnosed from MET response cohort compared to those with pre-existing AF Methods: Between 2015 and 2016, consecutive patients with new (n = 137) and pre-existing AFRVR (n = 137) defined by ventricular rate of >130 beats per minute were identified from the MET database. New AF was confirmed by a cardiologist on electrocardiogram and the primary outcome was defined as all-cause mortality at 2-year follow-up. Result(s): New-onset AF group were younger (74 +/- 12 vs. 78 +/- 11years, p = 0.003), with comparable gender distribution (Male:Female = 0.53:0.47 vs. 0.45:0.55,p = 0.23) and lower prevalence of hypertension (63% vs.76%,p = 0.02) and diabetes (28% vs.32%, p = 0.41) compared to those with pre-existing AF. Between new and pre-existing AF groups, there were no difference in mean temperature(36.8 +/- 0.8 vs. 36.8 +/- 0.9, p = 0.71) and systolic blood pressure (130 +/- 25 vs. 128 +/- 23, p = 0.63). Two-year mortality was high in both new and pre-existing AF group (27% vs.19%, p = 0.11). On multivariable analysis, anticoagulant therapy commenced after MET response, but not new AF (OR = 1.8,0.96-3.4, p = 0.069) was associated with 50% mortality reduction (OR = 0.51, 95%CI = 0.27-0.97, p = 0.04) whereas patients requiring a medical unit admission were 3.8 times more likely to die (OR = 3.8, 1.87-7.7, p < 0.0001). Conclusion(s): Amongst patients meeting MET team response for AFRVR, all-cause mortality at 2-year follow-up is high. Furthermore, anticoagulation therapy associates with a reduced risk, regardless of time of AF ons

Background/purpose: Biodegradable-polymer (BP) and polymer-free (PF) drug eluting stents (DES) were developed to reduce the risk of delayed arterial healing observed with durable-polymer (DP) platforms. Although trials demonstrate BP-DES and PF-DES are non-inferior to DP-DES, there is limited data directly comparing these technologies. We performed a meta-analysis to assess the efficacy and safety of BP-DES versus PF-DES for the treatment of coronary artery disease. Methods/materials: Electronic searches were performed identifying randomized trials comparing BP-DES with PF-DES. Co-primary efficacy endpoints were target vessel revascularization (TVR), target lesion revascularization (TLR) and angiographic in-stent late lumen loss (LLL). Co-secondary safety endpoints were all-cause death, myocardial infarction (MI) and stent thrombosis (ST). Result(s): Of 208 studies, 5 met inclusion criteria including 1975 patients. At mean follow-up (14 +/- 5 months), BP-DES were associated with significantly reduced rates of TVR (OR 0.58, 95%CI 0.37-0.92, p = 0.02), TLR (4.7% vs 9.5%) (OR 0.48, 95%CI 0.31-0.75, p = 0.001) and in-stent LLL (pooled mean difference -0.20 mm, 95%CI -0.24 to -0.16, p < 0.001). There was no difference in safety, including all-cause death (OR 1.24, 95%CI 0.68-2.28, p = 0.48), MI (OR 0.92, 95%CI 0.54-1.56, p = 0.75) or ST (OR 1.58, 95%CI 0.67-3.73, p = 0.30). Conclusion(s): These data suggests that BP-DES are more efficacious when compared with PF-DES for the treatment of CAD.Copyright © 2018 Elsevier Inc.

