J. Ramchand

Clopidogrel, Prasugrel or Ticagrelor in Patients with Acute Coronary Syndromes undergoing Percutaneous Coronary Intervention.

Guidelines recommend prasugrel or ticagrelor instead of clopidogrel in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary interventions (PCI).

Appropriate use of echocardiography in an Australian regional centre

The 2011 Appropriate Use Criteria (AUC) were developed by the American Society of Echocardiography (ASE) to provide guidance for referring physicians in response to growing concerns about unnecessary transthoracic echocardiogram (TTE) requests. When applied in multiple centres overseas, the rate of inappropriate referrals was as high as 22%.

Impact of door-to-balloon time on long-term mortality in high- and low-risk patients with ST-elevation myocardial infarction

BACKGROUND Door-to-balloon time (DTBT) less than 90min remains the benchmark of timely reperfusion in ST-elevation myocardial infarction (STEMI). The relative long-term benefit of timely reperfusion in STEMI patients with differing risk profiles is less certain. Thus, we aimed to assess the impact of DTBT on long-term mortality in high- and low-risk STEMI patients. METHOD We analysed baseline clinical and procedural characteristics of 2539 consecutive STEMI patients who underwent primary percutaneous coronary intervention (PCI) from the Melbourne Interventional Group registry from 2004 to 2012. Patients were classified high risk (HR-STEMI) if they presented with cardiogenic shock, out-of-hospital cardiac arrest (OHCA) or Killip class ≥2; or low-risk (LR-STEMI) if there were no high-risk features. We then stratified high- and low-risk patients by DTBT (≤90min vs. >90min) and assessed long-term mortality. RESULT Of the 2539 patients, 395 (16%) met the high-risk criteria. A DTBT ≤90min was achieved in 43% of HR-STEMI patients and in 55% of LR-STEMI patients. Patients in the HR-STEMI compared to LR-STEMI cohort had higher in-hospital (31% vs. 1%, p<0.01) and long-term mortality (37% vs. 7%, p<0.01). A DTBT ≤90min was associated with significant improvements in short- and long-term mortality in both groups. A DTBT ≤90min was an independent multivariate predictor of long-term survival in LR-STEMI (hazard ratio [HR] 0.5, 95% confidence interval [CI] 0.3-0.9, p=0.02) but not in HR-STEMI (HR 0.7, 95% CI 0.5-1.1, p=0.11). CONCLUSION A DTBT ≤90min was associated with improved short- and long-term outcomes in high- and low-risk STEMI patients. However, it was only an independent predictor of long-term survival in LR-STEMI patients.

Kruppel-Like Factor 15 Is Critical for the Development of Left Ventricular Hypertrophy

Left ventricular hypertrophy (LVH) is an independent risk factor for adverse cardiovascular events and is often present in patients with hypertension. Treatment to reduce blood pressure and regress LVH is key to improving health outcomes, but currently available drugs have only modest cardioprotective effects. Improved understanding of the molecular mechanisms involved in the development of LVH may lead to new therapeutic targets in the future. There is now compelling evidence that the transcription factor Kruppel-like factor 15 (KLF15) is an important negative regulator of cardiac hypertrophy in both experimental models and in man. Studies have reported that loss or suppression of KLF15 contributes to LVH, through lack of inhibition of pro-hypertrophic transcription factors and stimulation of trophic and fibrotic signaling pathways. This review provides a summary of the experimental and human studies that have investigated the role of KLF15 in the development of cardiac hypertrophy. It also discusses our recent paper that described the contribution of genetic variants in KLF15 to the development of LVH and heart failure in high-risk patients.

Early versus delayed percutaneous coronary intervention in patients with non-ST elevation acute coronary syndromes

BackgroundThe optimal timing of angiography and percutaneous coronary intervention (PCI) in patients with non-ST elevation acute coronary syndromes (NSTEACS) remains uncertain. We sought to assess clinical characteristics and outcomes of patients in real-world contemporary practice who have early versus delayed PCI for NSTEACS. MethodsWe analyzed baseline clinical and procedural characteristics of 4307 patients with NSTEACS who underwent PCI from the Melbourne Interventional Group registry. Patients were assigned to the early PCI group if intervention was performed within a calendar day of presentation. The delayed PCI group received an intervention after one calendar day, but within the index admission. We assessed 30 days and 12-month mortality, myocardial infarction, target vessel revascularization, and major adverse cardiovascular events. The safety endpoint was in-hospital bleeding. ResultsOf the 4307 patients, 2210 (51%) received early PCI. The delayed PCI group were older (67±12 vs. 64±12, P<0.01), more likely to have biomarker elevation (70 vs. 66%, P<0.01), and had more comorbidities. There was no difference in efficacy at 30 days between the groups. At 12 months, delayed PCI was associated with higher mortality (4.6 vs. 3.3%, P=0.02), myocardial infarction (7.9 vs. 5.2%, P<0.01), and MACE (15.5 vs. 12.4%, P<0.01). On multivariate analysis, delayed PCI was not associated with increased mortality at 12 months (odds ratio 0.95, 95% confidence interval 0.7–1.3). ConclusionIn patients with stable NSTEACS treated with PCI, delayed intervention was performed in those who were older and had higher risk features. However, there appears to be no mortality hazard for these high-risk patients where PCI is delayed beyond the first 24 h after presentation and performed within the index admission.

