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Background: Bioresorbable scaffolds (BRS) are a novel technology in coronary intervention. However, recent trials demonstrate higher rates of device failure compared to contemporary drug-eluting stents. This study sought to utilise a clinical quality registry to assess the medium-term safety of the Abbott Absorb BRS (Abbott Vascular, Santa Clara, CA, USA), in an Australian context. Method(s): A prospective, observational study of 192 BRS percutaneous coronary interventions (PCI) compared to 31,773 non-BRS PCIs entered in the Victorian Cardiac Outcomes Registry from 2013 to 2017. The main outcome measure was patient-oriented composite endpoint (POCE) events comprising all-cause mortality, any myocardial infarction (MI), and any revascularisation. Result(s): Bioresorbable scaffolds patients (mean age 61.6+/-10.5 years, 79% male) were younger, had less comorbidity, less prior PCI, fewer ST elevation myocardial infarction (STEMI) presentations, lower rates of multi-lesion disease and more adjuvant devices compared to non-BRS PCI (all p<0.01). All-cause mortality was 2.1%, myocardial infarction (MI) 2.1%, scaffold thrombosis 3.1% and any revascularisation 14.1% (mean follow-up 27.4+/-8.9 months). POCE events occurred in 11.5% at 1 year and 16.9% at 2 years, comparable to pooled-trial data. Multivariate predictors of POCE were >1 scaffold used (odds ratio [OR] 4.6, 95% confidence interval [CI] 1.9-11.4, p<0.01) and scaffold diameter <=2.5 mm (OR 3.3, 95% CI 1.4-7.6, p=0.02). Over 95% guideline adherence was achieved in six of eight patient selection criteria and four of six device deployment criteria. Conclusion(s): In an Australian setting, BRS were used in non-complex patients. Most guidelines for use were adhered to and outcomes were comparable to pooled trial data. Clinical quality registries are effective in assessing novel treatments and technologies when potential safety concerns develop.Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Su

Background: Serum alkaline phosphatase (ALP) is associated with incident cardiovascular disease (CVD), coronary artery disease, vascular calcification, cerebral small vessel disease and ischemic stroke. Recent studies also associate elevated ALP with impaired cognition, suggesting neuronal or neurovascular dysfunction. To date there is no specific pharmacological means to lower ALP. Bromodomain & extraterminal (BET) proteins bind to acetylated histones on chromatin and regulate gene transcription. Apabetalone (ABET) targets the second bromodomain of BET proteins and inhibits expression of genes that participate in vascular inflammation and calcification, coagulation and the complement pathway. In CVD patients (pts), ABET lowers serum ALP in a dose-dependent manner. Method(s): In phase 2 ABET studies (n=795) up to 26 weeks' duration in CVD pts, we assessed the relationship of ALP and CVD events. In the ongoing phase 3 BETonMACE study with ABET (n=2,425), baseline cognitive function (Montreal Cognitive Assessment, MoCA) and ALP were measured in pts aged 70 yrs and older (n=467). Result(s): In phase 2 studies, CVD events (death, non-fatal MI, coronary revascularization, or hospitalization for CV cause) were lowered by 44% (p=0.02) with ABET. Baseline ALP (median 72 U/L) independently predicted CVD events (hazard ratio [HR] per standard deviation [SD] 1.6, 95% CI 1.2-2.1, p<0.001). Mean ABET decrease in ALP from baseline was 8.45% (p<0.001), or 6.6 U/L. A 1 SD (13.0 U/L) reduction in ALP with ABET was associated with a HR for MACE of 0.58 (95% CI 0.43-0.78, p<0.001). In the BETonMACE trial pts were classified by baseline MoCA >26 (normal, n=221), 21-25 (borderline, n=161), or <21 (impaired, n=85). Pts with impaired cognition had higher ALP (trend p-value 0.006), lower eGFR (66 vs. 71, p=0.04), and higher hsCRP (4.8 vs.1.8, p=0.03). Conclusion(s): Serum ALP is associated with coronary and cerebral vascular disease. ABET is a BET-inhibitor that lowers serum ALP in CVD pts

