ORCID Profile
0000-0002-7643-0221
Current Organisations
University of Sydney
,
Liverpool Hospital
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Publisher: SNF Swedish Nutrition Foundation
Date: 2015
Abstract: Australia has a growing number of Asian Indian immigrants. Unfortunately, this population has an increased risk for coronary heart disease (CHD). Dietary adherence is an important strategy in reducing risk for CHD. This study aimed to gain greater understanding of the knowledge, attitudes and beliefs relating to food practices in Asian Indian Australians. Two focus groups with six participants in each were recruited using a convenience s ling technique. Verbatim transcriptions were made and thematic content analysis undertaken. Four main themes that emerged from the data included: migration as a pervasive factor for diet and health importance of food in maintaining the social fabric knowledge and understanding of health and diet and elements of effective interventions. Diet is a complex constructed factor in how people express themselves in idually, in families and communities. There are many interconnected factors influencing diet choice that goes beyond culture and religion to include migration and acculturation. Food and associated behaviors are an important aspect of the social fabric. Entrenched and inherent knowledge, attitudes, beliefs and traditions frame in iduals' point of reference around food and recommendations for an optimal diet.
Publisher: Wiley
Date: 29-06-2022
DOI: 10.1002/CCD.30300
Abstract: We examined the appropriateness of prehospital cardiac catheter laboratory activation (CCL‐A) in ST‐segment elevation myocardial infarction (STEMI) utilizing the University of Glasgow algorithm (UGA) and remote interventional cardiologist consultation. The incremental benefit of prehospital electrocardiogram (PH‐ECG) transmission on the diagnostic accuracy and appropriateness of CCL‐A has been examined in a small number of studies with conflicting results. We identified consecutive PH‐ECG transmissions between June 2, 2010 and October 6, 2016. Blinded adjudication of ECGs, appropriateness of CCL‐A, and index diagnoses were performed using the fourth universal definition of MI. The primary outcome was the appropriate CCL‐A rate. Secondary outcomes included rates of false‐positive CCL‐A, inappropriate CCL‐A, and inappropriate CCL nonactivation. Among 1088 PH‐ECG transmissions, there were 565 (52%) CCL‐As and 523 (48%) CCL nonactivations. The appropriate CCL‐A rate was 97% (550 of 565 CCL‐As), of which 4.9% ( n = 27) were false‐positive. The inappropriate CCL‐A rate was 2.7% (15 of 565 CCL‐As) and the inappropriate CCL nonactivation rate was 3.6% (19 of 523 CCL nonactivations). Reasons for appropriate CCL nonactivation ( n = 504) included nondiagnostic ST‐segment elevation ( n = 128, 25%), bundle branch block ( n = 132, 26%), repolarization abnormality ( n = 61, 12%), artefact ( n = 72, 14%), no ischemic symptoms ( n = 32, 6.3%), severe comorbidities ( n = 26, 5.2%), transient ST‐segment elevation ( n = 20, 4.0%), and others. PH‐ECG interpretation utilizing UGA with interventional cardiologist consultation accurately identified STEMI with low rates of inappropriate and false‐positive CCL‐As, whereas using UGA alone would have almost doubled CCL‐As. The benefits of cardiologist consultation were identifying “masquerading” STEMI and avoiding unnecessary CCL‐As.
