Leo Mahar

Keep off the grass: marijuana use and acute cardiovascular events.

Marijuana is one of the most widely used recreational substances in the world, considered by many consumers as a relatively safe drug with few significant side-effects. We report the case of a 21-year-old man who suffered an acute myocardial infarction following the use of marijuana, despite having no other identifiable risk factors for an acute cardiovascular event. We review the published medical literature regarding acute cardiovascular events following marijuana use and postulate a possible mechanism for this unusual pathological consequence of marijuana use.

Effects of fenofibrate on cardiovascular events in patients with diabetes, with and without prior cardiovascular disease: The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study

BACKGROUND In the FIELD study, comparison of the effect of fenofibrate on cardiovascular disease (CVD) between those with prior CVD and without was a prespecified subgroup analysis. METHODS The effects of fenofibrate on total CVD events and its components in patients who did (n = 2,131) and did not (n = 7,664) have a history of CVD were computed by Cox proportional hazards modeling and compared by testing for treatment-by-subgroup interaction. The analyses were adjusted for commencement of statins, use of other CVD medications, and baseline covariates. Effects on other CVD end points were explored. RESULTS Patients with prior CVD were more likely than those without to be male, to be older (by 3.3 years), to have had a history of diabetes for 2 years longer at baseline, and to have diabetic complications, hypertension, and higher rates of use of insulin and CVD medications. Discontinuation of fenofibrate was similar between the subgroups, but more patients with prior CVD than without, and also more placebo than fenofibrate-assigned patients, commenced statin therapy. The borderline difference in the effects of fenofibrate between those who did (hazard ratio [HR] 1.02, 95% CI 0.86-1.20) and did not have prior CVD (HR 0.81, 95% CI 0.70-0.94; heterogeneity P = .045) became nonsignificant after adjustment for baseline covariates and other CVD medications (HR 0.96, 95% CI 0.81-1.14 vs HR 0.78, 95% CI 0.67-0.90) (heterogeneity P = .06). CONCLUSIONS Our findings do not support treating patients with fenofibrate differently based on any history of CVD, in line with evidence from other trials.

A retrospective case study to assess the value of the implantable loop recorder for the investigation of undiagnosed syncope.

ASHBY, D.T., et al.: A Retrospective Case Study to Assess the Value of the Implantable Loop Recorder for the Investigation of Undiagnosed Syncope. If not diagnosed by history, examination, or ECG, the diagnosis of syncope can be difficult with a low yield from echocardiography, ambulatory ECG recording, electrophysiological study, and tilt table testing. During 2 years, 48 patients with unexplained syncope or presyncope from three hospitals in one city underwent the implantation of a Medtronic Reveal implantable loop recorder capable of cardiac monitoring for 14 months. All patients had at least two prior episodes of syncope or presyncope. Fifty‐two percent of patients had electrophysiological studies, all of which were negative. The implantable loop recorder remained implanted until a diagnostic event was recorded, or until the end of the battery life. After a mean follow‐up of 5.6 ± 5.7 months, symptoms reoccurred in 25 (52.1%) patients at a mean of 2.8 ± 2.1 months after insertion of an implantable loop recorder. No further symptoms occurred in 23 (47.9%) patients. Of the 25 patients who had a symptom and recorded an event, an arrhythmia was seen in 10 (40%) patients. Seven patients had bradycardia; 4 with profound sinus bradycardia/sinus arrest, 1 with complete heart block, and 2 in association with the cardioinhibitory component of vasovagal syncope. Three patients had tachycardias; two with supraventricular tachycardia and one with atrial flutter. Fifteen (60%) of the 25 patients who activated their device due to syncope or presyncope were in sinus rhythm during the event. The implantable loop recorder was effective in making a cardiological or noncardiological diagnosis for unexplained syncope or presyncope in 52.1% of the patients.

Problems, Solutions and Actions: Addressing Barriers in Acute Hospital Care for Indigenous Australians and New Zealanders

The burden of cardiovascular disease for Indigenous people in Australia and New Zealand is high and reflects the failings of our health care system to meet their needs. Improving the hospital care for Indigenous people is critical in improving health outcomes. This paper provides the results from a facilitated discussion on the disparities in acute hospital care and workforce issues. The workshop was held in Alice Springs, Australia at the second Cardiac Society of Australia and New Zealand (CSANZ) Indigenous Cardiovascular Health Conference. Critical issues to be addressed include: addressing systemic racism; reconfiguring models of care to address the needs of Indigenous people; cultural competence training for all health professionals; increasing participation of Indigenous people in the health workforce; improving information systems and facilitating communication across the health care sector and with Indigenous communities.

Clinical effectiveness in everyday practice: improving outcomes for all patients through a national acute coronary syndrome data collaborative

The management of acute coronary syndromes (ACS) has an extensive and impressive evidence‐base with which to guide clinical practice. Despite this, translation to the clinical environment has proved to be challenging and incomplete and can be attributed to patient, provider and system factors. Causes of suboptimal guideline adherence relate to diverse issues, including patient complexity, barriers in knowledge translation of guideline recommendations and a limited capacity within health services. Addressing these factors may enable more effective guideline implementation. In Australia, the infrastructure for clinical data management is fragmented, uncoordinated and often administratively driven, compromising access to important information, which might improve clinical effectiveness. An integrated approach is required to improve clinical effectiveness in ACS care in Australia. Greater access to information both to assist in clinical decision‐making and monitoring outcomes may help direct the focus towards understudied populations and improve performance and clinically relevant outcomes. A peer‐led initiative based on common datasets, providing rapid feedback, while developing and disseminating a ‘toolbox’ of proven and sustainable interventions, could improve clinical effectiveness in the Australian management of ACS and provides a rationale for a national ACS registry.

99mTc-imidodiphosphate — A better tracer for infarct-avid imaging

A new radiotracer, 99mTc-imidodiphosphate, has been investigated in a series of 101 consecutive admissions to a Coronary Care Unit in a large teaching hospital to assess its potential as an acute myocardial infarct imaging agent. This agent shows high sensitivity for transmural infarction (0.96), subendocardial infarction (0.88) and high overall specificity (1.00). The clarity of the images produced, and the time after the acute episode when studies were positive suggest that it is the agent of choice for imaging the acutely infarcted myocardium.