Women and patients with incomplete revascularization (IR) have a worse prognosis after ST elevation myocardial infarction (STEMI). However, the extent to which IR affects outcomes for women with STEMI compared with men is not well characterized. Thus, we examined late outcomes of 589 consecutive STEMI patients who received percutaneous coronary intervention and assessed SYNTAX scores (SS), both at baseline and after all procedures (residual SS). A residual SS >8 defined IR. The primary end point was cardiac death or myocardial infarction (MI), with median follow-up of 3.6 years [interquartile range [IQR] 2.6 to 4.7]. Women (n = 123) had lower baseline SSs 15.0 [IQR 9 to 20], than men (n = 466), 16.0 [IQR 9 to 20; p = 0.02. After all planned procedures, the residual SS was 5.0 [IQR 0 to 9] in women and 5.0 (IQR 1 to 11] in men, p = 0.37. Cardiac death or MI occurred in (97/589) patients (16%), 24% (30/123) in women and 14% (67/466) in men (hazard ratio [HR] 1.75; 95% confidence intervals [CI] 1.14 to 2.69; p = 0.01). In patients with residual SYNTAX score (rSS) >8 cardiac death or MI occurred in 43% (15/35) of women and 23% 36/158 men (HR 2.14; 95% CI 1.17 to 3.91; p = 0.01). In patients with rSS = 0 to 8 cardiac death or MI occurred in 17% (15/88) of women and 10% of men (31/308) (HR 1.68; 95% CI 0.91 to 3.12; p = 0.10; interaction p value 0.58). Multivariate analysis found women were 1.77 times more likely than men to experience cardiac death or MI (95% CI 1.13 to 2.77; p = 0.01). In conclusion, we found despite a lower burden of disease at presentation and no difference in rates of IR between men and women, outcome differences were substantial. Women with rSS >8 were twice as likely as men with the same rSS to experience cardiac death or MI post-STEMI. Differences remained significant postrisk adjustment.Copyright © 2020 Elsevier Inc.

The objective of the study was to report clinical outcomes of patients unsuitable for surgical coronary revascularization (CABG) treated with percutaneous revascularization (PCI) or medical therapy alone (MT). The decision to revascularize patients referred for CABG but who are unsuitable should be made at Heart Team meetings. The clinical outcomes in this important patient subset are not known, and while cases are considered individually, these decisions are not guided by robust data. Clinical data were analyzed for patients referred to the Heart Team for consideration of CABG over a 4-year period in a UK tertiary referral center. Outcome data for those managed with urgent PCI or MT were considered over a further 3-year period. 133 patients were treated with PCI and 117 with MT. MACE at 30 days were no different between groups (MT 10.3% versus PCI 12.2%); however, at 1 year MACE were higher in the MT group (MT 39.3% versus PCI 26.7%, P < 0.01). Log rank for MACE-free survival to 1 and 3 years was significantly lower in the MT group [HR 1.77 (0.60-1.11); P < 0.001]. Residual SYNTAX was an independent predictor of death. MT [OR 1.75 (1.03-2.99); P = 0.04] and a residual SYNTAX score [OR 6.45 (2.53-16.45); P < 0.001] were independent predictors of MACE at 1 year in the whole group. Our data reveal better outcomes in patients treated with PCI over MT at 1-3 years in CABG-ineligible patients. Patients without complete revascularization have worse outcomes.Copyright © 2018, Japanese Association of Cardiovascular Intervention and Therapeutics.

Background: Successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can markedly reduce angina symptom burden, but many patients often remain on multiple antianginal medications (AAMs) after the procedure. It is unclear when, or if, AAMs can be de-escalated to prevent adverse effects or limit polypharmacy. We examined the association of de-escalation of AAMs after CTO PCI with long-term health status. Method(s): In a 12-center registry of consecutive CTO PCI patients, health status was assessed at 6 months after successful CTO PCI with the Seattle Angina Questionnaire and the Rose Dyspnea Scale. Among patients with technical CTO PCI success, we examined the association of AAM de-escalation with 6-month health status using multivariable models adjusting for revascularization completeness and predicted risk of post-PCI angina (using a validated risk model). We also examined predictors and variability of AAMs de-escalation. Result(s): Of 669 patients with technical success of CTO PCI, AAMs were de-escalated in 276 (35.9%) patients at 1 month. Patients with AAM de-escalation reported similar angina and dyspnea rates at 6 months compared with those whose AAMs were reduced (any angina: 22.5% vs 20%, P = .43; any dyspnea: 51.8% vs 50.1%, P = .40). In a multivariable model adjusting for complete revascularization and predicted risk of post-PCI angina, de-escalation of AAMs at 1 month was not associated with an increased risk of angina, dyspnea, or worse health status at 6 months. Conclusion(s): Among patients with successful CTO PCI, de-escalation of AAMs occurred in about one-third of patients at 1 month and was not associated with worse long-term health status.Copyright © 2019 Elsevier Inc.