Publisher: Elsevier BV
Date: 06-2020
Publisher: Elsevier BV
Date: 04-2014
DOI: 10.1016/J.HLC.2014.11.011
Abstract: As patients are increasingly undergoing elective percutaneous coronary intervention (PCI) with same-day discharge (SDD), and as post-PCI troponin T (TnT) elevations are associated with increased rates of death/myocardial infarction (MI) following elective PCI, we examined late outcomes with respect to post-PCI TnT elevations in patients undergoing SDD. We studied 303 patients (mean age 62±9years, 89% male) who underwent elective-PCI between October 2007 and September 2012, of whom 149 had SDD and 154 stayed overnight (ON) who were age-and sex-matched. Eligibility for SDD excluded patients with: multi-vessel PCI, proximal LAD lesions, chronic total occlusions, side branch occlusions, or access site complications. Femoral access rates were 72% and 96% among SDD and ON patients respectively. Post-PCI, SDD patients left at 4.40[4.13-5.30]hours, and ON patients left at 23.44[21.50-25.41]hours (p<0.001). Overall 8.45% met the 2012 universal MI definition. No patients were re-hospitalised within 48hours. At 30-days, unplanned cardiac re-hospitalisation rates were 3.4% and 0.7% among SDD and ON patients (p=0.118) the only event was MI in an SDD patient. At 16[9-32] months, rates of death, MI, target vessel revascularisation, stroke, were 1.3%,1.3%,2.7% and 1% respectively the composite rate was 6%(6.1% SDD 6% ON p=0.965). Late death/MI rates among patients with, and without, post-PCI TnT levels≥5xURL were 3.4% and 2.8% respectively (p=0.588). SDD following elective PCI among low risk patients appears to be safe and ≥5 fold post-PCI TnT elevations did not appear to confer incremental short and long term risk. A larger cohort is required to confirm this observation.
Publisher: Elsevier BV
Date: 02-2021
Publisher: Elsevier BV
Date: 02-2003
DOI: 10.1067/MJE.2003.25
Publisher: Oxford University Press (OUP)
Date: 07-2008
Abstract: Cardiac involvement in lung cancer is found in up to 25% of autopsy cases. However, despite the considerable mortality and morbidity associated with cardiac metastasis, antemortem diagnosis is unusual. A rare case of lung cancer presenting as a left atrial mass is reported.
Publisher: Informa UK Limited
Date: 12-2012
DOI: 10.5172/CONU.2012.43.1.13
Abstract: Effective goal setting is a vital component of cardiac rehabilitation (CR) programs. The objectives of this study were to investigate the types of goals set by patients attending a CR program in a tertiary teaching hospital and the compatibility of the goals set with the patient's risk factor profile. A descriptive, cross sectional, retrospective audit of the medical records of patients who attended the CR program in a tertiary teaching hospital in Sydney NSW between January 2007 and December 2009 was undertaken. The medical records of 355 patients who attended CR within the stipulated time frame were audited. Short and long term goals were set by 104 and 50 patients, respectively. Four themes identified in the analysis of the goal data were reducing behavioural risk factors for further cardiovascular events, improvements in physical symptoms, enhancing mental well being and return to normal life. The majority of the goals related to physical activity (82%). Collaborative goal setting and the need to establish goals that are attainable and correspond with the patient's health behaviours and clinical measures that require modification is vital.
Publisher: BMJ
Date: 03-06-2011
Publisher: Elsevier BV
Date: 2021
Publisher: Elsevier BV
Date: 07-2013
DOI: 10.1016/J.HLC.2012.12.011
Abstract: Drug-eluting stent (DES) deployment during percutaneous coronary intervention (PCI) has reduced target-vessel revascularisation rates (TVR). The selective use of DES in patients at highest risk of restenosis may allay concerns about universal compliance of dual antiplatelet therapy for one year, and potentially reduce costs. If this strategy achieved acceptably low TVR rates, such an approach could be attractive. Late clinical outcomes were examined in 2115 consecutive patients (mean age 63±12 years, 75% male, 22% diabetics) who underwent PCI in the first three years from October 2003, after commencing the following selective criteria for DES use: left main stenosis ostial lesions of major epicardial arteries proximal LAD lesions lesions≥20mm in length with vessel diameter≤3.0mm lesions in vessels≤2.5mm diabetics with vessel(s)≤3.0mm and in-stent restenosis. Among patients undergoing PCI, 2075 (98%) patients received stents (29%≥1 DES and 71% bare metal stent [BMS]), and among those who received DES, there was a 92% compliance with these criteria. There were no differences in clinical outcomes between the two stent groups except for definite stent thrombosis, which occurred in 2% after DES, and 0.6% after BMS at one year (p=0.002). With BMS, large coronary arteries (≥3.5mm), intermediate (3-3.49mm) and small arteries (<3mm) in diameter had a TVR rate at one year of 3.6%, 7.2% and 8.2% respectively (p=0.005). It is possible to use selective criteria for DES while maintaining low TVR rates. The TVR rate with BMS was low in those with stent diameters≥3.5mm. The higher DES stent thrombosis rate reflects first generation DES use, though whether routine second generation DES use reduces these rates needs confirmation.
