E. Paratz

Different patients, different outcomes: A case-control study of spontaneous coronary artery dissection versus acute coronary syndrome

INTRODUCTION There is progressive interest worldwide in spontaneous coronary artery dissection (SCAD). To identify a SCAD cohort and compare risk factors, presentation, and management outcomes compared to acute coronary syndrome (ACS) matched controls. METHODS Retrospective analysis was performed from 2000 to 2015. Clinical data included a neuropsychiatric history, with management and clinical outcomes assessed at 12 months. Patients were matched on a 1:3 case-control basis according to type of ACS. Twenty-two SCAD patients were matched to 66 controls by ACS type (ST-elevation myocardial infarction 45%, Non-ST-elevation myocardial infarction 41%, unstable angina 14%). RESULTS The SCAD group were more likely female (77.3% vs 19.7%, P < 0.0001), of younger age (48.7 ± 10.7 years vs 61.3 ± 10.6 years, P < 0.0001) with no cases of diabetes (0% vs 33.3%, P = 0.002), compared to controls. SCAD patients had a high prevalence of anxiety, depression or previous neuropsychiatric history (52.4% SCAD vs 1.5% ACS, P < 0.0001). A conservative revascularization strategy with stenting was performed in a minority of SCAD patients (13.6% SCAD vs 83.3% ACS, P < 0.0001), with no significant difference in cumulative major adverse cardiac or cerebrovascular events (MACCE) of death, stroke, re-admission, or repeat angiography rates between both groups (13.6% SCAD vs 27.3% ACS P = NS). CONCLUSION SCAD affects young females with a paucity of cardiovascular risk factors. The major risk factor for SCAD was a history of anxiety, depression, or neuropsychiatric illness. A conservative approach to SCAD revascularization led to similar MACCE when compared to ACS controls undergoing guideline revascularization at 12 months.

Response to ‘Beta-Blockers and The Cardiac Complications of Methamphetamines’

Heart, Lung and Circulation - In Press.Proof corrected by the author Available online since samedi 5 novembre 2016

Systemic Mastocytosis, Kounis Syndrome and Coronary Intervention: Case Report and Systematic Review

A 72-year-old male reported a long-standing history of unexplained syncope. Stress echocardiography demonstrated inducible anterior hypokinesis, and he proceeded to percutaneous coronary intervention for an 80% stenosis of the left anterior descending artery. Thirty minutes post-procedure, he experienced a pulseless electrical activity (PEA) cardiac arrest. Urgent repeat angiography demonstrated profound coronary artery spasm consistent with Kounis syndrome. Three days later, a second PEA arrest occurred. Systemic mastocytosis was ultimately diagnosed as the cause of his recurrent syncopal episodes and cardiac arrests. Our patient was discharged 56days after his cardiac arrest on appropriate immunotherapy, and has made an excellent event-free recovery. Systemic mastocytosis is the pathological accumulation of mast cells in organs, and it may cause life-threatening syncope and cardiac arrests. It is estimated to affect up to 1 in 10,000 people, however is often underdiagnosed. No previous reviews have examined cardiac manifestations of systemic mastocytosis. We undertook a structured systematic review of cardiac presentations of systemic mastocytosis in adults, screening 619 publications. Twenty-three cases met inclusion criteria; our review suggests that short-term mortality is high (22%), and patients with cardiac presentations are predominantly male (83%). Unexplained cardiac arrest (26%) may be the first presentation of this haematological disorder. From our review of the literature, we have also derived suggested management approaches for cardiologists encountering or suspecting systemic mastocytosis in a variety of clinical scenarios.

Comparative Effectiveness of Routine Invasive Coronary Angiography for Managing Unstable Angina