BACKGROUND: Globally, >300 million patients have surgery annually, and <=20% experience adverse postoperative events. We studied the impact of both cardiac and noncardiac adverse events on 1-year disability-free survival after noncardiac surgery. METHOD(S): We used the study cohort from the Evaluation of Nitrous oxide in Gas Mixture of Anesthesia (ENIGMA-II) trial, an international randomized trial of 6992 noncardiac surgical patients. All were >=45 years of age and had moderate to high cardiac risk. The primary outcome was mortality within 1 postoperative year. We defined 4 separate types of postoperative adverse events. Major adverse cardiac events (MACEs) included myocardial infarction (MI), cardiac arrest, and myocardial revascularization with or without troponin elevation. MI was defined using the third Universal Definition and was blindly adjudicated. A second cohort consisted of patients with isolated troponin increases who did not meet the definition for MI. We also considered a cohort of patients who experienced major adverse postoperative events (MAPEs), including unplanned admission to intensive care, prolonged mechanical ventilation, wound infection, pulmonary embolism, and stroke. From this cohort, we identified a group without troponin elevation and another with troponin elevation that was not judged to be an MI. Multivariable Cox proportional hazard models for death at 1 year and assessments of proportionality of hazard functions were performed and expressed as an adjusted hazard ratio (aHR) and 95% confidence intervals (CIs). RESULT(S): MACEs were observed in 469 patients, and another 754 patients had isolated troponin increases. MAPEs were observed in 631 patients. Compared with control patients, patients with a MACE were at increased risk of mortality (aHR, 3.36 [95% CI, 2.55-4.46]), similar to patients who suffered a MAPE without troponin elevation (n = 501) (aHR, 2.98 [95% CI, 2.26-3.92]). Patients who suffered a MAPE with troponin elevation but

Aims: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been shown to reduce angina and improve quality of life, but the frequency of new or residual angina after CTO PCI and its relationship with titration of anti-anginal medications (AAMs) has not been described. Methods and Results: Among consecutive CTO PCI patients treated at 12 US centres in the OPEN CTO registry, angina was assessed 6 months after the index PCI using the Seattle Angina Questionnaire (SAQ) Angina Frequency scale (a score <100 defined new or residual angina). We then compared the proportion of patients with AAM escalation (defined as an increase in the number or dosage of AAMs between discharge and follow-up) between those with and without 6-month angina. Of 901 patients who underwent CTO PCI, 197 (21.9%) reported angina at 6-months, of whom 80 (40.6%) had de-escalation, 66 (33.5%) had no change, and only 51 (25.9%) had escalation of their AAM by the 6-month follow-up. Rates of AAM escalation were similar when stratifying patients by the ultimate success of the CTO PCI, completeness of physiologic revascularization, presence or absence of angina at baseline, history of heart failure, and by degree of symptomatic improvement after CTO PCI. Conclusion(s): One in five patients reported angina 6 months after CTO PCI. Although patients with new or residual angina were more likely to have escalation of AAMs in follow-up compared with those without residual symptoms, only one in four patients with residual angina had escalation of AAMs. Although it is unclear whether this finding reflects maximal tolerated therapy at baseline or therapeutic inertia, these findings suggest an important potential opportunity to further improve symptom control in patients with complex stable ischaemic heart disease.Copyright © 2019 Published on behalf of the European Society of Cardiology. All rights reserved.

The presence and extent of myocardial ischaemia is a major determinant of prognosis and benefit from revascularisation in patients with stable coronary artery disease. Fractional Flow Reserve (FFR) is accepted as the reference standard for invasive assessment of ischaemia. Its ability to detect lesion specific ischaemia makes it a useful test in a wide range of patient and lesion subsets, with FFR guided intervention improving clinical outcomes and reducing health care costs compared to assessment with coronary angiography alone. This article will review the basic principles in FFR, practical tips in FFR guided revascularisation and the role of emerging non-hyperaemic indices of ischaemia.Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

INTRODUCTION? Many risk prediction models are currently in use for predicting short-Term mortality following coronary artery bypass graft (CABG) surgery. This review critically appraised the methods that were used for developing these models to assess their applicability in current practice setting as well as for the necessity of up-gradation. EVIDENCE ACQUISITION? Medline via Ovid was searched for articles published between 1946 and 2016 and EMBASE via Ovid between 1974 and 2016 to identify risk prediction models for CABG. Article selection and data extraction was conducted using the CHARMS checklist for review of prediction model studies. Association between model development methods and model's discrimination was assessed using Kruskal-Wallis one-way analysis of variance and Mann-Whitney U-Test. EVIDENCE SYNTHESIS? A total of 53 risk prediction models for short-Term mortality following CABG were identified. The review found a wide variation in development methodology of risk prediction models in the field. Ambiguous predictor and outcome definition, sub-optimum sample size, inappropriate handling of missing data and inefficient predictor selection technique are major issues identified in the review. Quantitative synthesis in the review showed "missing value imputation" and "adopting machine learning algorithms" may result in better discrimination power of the models. CONCLUSIONS? There are aspects in current risk modeling, where there is room for improvement to reflect current clinical practice. Future risk modelling needs to adopt a standardized approach to defining both outcome and predictor variables, rational treatment of missing data and robust statistical techniques to enhance performance of the mortality risk prediction.Copyright © 2016 EDIZIONI MINERVA MEDICA.