Publisher: Elsevier BV
Date: 2014
DOI: 10.1016/J.HLC.2013.09.007
Abstract: The direct thrombin inhibitors and Factor-Xa inhibitors are novel oral anticoagulants which are gaining rapid acceptance not only as alternatives to warfarin, but also as recommended first line agents for use as stroke prophylaxis in patients with non-valvular atrial fibrillation. There are, however, other patient settings in which anticoagulation is either indicated or has a potential role. Warfarin is still the predominant anticoagulant used for the treatment and prevention of venous thromboembolic events including deep vein thrombosis and pulmonary embolism as well as in patients with mechanical prosthetic heart valves. In this article, we review the current evidence for the use of dabigatran, rivaroxaban, apixaban and edoxaban in these settings. A summary of suggested regimens utilising these agents is provided. Importantly, in addition, attention is also drawn to clinical scenarios in which use of such agents is considered inappropriate.
Publisher: Elsevier BV
Date: 04-2012
DOI: 10.1016/J.AHJ.2012.01.014
Abstract: Fibrinolytic therapies remain widely used for ST-elevation myocardial infarction, and for "failed reperfusion," rescue percutaneous coronary intervention (PCI) is guideline recommended to improve outcomes. However, these recommendations are based on data from an earlier era of pharmacotherapy and procedural techniques. To determine factors affecting prognosis after rescue PCI, we studied 241 consecutive patients (median age 55 years, interquartile range [IQR] 48-65) undergoing procedures between 2001 and 2009 (53% anterior ST-elevation myocardial infarction and 78% transferred). The median treatment-related times were 1.2 hours (IQR 0.8-2.2) from symptom onset to door, 2 hours (IQR 1.3-3.2) from symptom onset to fibrinolysis (93% tenecteplase), and 3.9 hours (IQR 3.1-5.2) from fibrinolysis to balloon. Procedural characteristics were stent deployment in 95% (11.6% drug eluting) and 78% glycoprotein IIb/IIIa inhibitor use, and Thrombolysis In Myocardial Infarction (TIMI) 3 flow rates pre-PCI and post-PCI were 41% and 91%, respectively (P < .001). At 30 days, TIMI major bleeding occurred in 16 (6.6%) patients, and 23 (9.5%) patients received transfusions nonfatal stroke occurred in 4 (1.7%) patients (2 hemorrhagic). Predictors of TIMI major bleeding were female gender (odds ratio 3.194, 95% CI 1.063-9.597 P = .039) and pre-PCI shock (odds ratio 3.619, 95% CI,1.073-12.207 P = .038). Mortality at 30 days was 6.2%, and 3.2% in patients without pre-PCI shock. One-year mortality was 8.2% (5.3% in patients without pre-PCI cardiogenic shock), 5.2% had reinfarction, and the target vessel revascularization rate was 6.4% (2.6% in arteries ≥ 3.5 mm in diameter). Pre-PCI shock, female gender, and post-PCI TIMI flow grades ≤ 2 were significant predictors of 1-year mortality on multivariable regression modeling, but TIMI major bleeding was not. Rescue PCI with contemporary treatments can achieve mortality rates similar to rates for contemporary primary PCI in patients without pre-PCI shock. Whether rates of bleeding can be reduced by different pharmacotherapies and interventional techniques needs clarification in future studies.