Background: Atrial fibrillation (AF) occurs frequently following cardiothoracic surgery and treatment decisions are informed by evidence-based clinical guidelines. Outside this setting there are few data to guide clinical management. Aim(s): To describe the characteristics, management and outcomes of hospitalised adult patients with new-onset AF. Method(s): The medical emergency team (MET) database was utilised to identify patients who had a 'MET call' activated for tachycardia between 2015 and 2016. Patients with sinus tachycardia, pre-existing AF/atrial flutter or other known tachyarrhythmia were excluded. Primary outcomes were length of hospital stay and in-hospital mortality. Result(s): New-onset AF was identified in 137 patients: 68 medically managed; 38 non-cardiothoracic post-operative; and 31 cardiothoracic post-operative. Mean age was 74 +/- 11.6 years and 72 (53%) were male. Of 79 patients who underwent echocardiography, 80% had left atrial dilatation and 14% had reduced left ventricular ejection fraction (LVEF). Mean length of stay (LOS) was 12 days and in-hospital mortality rate was 11%. On multivariable analysis, the odds of death during acute hospitalisation was 7.4 times higher in patients with heart failure with reduced LVEF (odds ratio 7.4, 95% confidence interval (CI) 1.23-44.8, P = 0.028). Length of acute hospital stay increased by 36% if the duration of AF was longer than 48 h (beta coefficient 0.36, 95% CI -0.015 to 0.74, P = 0.059). Conclusion(s): Left ventricular systolic dysfunction in hospitalised patients with new-onset AF is associated with increased all-cause mortality whereas lower serum potassium levels are associated with an increased LOS. A prospective study is planned to compare outcomes based on in-hospital treatment strategies.Copyright © 2019 Royal Australasian College of Physicians

Introduction: Familial hypercholesterolaemia (FH) is a commonly underdiagnosed hereditary lipid disorder characterised by increased low density lipoprotein cholesterol (LDL-C). FH predisposes patients to premature cardiovascular disease (CVD). Achilles tendon (AT) xanthoma is pathognomonic of FH and can be detected via physical examination or ultrasound. Objective(s): Evaluate the accuracy of ultrasound in AT xanthoma detection compared to physical examination in FH patients. Method(s): Forty-two consecutive patients from MonashHEART lipid clinic with likely FH according to the Dutch Lipid Clinic Network Score were included in the study. On physical examination, patients were categorised as xanthoma (+) and xanthoma (-) based on tendon thickness and/or nodularity. On ultrasound, patients were categorised based on AT thickness or presence of hypoechogenic lesions within the tendon. Result(s): Eighty-four AT were investigated in total. Mean age 35.5 +/- 14.7 years, mean LDL-C 5.5 +/- 1.95 mmol/L and 47.6% were male. Premature CVD was present in 50% of the patients. The frequency of xanthoma was 73.8% by ultrasound and the median antero-posterior diameter was 5.15mm (IQR 4.7-5.7). Physical examination had sensitivity of 38% [95% confidence interval (CI) 24.7-52.8] and specificity of 73.5% [95% CI 55.6-87.1] in AT xanthoma detection. No statistically significant association between age and xanthoma was observed. Conclusion(s): This study suggests that ultrasound, used in conjunction with physical examination increases the accuracy of AT xanthoma detection in patients with likely FH.Copyright © 2019

Background: Familial hypercholesterolemia (FH) is a common monogenic hereditary lipid disorder characterised by increased serum low-density lipoprotein cholesterol (LDL-cholesterol) concentrations and high risk of premature atherosclerotic cardiovascular disease. The prevalence of FH identified in a tertiary hospital laboratory was investigated by performing an opportunistic screen for index cases. Method(s): The prevalence of likely FH based on LDL-cholesterol thresholds >4.9 mmol/L as employed by the Dutch Lipid Clinic Network Criteria (DLCNC) score was evaluated retrospectively in a single tertiary hospital laboratory over a six-month period (July to December 2016). Result(s): 4943 lipid profiles screened, 106 patients (mean age 53.2 +/- 12.9 and 41% male) had LDL-cholesterol of >4.9 mmol/L after exclusion of 5 patients (0.1%) with secondary causes. Possible (n = 90) and probable/definite (n = 16) FH according to DLCNC score was seen in 1.8% and 0.4% of the overall screened population, respectively. Conclusion(s): Point prevalence of screening for FH in patients undergoing lipid profile testing in a tertiary hospital laboratory was comparable with prevalence of FH in general population (based on 1 in 200-250). This supports the benefit of establishing an efficient "alert system" in conjunction with a trigger "reflex testing" to facilitate further formal FH scoring and exclusion of possible secondary causes of hyperlipidemia in potential index FH.Copyright © 2019