Background: Non-ST-segment elevation acute coronary syndromes include unstable angina and non-ST-segment elevation myocardial infarction. Most randomized controlled trials of routine versus selective invasive coronary angiography have high rates of crossover from control to intervention groups and do not include subgroup analysis for unstable angina. Consequently, no clear, specific recommendations exist regarding the use of angiography in unstable angina. Objective(s): To assess the effect of angiography on mortality in unstable angina, incorporating the results of additional cardiac procedures and events. Design(s): Longitudinal study using hospital discharge data, discrete-time survival analysis with propensity score adjustment, and sensitivity analysis. Setting(s): Victoria, Australia, 2001 to 2011. Participant(s): All residents, all ages. Intervention(s): Routine invasive coronary angiography. Measurements: 12-month all-cause mortality. Result(s): Emergently admitted patients with unstable angina (n = 33 901) who did or did not receive angiography during their first hospitalization were balanced on 44 covariates of propensity score. Routine angiography was associated with a 52% decrease in 12-month mortality (hazard ratio, 0.48 [95% CI, 0.38 to 0.61]); revascularization offered no additional statistical mortality benefit compared with diagnostic angiography alone. The predicted cumulative probability of death at 12 months was 0.024 (CI, 0.021 to 0.027) for patients receiving angiography within 2 months of their index unstable angina versus 0.097 (CI, 0.090 to 0.105) for those not receiving it. Sensitivity analysis demonstrated that to negate the observed effect size, an unmeasured confounder must independently decrease mortality by 90% and have a prevalence gap of 15% or greater between the angiographic groups. Limitation(s): Nonrandom allocation of angiography. Conclusion(s): Patients with unstable angina benefit from an invasive management pathway initiated b

Cardiovascular disease remains the leading cause of morbidity and mortality in developed nations, with elevated low-density lipoprotein-cholesterol (LDL-C) levels being a major modifiable risk factor for coronary atherosclerosis. While lipid-lowering therapies such as statins are effective in lowering LDL-C, a proportion of patients do not achieve target LDL-C goals with statins or are intolerant to statins necessitating other treatment options. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are a new class of agents that reduce LDL-C beyond the maximum achievable LDL-C reductions with statins, and have been well studied in different patient groups. However, there are concerns regarding their potential adverse effects and cost, given that morbidity and mortality benefits have not yet been demonstrated. This state-of-the art review provides an overview of the development of PCSK9 inhibitors, the evidence regarding their clinical efficacy in specific target populations, and highlights future trials and challenges that need to be addressed before PCSK9 inhibitors are widely adopted into contemporary clinical practice.Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Aims: Our aim was to assess whether intravascular ultrasound (IVUS) improves clinical outcomes during implantation of first-and second-generation drug-eluting stents (DES). IVUS guidance is associated with improved clinical outcomes during DES implantation, but it is unknown whether this benefit is limited to either first-or second-generation devices. Methods and Results: MEDLINE, EMBASE and PubMed were searched for studies comparing outcomes between IVUS-and angiography-guided PCI. Among 909 potentially relevant studies, 15 trials met the inclusion criteria. The primary endpoint was MACE, defined as death, myocardial infarction, target vessel/ lesion revascularisation (TVR/TLR) or stent thrombosis (ST). Summary estimates were obtained using Peto modelling. In total, 9,313 patients from six randomised trials and nine observational studies were included. First-generation DES were implanted in 6,156 patients (3,064 IVUS-guided and 3,092 angiography-guided) and second-generation in 3,157 patients (1,528 IVUS-guided and 1,629 angiography-guided). IVUS guidance was associated with a significant reduction in MACE (odds ratio [OR] 0.73, 95% CI: 0.64-0.85, p<0.001), across both first-(OR 0.79, 95% CI: 0.67-0.92, p=0.01) and second-generation DES (0.57, 95% CI: 0.43-0.77, p<0.001). For second-generation DES, IVUS guidance was associated with significantly lower rates of cardiac death (OR 0.33, 95% CI: 0.14-0.78, p=0.02), TVR (OR 0.47, 95% CI: 0.28-0.79, p=0.006), TLR (OR 0.61, 95% CI: 0.42-0.90, p=0.01) and ST (OR 0.31, 95% CI: 0.12-0.78, p=0.02). Cumulative meta-analysis highlighted progressive temporal benefit towards IVUS-guided PCI to reduce MACE (OR 0.60, 95% CI: 0.48-0.75, p<0.001). Conclusion(s): IVUS guidance is associated with a significant reduction in MACE during implantation of both first-and second-generation DES platforms. These data support the use of IVUS guidance in contemporary revascularisation procedures using second-generation DES.Copyright © Europa Digi