Publisher: Oxford University Press (OUP)
Date: 23-12-2015
Abstract: To determine if high sensitivity troponin T (hs-TnT) measurements performed during the 'plateau phase' of troponin release (≥48 h) following ST-segment elevation myocardial infarction (STEMI) can predict major adverse cardiovascular endpoints (MACE), and to evaluate its prognostic value compared with cardiac magnetic resonance imaging (CMRI) parameters. We prospectively recruited 201 first presentation STEMI patients. Serial hs-TnT levels were measured at admission, peak (highest), 24, 48 and 72 h. CMRI and transthoracic echocardiography were performed (4 days median) post-STEMI, evaluating infarct scar characteristics and left ventricular ejection fraction (LVEF). Associations were determined between hs-TnT levels and CMRI parameters early after STEMI with MACE (comprising mortality, re-infarction, new or worsening of heart failure, cerebrovascular accident, and sustained ventricular arrhythmias) at medium-term follow-up. After 602 days (median), 33 (17%) patients had MACE. Upper tertile hs-TnT levels at 48 and 72 h were associated with MACE (Kaplan-Meier P = 0.002 and P = 0.012, respectively). Multivariate Cox analyses, incorporating diabetes, CMRI scar size, LVEF and hs-TnT levels (applied at a single hs-TnT time point) showed that 48 and 72 h hs-TnT levels were independent predictors for MACE (HR = 1.20, P = 0.002, and HR = 1.21, P = 0.035 respectively). Measurement of hs-TnT in the plateau phase after STEMI is an inexpensive method of prognostic risk assessment.
Publisher: MDPI AG
Date: 08-02-2023
DOI: 10.3390/ANTIBIOTICS12020355
Abstract: Infective endocarditis (IE) is a serious infectious disease with significant mortality and morbidity placing a burden on healthcare systems. Outpatient antimicrobial therapy in selected patients has been shown to be safe and beneficial to both patients and the healthcare system. In this article, we review the literature on the model of care for outpatient parenteral antimicrobial therapy in infective endocarditis and propose that systems of care be developed based on local resources and all patients admitted with infective endocarditis be screened appropriately for outpatient antimicrobial therapy.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2022
DOI: 10.1161/CIRCINTERVENTIONS.121.011419
Abstract: Coronary microvascular dysfunction after acute coronary syndrome is an important predictor of long-term prognosis. Data is lacking on the effects of oral P2Y 12 -inhibitors on coronary microvascular function in non–ST-segment–elevation acute coronary syndrome. The aim of this study was to compare the acute effects of ticagrelor versus clopidogrel pretreatment on coronary microvascular function in non–ST-segment–elevation acute coronary syndrome patients. Hospitalized non–ST-segment–elevation acute coronary syndrome patients were randomized (1:1) to ticagrelor or clopidogrel. The index of microcirculatory resistance, coronary flow reserve, and resistive reserve ratio were obtained using an intracoronary pressure-temperature sensor-tipped wire. In total, 128 patients were randomized between March 2018 and July 2020. Mean age 59.2±11.8 years, 84% were male, mean Global Registry of Acute Coronary Events score was 93.7±24.5. Intracoronary physiological measurements were obtained in 118 patients (60 ticagrelor, 58 clopidogrel). In the infarct-related artery, the ticagrelor group had lower baseline index of microcirculatory resistance (22.0 [13.0–34.9] versus 27.7 [19.3–29.8] P =0.02) and higher baseline resistive reserve ratio (3.0 [2.3–4.4] versus 2.4 [1.7–3.4] P =0.01) compared with the clopidogrel group. A total of 88 patients underwent percutaneous coronary intervention (PCI 45 ticagrelor, 43 clopidogrel). The ticagrelor group had lower post-PCI index of microcirculatory resistance (22.0 [15.0–29.0] versus 27.0 [18.5–47.5] P =0.02) and higher post-PCI resistive reserve ratio (3.0 [1.8–3.8] versus 1.8 [1.5–3.4] P =0.006) compared with the clopidogrel group. The coronary flow reserve was not significantly different between the 2 groups at baseline or post-PCI. No between-group differences were seen in any of the indices in the non-infarct-related artery. In non–ST-segment–elevation acute coronary syndrome patients, ticagrelor significantly improved coronary microvascular function before and after PCI compared with clopidogrel. URL: www.anzctr.org.au Unique identifier: ACTRN12618001610224.