Elevated plasma angiotensin converting enzyme 2 activity is an independent predictor of major adverse cardiac events in patients with obstructive coronary artery disease.

Background Angiotensin converting enzyme 2 (ACE2) is an endogenous regulator of the renin angiotensin system. Increased circulating ACE2 predicts adverse outcomes in patients with heart failure (HF), but it is unknown if elevated plasma ACE2 activity predicts major adverse cardiovascular events (MACE) in patients with obstructive coronary artery disease (CAD). Methods We prospectively recruited patients with obstructive CAD (defined as ≥50% stenosis of the left main coronary artery and/or ≥70% stenosis in ≥ 1 other major epicardial vessel on invasive coronary angiography) and measured plasma ACE2 activity. Patients were followed up to determine if circulating ACE2 activity levels predicted the primary endpoint of MACE (cardiovascular mortality, HF or myocardial infarction). Results We recruited 79 patients with obstructive coronary artery disease. The median (IQR) plasma ACE2 activity was 29.3 pmol/ml/min [21.2–41.2]. Over a median follow up of 10.5 years [9.6–10.8years], MACE occurred in 46% of patients (36 events). On Kaplan-Meier analysis, above-median plasma ACE2 activity was associated with MACE (log-rank test, p = 0.035) and HF hospitalisation (p = 0.01). After Cox multivariable adjustment, log ACE2 activity remained an independent predictor of MACE (hazard ratio (HR) 2.4, 95% confidence interval (CI) 1.24–4.72, p = 0.009) and HF hospitalisation (HR: 4.03, 95% CI: 1.42–11.5, p = 0.009). Conclusions Plasma ACE2 activity independently increased the hazard of adverse long-term cardiovascular outcomes in patients with obstructive CAD.

Left ventricular hypertrophy and cognitive function: a systematic review

Cognitive impairment is common in patients with hypertension. Left ventricular hypertrophy (LVH) is recognised as a marker of hypertension-related organ damage and is a strong predictor of coronary artery disease, heart failure and stroke. There is evidence that LVH is independently associated with cognitive impairment, even after adjustment for the presence of hypertension. We conducted a systematic review that examined cognitive impairment in adults with LVH. Independent searches were performed in Ovid MEDLINE, Ovid psycInfo and PubMed with the terms left ventricular hypertrophy and cognition. Seventy-three studies were identified when both searches were combined. After limiting the search to studies that were: (1) reported in English; (2) conducted in humans; (3) in adults aged 50 years and older; and (4) investigated the relationship between LVH and cognitive performance, nine papers were included in this systematic review. The majority of studies found an association between LVH and cognitive performance. Inspection of results indicated that individuals with LVH exhibited a lower performance in cognitive tests, when compared to individuals without LVH. Memory and executive functions were the cognitive domains that showed a specific vulnerability to the presence of LVH. A possible mechanism for the relationship between LVH and cognition is the presence of cerebral white matter damage. White matter lesions occur frequently in patients with LVH and may contribute to cognitive dysfunction. Together, the results of this review suggest that memory impairment and executive dysfunction are the cognitive domains that showed a particular association with the presence of LVH.

The Short-Term Effect of Right Ventricular Mid-septal Pacing on Right Ventricular Function

Characterisation of soft tissue lesions is a common reason for paediatric patients to be referred to the ultrasound department. These lesions commonly occur in the head and neck and include haemangiomas, lymphatic and vascular malformations, thyroglossal duct cysts, brachial cleft cysts and ranulas. Soft tissue lesions may also occur on the body or limbs and can include lipomas, dermoid cysts and epidermal inclusion cysts. With the use of bmode, colour flow and spectral imaging it is possible to characterise these lesions and provide the most likely differential diagnosis. This e-poster demonstrates a simple approach to this type of examination, summarises the ultrasound features of these lesions and provides examples using high resolution images. The HeRO® Vascular Access Graft A Single Centre

Long-term prognostic significance of periprocedural myonecrosis in patients with stable coronary artery disease undergoing elective percutaneous coronary intervention

The clinical significance of myonecrosis, measured by cardiac troponin, in the context of percutaneous coronary intervention (PCI) is a matter of ongoing debate. The lack of substantial scientific evidence in this domain is apparent from the ever-changing definitions of periprocedural myocardial infarction and the uncertainty regarding its prognostic relevance.Myonecrosis due to PCI is common and occurs in up to 40% of cases, depending on the definition and biomarker used5. In the Third Universal Definition of Myocardial Infarction (MI), the cutoff cardiac troponin level to diagnose myonecrosis increased from 3 to 5 times the upper reference limit (URL). In contrast to previous definitions, troponin elevation needs to be associated with clinical, electrocardiographic, angiographic or cardiac imagingrelated evidence of ischaemia to be classified as a periprocedural MI, or type 4a MI. However, the occurrence of post-PCI chest pain without troponin elevation and troponin elevation without chest pain, angiographic complications or other signs of ischaemia is well documented. The Society of Cardiovascular Angiography and Interventions (SCAI) has proposed an alternative definition of “clinically significant myocardial infarction” requiring troponin levels of ≥70x upper limit of normal (ULN) or ≥35x ULN with electrocardiographic evidence of infarction.