Background Long-term benefits of coronary stenosis treatment with an everolimus-eluting bioresorbable scaffold are unknown. Objectives This study sought to evaluate clinical and imaging outcomes 5 years after bioresorbable scaffold implantation. Methods In the ABSORB multicenter, single-arm trial, 45 (B1) and 56 patients (B2) underwent coronary angiography, intravascular ultrasound (IVUS), and optical coherence tomography (OCT) at different times. At 5 years, 53 patients without target lesion revascularization underwent final imaging. Results Between 6 months/1 year and 5 years, angiographic luminal late loss remained unchanged (B1: 0.14 +/- 19 mm vs. 0.13 +/- 0.33 mm; p = 0.7953; B2: 0.23 +/- 0.28 mm vs. 0.18 +/- 0.32 mm; p = 0.5685). When patients with a target lesion revascularization were included, luminal late loss was 0.15 +/- 0.20 mm versus 0.15 +/- 0.24 mm (p = 0.8275) for B1 and 0.30 +/- 0.37 mm versus 0.32 +/- 0.48 mm (p = 0.8204) for B2. At 5 years, in-scaffold and -segment binary restenosis was 7.8% (5 of 64) and 12.5% (8 of 64). On IVUS, the minimum lumen area of B1 decreased from 5.23 +/- 0.97 mm2 at 6 months to 4.89 +/- 1.81 mm2 at 5 years (p = 0.04), but remained unchanged in B2 (4.95 +/- 0.91 mm2 at 1 year to 4.84 +/- 1.28 mm2 at 5 years; p = 0.5). At 5 years, struts were no longer discernable by OCT and IVUS. On OCT, the minimum lumen area in B1 decreased from 4.51 +/- 1.28 mm2 at 6 months to 3.65 +/- 1.39 mm2 at 5 years (p = 0.01), but remained unchanged in B2, 4.35 +/- 1.09 mm2 at 1 year and 4.12 +/- 1.38 mm2 at 5 years (p = 0.24). Overall, the 5-year major adverse cardiac event rate was 11.0%, without any scaffold thrombosis. Conclusions At 5 years, bioresorbable scaffold implantation in a simple stenotic lesion resulted in stable lumen dimensions and low restenosis and major adverse cardiac event rates.Copyright © 2016 American College of Cardiology Foundation.

Objectives: Primary: to determine incidence of 30 day major adverse cardiac events (MACE) in patients discharged from the ED following assessment using an accelerated diagnostic pathway (ADP). Secondary: to determine incidence of 30 day MACE for all ADP patients. Method(s): Monash Health ED patients thought at low risk for acute myocardial infarction (AMI) or hospital admission are assessed using an ADP, based on arrival and 90 min point-of-care (POC) cardiac troponin I and myoglobin concentration. Other patients are assessed using a traditional pathway of arrival and 6 h central lab cardiac troponin I. Choice of pathway is based on the clinical judgement of the attending ED doctor. To investigate the safety of the ADP component, an observational study of all ADP patients presenting from 6 June 2013 to 30 September 2013 was conducted. After 30 days, occurrence of MACE was determined by examination of hospital records or telephone contact with patients who had not returned. Result(s): Of 1547 eligible patients, 1384 (89.5%) were followed up. Of the 1143 discharged patients with follow-up information, 30 day MACE occurred in one (0.09%, 95% CI 0.002-0.5). Of all 1547 patients, 60 patients had a MACE detected: 56 AMI during the initial attendance, four AMI post-discharge (one from ED, three after hospital admission). In total, of the 1328 patients who did not have AMI during the target admission and were followed up, 30 day post-discharge MACE occurred in four patients (0.3%, 95% CI 0.08-0.8). Conclusion(s): The ADP supports safe, early discharge of low-risk chest pain patients from the ED.Copyright © 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

We describe a case of left arm swelling over nine months post coronary artery bypass grafting (CABG), due to occlusion of the left brachiocephalic vein. The patient's perioperative course, diagnosis, and management of this complication are presented. doi: 10.1111/jocs.12765 (J Card Surg 2016;31:432-434).Copyright © 2016 Wiley Periodicals, Inc.

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. Method(s): 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. Result(s): 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(s): 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.Copyright © 2016 AMP

Aim: Using Australian guidelines for management of acute coronary syndromes, we assessed the probability of an Indigenous patient receiving interventional and therapeutic care after presenting in two metropolitan hospitals. Methods: A retrospective case note review of patients admitted through two Adelaide public tertiary hospital emergency departments from December 2007 to December 2009. The study cohort was 488 patients with high-risk clinical features without ST-segment elevation. Results: Indigenous patients were significantly younger, present later in the disease process and have a higher burden of cardiovascular risk factors when compared with non-Indigenous patients. Indigenous patients were 54% more likely to receive angiography (Risk ratios (RR)=1.54; 95% CI 1.31; 1.81) than non-Indigenous patients, however, this difference disappeared after adjustment for age, sex and propensity score. Indigenous patients were 20% more likely to receive the recommended medications (RR=1.19, 95% CI 1.01; 1.40) compared with non-Indigenous patients. Patients over 65years were 53% less likely to receive an angiogram (RR=0.47, 95% CI 0.38; 0.56) and were 35% less likely to receive the recommended medications (RR=0.65, 95% CI 0.54; 0.78) than a patient at the ages of 18-49. Women were almost 20% less likely to receive an angiogram (RR=0.81, 95% CI 0.66; 0.99) and 20% less likely to receive the recommended medications (RR=0.80, 95% CI 0.71; 0.91) when compared with men. The likelihood of receiving medications on discharge was significantly influenced by age, gender, ethnicity, comorbid burden and revascularisation. Conclusions: The younger age and significantly higher-risk profile of Indigenous adults presenting to SA hospitals with acute coronary syndromes appears to lead to different management decisions, which may well be led by patient factors. Many of these risk conditions can be better managed in the primary care setting. © 2016 The Authors Internal Medicine Journal © 2016