Publisher: Elsevier BV
Date: 04-2013
DOI: 10.1016/J.AHJ.2012.12.023
Abstract: During percutaneous coronary intervention (PCI) performed in the emergent setting of ST-segment elevation myocardial infarction (STEMI), uncertainty about patients' ability to comply with 12 months dual antiplatelet therapy after drug-eluting stenting is common, and thus, selective bare-metal stent (BMS) deployment could be an attractive strategy if this achieved low target vessel revascularization (TVR) rates in large infarct-related arteries (IRAs) (≥3.5 mm). To evaluate this hypothesis, among 1,282 patients with STEMI who underwent PCI during their initial hospitalization, we studied 1,059 patients (83%) who received BMS, of whom 512 (48%) had large IRAs ≥3.5 mm in diameter, 333 (31%) had IRAs 3 to 3.49 mm, and 214 (20%) had IRAs <3 mm. At 1 year, TVR rate in patients with BMS was 5.8% (2.2% with large BMS [≥3.5 mm], 9.2% with BMS 3-3.49 mm [intermediate], and 9.0% with BMS <3.0 mm [small], P < .001). The rates of death/reinfarction among patients with large BMS compared with intermediate BMS or small BMS were lower (6.6% vs 11.7% vs 9.0%, P = .042). Among patients who received BMS, the independent predictors of TVR at 1 year were the following: vessel diameter <3.5 mm (odds ratio [OR] 4.39 [95% CI 2.24-8.60], P < .001), proximal left anterior descending coronary artery lesions (OR 1.89 [95% CI 1.08-3.31], P = .027), hypertension (OR 2.01 [95% CI 1.17-3.438], P = .011), and prior PCI (OR 3.46 [95% CI 1.21-9.85], P = .02). The predictors of death/myocardial infarction at 1 year were pre-PCI cardiogenic shock (OR 8.16 [95% CI 4.16-16.01], P < .001), age ≥65 years (OR 2.63 [95% CI 1.58-4.39], P < .001), left anterior descending coronary artery culprit lesions (OR 1.95 [95% CI 1.19-3.21], P = .008), female gender (OR 1.93 [95% CI 1.12-3.32], P = .019), and American College of Cardiology/American Heart Association lesion classes B2 and C (OR 2.17 [95% CI 1.10-4.27], P = .026). Bare-metal stent deployment in STEMI patients with IRAs ≥3.5 mm was associated with low rates of TVR. Their use in this setting warrants comparison with second-generation drug-eluting stenting deployment in future randomized clinical trials.
Publisher: Wiley
Date: 09-2021
DOI: 10.1002/CCD.29245
Publisher: Elsevier BV
Date: 10-2018
Publisher: SAGE Publications
Date: 04-2015
Abstract: The aim of this study was to assess the coronary heart disease risk factors in the Asian Indian community living in a large city in Australia. A cross-sectional survey was conducted at the Australia India Friendship Fair in 2010. All people of Asian Indian descent who attended the Fair and visited the health promotion stall were eligible to participate in the study if they self-identified as of Asian Indian origin, were aged between 18 and 80 years, and were able to speak English. Blood pressure, blood glucose, waist circumference, height, and weight were measured by a health professional. Smoking, cholesterol levels, and physical activity status were obtained through self-reports. Data were analyzed for 169 participants. More than a third of the participants under the age of 65 years had high blood pressure. Prevalence of diabetes (16%) and obesity (61%) was significantly higher compared with the national average. Ten women identified themselves as smokers. Physical activity patterns were similar to that of the wider Australian population. The study has provided a platform for raising awareness among nurses and promoting advocacy on the cardiovascular risk among Asian Indians. Strategies involving Asian Indian nurses and other Asian Indian health professionals as well as support from the private and public sectors can assist in the reduction of the coronary heart disease risk factors among this extremely susceptible population.