Acute coronary syndromes consist of ST-segment elevation myocardial infarction (MI), nonST-segment elevation MI, and unstable angina. The latter 2 conditions, collectively termed nonST-segment elevation acute coronary syndromes, are differentiated primarily by whether the patients troponin level is elevated (nonST-segment elevation MI) or not (unstable angina). Reported rates of unstable angina have declined with the introduction of high-sensitivity troponin testing, which identifies patients with nonST-segment elevation MI (1). However, patients with unstable angina still account for one quarter to one half of all those with acute coronary syndromes who present to the hospital (2, 3). In general, current guidelines recommend routine invasive coronary angiography for patients with nonST-segment elevation MI but not for those with unstable angina (46). European guidelines recommend a selective rather than routine invasive strategy for patients with a negative troponin test, no further chest pain, no evidence of heart failure, and a normal electrocardiogram; however, they do not give explicit advice regarding the timing of angiography in all patients with unstable angina and negative biomarkers (6). The U.S. guidelines advise against a routine, early, invasive strategy in patients (particularly women) with troponin-negative chest pain and a low likelihood of acute coronary syndromes (4). Five trials have included patients with unstable angina; the 3 largestthe FRISC II (Fragmin and Fast Revascularization During Instability in Coronary Artery Disease [1996 to 1998]) trial (n= 2456, 45% with negative biomarkers) (7), the TACTICS TIMI 18 (Treat Angina With Aggrastat and Determine Cost of Therapy With an Invasive or Conservative StrategyThrombolysis in Myocardial Infarction 18 [1997 to 1999]) trial (n= 2220, 46% with negative biomarkers) (8), and RITA-3 (Randomized Intervention Trial of Unstable Angina 3 [1997 to 2001]) (n= 1810, 25% with negative biomarkers) (9)were done in the era of dual-antiplatelet therapy and stenting. Several meta-analyses of these trials have been conducted (1012), 2 of which commented on patients with biomarker-negative unstable angina. Mehta and colleagues (12) found that among patients with negative results on troponin testing, the odds of death or acute MI within the average follow-up of 17.3 months were 11% lower in those who received invasive management; however, this finding was not statistically significant (odds ratio [OR], 0.89 [95% CI, 0.67 to 1.18]). Manfrini and colleagues (11), using a different meta-analytic approach, reported a statistically significant decrease in odds of 21% (OR, 0.79 [CI, 0.70 to 0.90]) for studies including patients with unstable angina. Of note, all included trials had high crossover rates, with nearly 50% of the control group having revascularization within 2 years, predominantly to manage refractory symptoms or recurrent acute coronary syndromes (13). To add to the evidence in this area, we sought to examine the effect of a routine invasive management strategy, beginning with invasive coronary angiography and followed by revascularization as indicated, on the cumulative risk for death at 12 months in patients with unstable angina by using clinically coded hospital discharge data from Victoria, Australia, between 2001 and 2011. Moreover, we used an analytic approach that accounted for additional angiograms, revascularizations, and acute coronary syndromes during this 12-month period. Methods Setting and Data Sources Victoria is Australias second largest state; during the study, its multiethnic population ranged from 4.8 million to 5.6 million. The states age and sex distribution is similar to that of the United States. Public hospitals are freely accessible to all permanent residents of Australia and are funded by state and federal governments through a prospective payment system with capped funding. Approximately 45% of Australians have private health insurance. In each hospital and emergency department in Victoria (131 public and 179 private hospitals), routinely collected data are coded by qualified coders (hospitals) or attending doctors (emergency departments) using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10AM), and the Australian Classification of Health Interventions, 7th edition. A statewide independent audit program maintains hospital coding quality, and a series of internal logic checks combined with manual reviews of randomly selected case groups ensures high-quality data linkage. Linked death data released for this project were rounded to the nearest month of death after hospital discharge. Study Population The sampling frame included all patients admitted to the hospital from 1 July 2001 to 30 June 2011 who had a discharge diagnosis of unstable angina (ICD-10AM 4-digit code I200 as a primary diagnosis) but no history of acute coronary syndromes, invasive coronary angiography, percutaneous coronary intervention, or coronary artery bypass grafting in the year before this index hospitalization. The University of Melbourne ethics committee approved the study (approval number 1033080). Statistical Analysis Data are presented as frequencies and percentages for categorical variables and as means and SDs for continuous variables. To quantify the treatment effect of angiography (henceforth referred to as the treatment effect) on the cumulative incidence of death at 12 months in patients with unstable angina, we obtained 3 treatment effect estimates: the average treatment effect, the average treatment effect in treated patients, and the average treatment effect in untreated patients. The average treatment effect provides a whole-population perspective, as if the entire sample of observed patients with unstable angina were moved from the untreated to the treated group (14). The average treatment effect in treated patients demonstrates the effect of angiography in the sample who originally were chosen for treatment; this subsample may be younger, with fewer comorbid conditions. The average effect of treatment in untreated patients estimates the effect of angiography if patients who did not receive this treatment had received it. This group likely is older and frailer, with more comorbid conditions. To account for the observational nature of the data, a propensity score was developed from which weights were calculated for each treatment effect. These weights were used in separate discrete-time survival models to estimate each treatment effect (14, 15). To determine the association between angiography and mortality given the time variability of further angiograms, revascularizations, and acute coronary episodes, these events were included as time-varying covariates (16). The model also included further adjustments for age, sex, and comorbidity burden based on Charlson comorbidity score. Sensitivity analysis was conducted to determine whether the presence of an unmeasured confounder (such as receipt of optimal medical therapy) altered the observed treatment effect. The prevalence in the exposed versus unexposed group (the prevalence gap) and the effect size of the putative unmeasured confounder used in the sensitivity analysis were based on the basis of previous studies. The sensitivity analysis was performed by using the user-written Stata (StataCorp) command episensrri (17). All analyses were performed by using Stata 13.1 (18). Further details on the statistical methods are presented in the Appendix. Role of the Funding Source Grants from the National Health and Medical Research Council, the Victorian Department of Health and Human Services, and the BUPA Health Foundation funded the study; none of the funders had any role in study design, conduct, or reporting. Results Our study included 33901 patients with a primary diagnosis of unstable angina (Figure 1); their baseline characteristics are presented in Table 1. Figure 1. Flowchart of sample selection. Table 1. Baseline Characteristics of Overall and Propensity ScoreWeighted Samples* In the overall sample, 43% of patients received angiography at the index admission and an additional 9% received it within 12 months (mostly within 3 months of the index admission). The proportion of patients receiving revascularization at index admission was similar to that of patients who received it later: 41.1% versus 42.5% (Table 2). Of patients who had 2 or more angiograms during the 12-month period, nearly 100% had revascularization after the second angiogram. At the index hospitalization, percutaneous coronary intervention was performed twice as often as coronary artery bypass grafting; this ratio decreased to 1.7:1 when angiography and revascularization were delayed. Table 2. Receipt of ICA and Revascularization in Overall Sample* During the 12 months after the index admission, approximately 3.1% of patients who received angiography and 5.2% of those who did not (P < 0.001) had at least 1 readmission for acute MI (Table 3). Readmission was more than 3 times likelier during the first month after the index admission than in the subsequent 11 months. Table 3. Hospital Readmissions After Index Hospitalization for Unstable Angina in Overall Sample, Stratified by the Receipt of ICA at Index Admission* Characteristics of weighted samples used to evaluate the average treatment effect represent those of all patients with unstable angina, characteristics of those used to evaluate the effect in treated patients represent those of patients who received angiography, and characteristics of those used to evaluate the effect in untreated patients represent those of patients who did not receive angiography. Patients who received angiography were younger, mostly male, and from rural areas; a larger proportion arrived by ambulance and used private health insurance. The comorbidity burden and cardiac sequelae were fairly similar, whereas car