Purpose: To review the introduction of new technology bioresorbable scaffolds in a single centre. Method(s): To retrospectively analyse the immediate,1 month and 1 year clinical review data of patients with bioresorbable scaffolds, inserted under TGA approved provider conditions, from October 2012 to February 2014 at Epworth Hospital, Richmond. Result(s): There were 113 patients(n=113) with an average age of 65 comprising male(78.76%) and female(21.24%). The indications for performing coronary angiogram were STEMI(3.5%), NSTEMI(23.9%), unstable angina(26.5%), stable angina(31%), staged procedure(9.7%) and other(5.3%). There were 136 lesions, and 139 scaffolds were inserted. Lesion category according to severity was type A(4.44%), type B1(17.03%), type B2(49.62%) and type C(28.88%) which is higher in complexity than published data. Twelve lesions were treated with overlapping scaffolds. The overall device success rate was(93.53%). The bailout stent rate with everolimusTM-metallic stents (Xience) was(6.47%). In the immediate follow-up during the hospital stay, there were no Major Adverse Cardiac Events(MACE). However in the first month, there was 1 non-cardiac death (0.088%). In the 1-year follow-up period there was no target lesion revascularisa tion, 1 coronary revascularisation with CABG and there was 1 cardiac death due to MI from sub-acute scaffold thrombosis( 0.088%). The overall mortality rate at 1 year was 1.76%. Conclusion(s): This single centre "real world" experience suggests safety and good performance of the bioresorbable scaffold in different clinical settings. The small series that was followed-up gives reassuring data. However more data is needed with longer follow-up to establish safety, efficacy and performance of these bioresorbable scaffolds.

Background Angiographic evaluation of diameter stenosis has modest predictive value for functionally significant coronary artery stenoses as assessed by fractional flow reserve (FFR). Lesion length and assessment of area of myocardium at risk (Bypass Angioplasty Revascularization Investigation [BARI] Myocardial Jeopardy Index [MJI]) subtended by the stenotic coronary arteries are also predictors of functionally significant coronary artery stenoses. We sort to assess the diagnostic accuracy of DILEMMA score, which combines minimal lumen diameter (MLD), lesion length, and BARI MJI in prediction of significantly reduced FFR (<=0.8). Methods We assessed patients who underwent coronary angiography and FFR. Lesion length and MLD were assessed by quantitative coronary angiography. Estimation of area of myocardium at risk subtended by coronary stenoses was performed using the BARI MJI. Results A total of 296 patients (age 64 +/-10.6 years, 68% male, 497 vessels) were included. DILEMMA score was significantly higher in vessels with significant FFR, 6.09 +/-3.23 versus 3.84 +/-2.99 (P <0.001). In the derivation cohort, the optimism-adjusted Harrell c statistic for DILEMMA score was 0.82 compared with 0.76 for BARI MJI, 0.75 for lesion length, and 0.7 for MLD. In the validation cohort, the c-statistic for DILEMMA score, BARI MJI, lesion length, and MLD was 0.88, 0.77, 0.81, and 0.72, respectively. The DILEMMA score was a better predictor of FFR <=0.8 compared with MLD, lesion length, and BARI MJI individually (P <.001, P <.02, and P <.045, respectively) on Bonferroni-adjusted pairwise comparison. Conclusions DILEMMA score, taking into account MLD, lesion length, and BARI MJI, may have incremental predictive value beyond the individual indices alone for detecting functionally significant coronary artery stenoses.Copyright © 2014 Elsevier Inc.