Publisher: Public Library of Science (PLoS)
Date: 20-07-2017
Publisher: Springer Science and Business Media LLC
Date: 11-01-2019
Publisher: Emerald
Date: 06-07-2020
DOI: 10.1108/JICA-04-2020-0018
Abstract: This study has demonstrated how technology may contribute to integrated care solutions by comparing conventional ward telemetry (WT) to a wearable ECG monitor (S-Patch) to detect atrial fibrillation (AF) in patients with stroke. 51 patients admitted for stroke workup were recruited across two major tertiary centres to compare WT monitoring for two days versus S-Patch for four days in the detection of AF. The efficacy to detect AF using both technologies was assessed via data extractions and medical officer review. A matrix was used to measure nursing atient satisfaction and setup/resource times were assessed. Patients (84–94%) and nursing staff (75–95%) preferred the S-Patch wearable technology. Non-parametric tests indicated significant time saving for removal of S-Patch versus WT [2.2 min vs 5.1 min ( p = 0.00)]. Efficacy of S-Patch to detect AF following medical officer review was greater than WT, with seven patients identified with AF by S-Patch versus one using WT. The S-patch had a false positive rate of 78%. The S-Patch is sensitive in the detection of AF however, it showed a high false-positive rate with automated reporting. This study has provided insight into the details of delivery of integrated healthcare using wearable technology. The technology and partnership were the first-in-kind in Australia. The S-Patch had a higher detection rate of AF compared to WT which allows patients to be anti-coagulated appropriately for the prevention of further stroke. The results of this study will be ideally placed to inform future policy in integrated healthcare using new technologies.
Publisher: Elsevier BV
Date: 10-2016
DOI: 10.1016/J.AHJ.2016.05.020
Abstract: We sought to determine the relationship of adverse diastolic remodeling (ie, worsening diastolic or persistent restrictive filling) with infarct scar characteristics, and to evaluate its prognostic value after ST-segment elevation myocardial infarction (STEMI). Severe diastolic dysfunction (restrictive filling) has known prognostic value post STEMI. However, ongoing left ventricular (LV) remodeling post STEMI may alter diastolic function even if less severe. There were 218 prospectively recruited STEMI patients with serial echocardiograms (transthoracic echocardiography) and cardiac magnetic resonance imaging (CMR) performed, at a median of 4 days (early) and 55 days (follow-up). LV ejection fraction and infarct characteristics were assessed by CMR, and comprehensive diastolic function assessment including a diastolic grade was evaluated on transthoracic echocardiography. 'Adverse diastolic remodeling' occurred if diastolic function grade either worsened (≥1 grade) between early and follow-up imaging, or remained as persistent restrictive filling at follow-up. Follow-up infarct scar size (IS) predicted adverse diastolic remodeling (area under the curve 0.86) and persistent restrictive filling (area under the curve 0.89). The primary endpoint of major adverse cardiovascular events (MACE) occurred in 48 patients during follow-up (mean, 710±79 days). Kaplan-Meier analysis showed that adverse diastolic remodeling (n=50) and persistent restrictive filling alone (n=33) were significant predictors of MACE (both P<.001). Multivariate Cox analysis, when adjusted for TIMI risk score and CMR IS, microvascular obstruction, and LV ejection fraction, showed adverse diastolic remodeling (HR 3.79, P<.001) was an independent predictor of MACE, as was persistent restrictive filling alone (HR 2.61, P=.019). Larger IS is associated with adverse diastolic remodeling. Following STEMI, adverse diastolic remodeling is a powerful prognostic marker, and identifies a larger group of 'at-risk' patients, than does persistent restrictive filling alone.