First reported case of khat cardiomyopathy and malignant hypertension in Australia

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Evolving management and improving outcomes of pregnancy-associated spontaneous coronary artery dissection (P-SCAD): a systematic review

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.

Many shades of grey: seeking the optimal medical therapy of acute coronary syndrome in older people

Ischaemic heart disease is the leading cause of death worldwide. Age is the strongest risk factor, yet older patients are consistently underrepresented in clinical trials. With an ageing population, knowledge of the evidence base for the treatment of older patients with acute coronary syndrome (ACS) is crucial. As people age, their responses to medications change, and they may become more susceptible to adverse effects of cardiovascular medications. Management of ACS in older people may be further complicated by the presence of comorbidities, polypharmacy and frailty. Treatment decisions need to be individualised, with consideration of patient preferences, functional and cognitive status and life expectancy. This review aims to summarise the current data for the management of older patients with ACS, with a focus on pharmacological treatment.

Is an Abnormal ECG Just the Tip of the ICE-berg? Examining the Utility of Electrocardiography in Detecting Methamphetamine-Induced Cardiac Pathology

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.

Outcomes of Obese and Morbidly Obese Patients Undergoing Percutaneous Coronary Intervention

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/m2, n=688), obese (O, BMI 30-40kg/m2, n=354) or morbidly obese (MO, BMI ≥40kg/m2, 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]Gycm2, O=116.4 [76.11-157.82]Gycm2, MO=125.62 [92.22-158.81]Gycm2, 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.