In the randomized PLATINUM trial, the PROMUS Element platinum-chromium everolimus-eluting stent (PtCr-EES; Boston Scientific, Natick, Massachusetts) was noninferior to the XIENCE V cobalt-chromium everolimus-eluting stent (CoCr-EES; Boston Scientific and Abbott Vascular, Santa Clara, California) for the primary end point of 1-year target lesion failure. This study reports the 3-year outcomes. Patients (n = 1,530) with 1 or 2 de novo native coronary artery lesions (baseline vessel diameter >=2.50 mm to <=4.25 mm and length <=24 mm) were randomized 1:1 to PtCr-EES versus CoCr-EES. Three-year follow-up was available in 93.9% (703 of 749) of patients with CoCr-EES and 96.7% (733 of 758) of patients with PtCr-EES. Comparing CoCr-EES with PtCr-EES, 3-year rates of death (4.3% vs 3.7%, hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.52 to 1.48, p = 0.62), cardiac death (1.9% vs 1.2%, HR 0.63, 95% CI 0.27 to 1.45, p = 0.27), myocardial infarction (2.5% vs 2.3%, HR 0.92, 95% CI 0.48 to 1.79, p = 0.81), ischemia-driven target lesion revascularization (4.9% vs 3.5%, HR 0.72, 95% CI 0.43 to 1.20, p = 0.21), and Academic Research Consortium definite or probable stent thrombosis (0.5% vs 0.7%, HR 1.23, 95% CI 0.33 to 4.57, p = 0.76) were not significantly different. In conclusion, 3-year results of the PLATINUM randomized, controlled, clinical trial demonstrate comparable safety and efficacy outcomes of the PROMUS Element PtCr-EES and the XIENCE V CoCr-EES. © 2014 Elsevier Inc. All rights reserved.

Background Comorbidities, such as diabetes, affect revascularization strategy for coronary disease. We sought to determine if the degree of renal impairment affected long-term mortality after percutaneous coronary intervention (PCI) compared to coronary artery bypass grafting (CABG) in patients with multi-vessel coronary disease (MVD). Methods and results 8970 patients with MVD undergoing revascularization between 2004 and 2008, in two multi-center parallel PCI and CABG Australian registries were assigned to three groups based on their estimated glomerular filtration rate (eGFR) >= 60 mL/min/1.73 m2 (n = 1678:839), 30-59 mL/min/1.73 m2 (n = 452:226) and < 30 mL/min/1.73 m2 (n = 74:37). We used 2:1 propensity matching to compare 3306 patients undergoing primary CABG versus PCI. Shock, myocardial infarction (MI) < 24 h, previous CABG, valve surgery or PCI were exclusions. Long-term mortality (mean 3.1 years) was compared with Cox-proportional hazard-adjusted modeling. Observed long-term mortality rates (CABG vs. PCI) were 4.5% vs. 4.3% p = 0.84, 12.8% vs. 17.3% p = 0.12, and 23.0% vs. 40.5% p = 0.05 in the three strata, respectively. In patients with eGFR >= 60 mL/min/1.73 m2, long-term mortality between PCI and CABG (HR 0.99, 95% CI 0.65-1.49, p = 0.95) was similar. However, amongst patients with eGFR 30-59 mL/min/1.73 m2, there was a significant mortality hazard with PCI (HR 2.00, 95% CI 1.32-3.04, p = 0.001). In patients with eGFR < 30 mL/min/1.73 m2, there was a trend for hazard with PCI (HR 1.66, 95% CI 0.80-3.46, p = 0.17). Conclusion Long-term mortality in MVD patients with preserved renal function was very low and similar between PCI and CABG. However there was a long-term mortality hazard associated with PCI amongst patients with moderate renal impairment. © 2014 Elsevier Ireland Ltd.

Objectives: To determine the accuracy of 320-row multidetector coronary computed tomography angiography (M320-CCTA) to detect functional stenoses using fractional flow reserve (FFR) as the reference standard and to predict revascularisation in stable coronary artery disease. Method(s): One hundred and fifteen patients (230 vessels) underwent M320-CCTA and FFR assessment and were followed for 18 months. Diameter stenosis on invasive angiography (ICA) and M320-CCTA were assessed by consensus by two observers and significant stenosis was defined as >=50 %. FFR <=0.8 indicated functionally significant stenoses. Result(s): M320-CCTA had 94 % sensitivity and 94 % negative predictive value (NPV) for FFR <=0.8. Overall accuracy was 70 %, specificity 54 % and positive predictive value 65 %. On receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) for CCTA to predict FFR <=0.8 was 0.74 which was comparable with ICA. The absence of a significant stenosis on M320-CCTA was associated with a 6 % revascularisation rate. M320-CCTA predicted revascularisation with an AUC of 0.71 which was comparable with ICA. Conclusion(s): M320-CCTA has excellent sensitivity and NPV for functional stenoses and therefore may act as an effective gatekeeper to defer ICA and revascularisation. Like ICA, M320-CCTA lacks specificity for functional stenoses and only has moderate accuracy to predict the need for revascularisation. Key Points: * Important information about the heart is provided by 320-row multidetector CT coronary angiography (M320-CCTA). * M320-CCTA accurately detects and excludes functional stenoses determined by fractional flow reserve (FFR). * Non-significant stenoses on M320-CCTA associated with fewer cardiac events and less revascularisation. * M320-CCTA may act as a gatekeeper for invasive angiography and inappropriate revascularisation. * Like ICA, M320-CCTA only has moderate accuracy to predict vessels requiring revascularisation. © 2013 European So