Background: Improving quality of care with a clinical pathway is an ongoing process and requires continuing feedback, monitoring along with staff training. A large body of our epidemiological evidence suggests Australian Indigenous (Aboriginal and Torres Strait Islander people) are at higher risk of having a major coronary event and cardiac mortality. Method(s): This was a multifaceted quality research, conducted five discrete but inter-related studies using audit (n = 14), incidence review (n = 4), direct observation of patient's journey (n = 14), chart review, and an anonymised interview (n = 3) between Feb 2014-Aug 2016 at multi-sites within Queensland Health. Result(s): There were no considerable differences in the action of chest pain pathway delivery in Indigenous versus non-Indigenous patients. However, several factors were identified as clear barriers in applying chest pain pathway for the Indigenous population including compromised communications via "000" during the emergency situation, lack of reliable transportation to adequate health facilities either primary or tertiary care and ineffective education mainly perpetuated by unfamiliarity with Western medicine. It was also highlighted the crucial role of involving a local "Indigenous Health Professionals" from the get-go not only improved efficacy but resulted with increased further compliance. Conclusion(s): A special consideration should be taken to evaluate chest pain symptoms in Indigenous patients due to mentioned barriers and carrying a higher risk. The authors suggest it is critical to apply a "wellness improvement system model" with a holistic approach to engaging the community to develop cultural competency for successful outcomes.

Acute ST elevation myocardial infarction (STEMI) is a very rare complication post orthotopic heart transplantation. There are only limited data regarding pathophysiological mechanisms and early occurrence of STEMI in heart transplant recipients. Background(s): We describe a 45-year-old Caucasian man with severe dilated cardiomyopathy, on approximately nine months left ventricular assist device (LVAD), and a temporary right ventricular assist device (RVAD) as a bridge to cardiac transplantation. He received the organ from a 48-year-old male with no cardiac risk factors. The donor's heart had normal left ventricular (LV) ejection fraction, accordingly the presence of coronary heart disease was not tested before transplantation. The total ischaemic time was about 210 minutes. On day one post operation, he suffered left leg compartment syndrome requiring urgent fasciotomy 48 hours post-transplant, he developed a progressive reduction of cardiac output and the incremental need for inotropic support. Electrocardiogram revealed inferolateral ST elevations associated with raised troponin I (93ug/L) and echocardiogram showed severe LV dysfunction with inferolateral and inferior wall akinesia. Result(s): Percutaneous coronary intervention (PCI) and drug eluting stent insertion in the left circumflex coronary artery was successfully performed. (Fig. 1) Subsequent endomyocardial biopsy showed International Society for Heart and Lung Transplantation grade 0R and he survived after a prolonged hospital admission with minor clinical sequelae. [Figure Presented] Conclusion(s): In reviewing the pathophysiology of this case, several reasons for thrombosis were postulated including acute organ rejection, haemostasis imbalance due to Systemic inflammation, immunosuppressive therapy. This case highlights the rarity but the significant early occurrence of STEMI in transplant recipients manifesting as changes in haemody-namic status.

Background: Lipoprotein (a) (Lp (a)) is a complex serum lipoprotein particle, distinguished as an independent atherogenic and atherothrombotic element, attributed to increased cardiovascular disease. Emerging data suggest that intense lowering of raised Lp(a) may significantly diminish major car-diovascular events. Current limited evidence indicates Lp (a) apheresis (Lp(a)A) is the most effective therapy in patients with refractory raised Lp(a) and high risk for cardiovascular disease. Objective(s): This review aims to investigate whether reduction of raised Lp (a) by apheresis, as a last resort in patients who have already been on maximum medical treatment, improves future cardiovascular outcome. Method(s): Search terms word: "Lipoprotein (a) or Lp(a)", "apheresis", "cardiovascular events or outcome" derived from Medline and Embase database. We included published full text prospective studies in English, involving adult human, between 2000-2016, assessing Lp(a) A as a treatment route in subsets with measured endpoint of cardiovascular outcomes. Result(s): 4 out of 13 reviewed articles, including 497 patients, 73.8% male with median age of 55.45 (range 48.9-58) were analysed. All studies were conducted in Germany at an "apheresis centre" with uniform outcome, suggested Lp(a)A treatment diminishes cardiovascular events (CVE) compared with pharmacological treatment only (Table 1). No major complications or safety issues were raised during treatment or follow up. [Table Presented] Conclusion(s): This review suggests that Lp(a)A is an effective and safe, therapy for the treatment of selected high risk non familial hypercholesterolaemia (FH) patients. Additional international data and randomised trials are needed prior to endorsing Lp(a)A in routine clinical practice.