Purpose: The international multicentre FAME Study (n=1,005) demonstrated significant health benefits for patients undergoing multivessel percutaneous coronary intervention (PCI) guided by fractional flow reserve (FFR) measurement compared with angiography guidance alone (ANGIO). We determined the cost-effectiveness and the public health/budget impact for Australia. Method(s): We performed a prospective economic evaluation comparing FFR vs. ANGIO in patients with multivessel disease based on original patient-level FAME data. We used Australian utilities (EQ-5D) and costs to calculate quality-adjusted life years (QALYs) and incremental cost-effectiveness adopting the societal perspective. The public health and budget impact from the payer's perspective was based on Australian PCI registries. Uncertainty was explored using deterministic sensitivity analyses and the bootstrap method (n=5,000 samples). Result(s): The cost-effectiveness analysis showed that FFR was cost-saving and reduces costs by 1,776 AUD per patient during one year. Over a two-year time horizon, the public health impact ranged from 7.8 to 73.9 QALYs gained and the budget impact from 1.8 to 14.5 million AUD total cost savings. Sensitivity analyses demonstrated that FFR was cost-saving over a wide range of assumptions. Conclusion(s): FFR-guided PCI in patients with multivessel coronary disease substantially reduces cardiac events, improves QALYs and is cost-saving in the Australian health care system. © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).

Introduction: It is well established that Indigenous Australians (IA) have higher rates of cardiovascular disease and contributing co-morbidities compared to their non-Indigenous Australian (NIA) counterparts. Whether this translates into worse outcomes following coronary revascularization is unclear. Objective(s): We sought to evaluate whether Indigenous status per se portends a poorer short-term (30-day) prognosis following isolated coronary artery bypass grafting (CABG). Method(s): The outcomes of 778 Indigenous Australians (55+/-10 years; 32% female) enrolled in the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registry were compared to 36,124 non-Indigenous Australians (66+/-10 years; 21% female) following isolated CABG. In a secondary analysis, patients were propensitymatched (1:1) by age, gender, renal function, diabetes, and left ventricular ejection fraction (778 individuals in each group). Result(s): IA were younger and more likely to be female, current smokers, to have diabetes, hypertension, renal impairment, peripheral and cerebrovascular disease, heart failure, and previous CABG (all p<0.04). Although both groups had similar rates of double-and triple-vessel coronary disease (p=0.68), IA had lower rates of left main disease, less distal arterial anastomoses with arterial conduits (including less internal mammary artery use), and a higher number of distal vein anastomoses (p<0.001 for the latter four comparisons). IA had shorter cross-clamp and cardiopulmonary bypass times (p<0.001). IA had lower rates of post-operative complications such as myocardial infarction, inotrope use, arrhythmia and new renal impairment (all p<0.04), though bleeding rates were higher (p=0.001). However, in-hospital and 30-day mortality, and rates of 30-day readmission were similar between the IA and NIA groups. With propensity-matching, rates of postoperative complications become similar amongst the two groups, with the exception of bleeding, wh

Objectives: The aim of this study was to evaluate late safety and efficacy outcomes among patients enrolled in clinical trials comparing Endeavor zotarolimus-eluting stents (E-ZES) (Medtronic, Inc., Santa Rosa, California) with first-generation drug-eluting stents (DES) and bare-metal stents (BMS). Background(s): Despite demonstration of higher angiographic luminal loss and restenosis with E-ZES compared with alternative DES, whether differences in these early angiographic measures translate into more disparate late clinical events is uncertain. Method(s): Among 3,616 patients undergoing percutaneous coronary revascularization in 5 registration trials, late safety and efficacy events were compared between E-ZES (n = 2,132) versus sirolimus- or paclitaxel-eluting stents (n = 888) or BMS (n = 596). Result(s): Compared with a parallel cohort of patients treated with first-generation DES and BMS, 5-year rates of cardiac death/myocardial infarction (MI) (5.8% vs. 8.8% DES, p = 0.003; vs. 8.4% BMS, p = 0.02) and major adverse cardiac events (16.1% vs. 20.6% DES, p = 0.009; vs. 24.6% BMS, p < 0.001) were significantly lower with E-ZES. The E-ZES was associated with significantly lower target lesion revascularization (TLR) compared with BMS (7.4% vs. 16.3%, p < 0.001) but similar to comparator DES (7.4% vs. 8.1%, p = 0.63). Despite higher TLR in the first year with E-ZES compared with DES, between 1- and 5-year follow-up, rates of cardiac death/MI, TLR, and definite/probable stent thrombosis were significantly lower with E-ZES. Conclusion(s): Over 5 years, significant differences in cardiac death/MI and composite endpoints favored treatment with E-ZES over comparator BMS and DES. Rates of clinical restenosis and safety events, including stent thrombosis beyond the first year of revascularization, remain stable with E-ZES, leading to significant differences compared with first-generation DES. © 2013 American College of Cardiology Foundation.