Publisher: Elsevier BV
Date: 07-2016
DOI: 10.1016/J.HLC.2016.11.004
Abstract: Detectable levels of high sensitivity (cardiac) troponin T (HsTnT), occur in the majority of patients with stable coronary heart disease (CHD), and often in 'healthy' in iduals. Extreme physical activity may lead to marked elevations in creatine kinase MB and TnT levels. However, whether HsTnT elevations occur commonly after exercise stress testing (EST), and if so, whether this has clinical significance, needs clarification. To determine whether HsTnT levels become elevated after EST (Bruce protocol) to ≥95% of predicted maximum heart rate in presumed healthy subjects without overt CHD, we assayed HsTnT levels for ∼5h post-EST in 105 subjects (median age 37 years). Pre-EST HsTnT levels 14 ng/L, with troponin elevation occurring at least three hours post-EST. Additionally, a detectable ≥ 50% increase in HsTnT levels (4.9→9ng/L) occurred in 28 (27%) of subjects who during EST achieved ≥ 95% of their predicted target heart rate. The median age of the subjects with HsTnT elevations to > 14ng/L post-EST was higher than those without such elevation (42 and 36 years respectively p=0.038). At a median follow-up of 13 months no adverse events were recorded. The current study demonstrates that detectable elevations occur in HsTnT post-EST in 'healthy' subjects without overt CHD. Future studies should evaluate the clinical significance of detectable elevations in post-EST HsTnT with long-term follow-up for adverse cardiac events.
Publisher: Wiley
Date: 19-11-2007
Publisher: Cold Spring Harbor Laboratory
Date: 07-12-2021
DOI: 10.1101/2021.12.05.21267214
Abstract: Heart failure (HF) has become a major cause of morbidity and mortality worldwide. Despite significant improvements in the management of HF, the overall outcomes remain poor. In addition to pharmacotherapy and device therapy, non-pharmacological interventions are needed to mitigate the effects of this illness. The aim of this study was to evaluate the impact of the heart failure outreach program on the rate of mortality, HF hospitalisations and guideline directed medical therapy (GDMT) for HF in South Western Sydney Local Health District (SWSLHD). In this observational, registry based study, adult patients diagnosed with Heart failure with reduced ejection fraction (HFrEF) within the South Western Sydney Local Health District (SWSLHD) and invited to participate in the heart failure outreach service between March 2011 and January 2016 were included in the study. The primary outcome was all-cause mortality. In addition, we examined the rate of optimal medical therapy, HF hospitalisations and the total lengths of stay. A total of 818 patients were included in the study 470 (57.5%) patients were enrolled and 348 (42.5 %) not enrolled into the program. At the end of the follow up period (median 978 days, interquartile range (IQR) 720-1237), the primary outcome of mortality was observed significantly less in the enrolled group (122 (26%) vs. 133 (38.2%), p .001) independently of other variables. In addition, significantly fewer enrolled patients had hospital admissions for HF (16.2% vs. 35.6%, p .001) and reduced median admission days (14.5 days [IQR 8-25] vs 22 [IQR 12-37], p .001). Patients enrolled into the program were much more likely to be on GDMT (76.6% vs 56.6%, p .001). Enrolment in the heart failure outreach program was associated with a significant reduction in mortality as well as a reduction in the frequency and length of hospital admissions. In addition, the rate of GDMT was significantly higher in the enrolled group. With the high prevalence of heart failure, these programs should be considered in the routine management of patients with HFrEF.
Publisher: AMPCo
Date: 23-07-2018
DOI: 10.5694/MJA17.01109
Abstract: To examine whether there are sex differences in the characteristics, management, and clinical outcomes of patients with an ST-elevation myocardial infarction (STEMI). Design, setting: Cohort study analysis of data collected prospectively by the CONCORDANCE acute coronary syndrome registry from 41 Australian hospitals between February 2009 and May 2016. 2898 patients (2183 men, 715 women) with STEMI. Rates of revascularisation (percutaneous coronary intervention [PCI], thrombolysis, coronary artery bypass grafting [CABG]), adjusted for GRACE risk score quartile. timely vascularisation rates major adverse cardiac event rates clinical outcomes and preventive treatments at discharge. The mean age of women with STEMI at presentation was 66.6 years (SD, 14.5 years), of men, 60.5 years (SD, 12.5 years). The proportions of women with hypertension, diabetes, prior stroke, chronic kidney disease, chronic heart failure, or dementia were larger than those of men fewer women had histories of previous coronary artery disease or myocardial infarction, or of prior PCI or CABG. Women were less likely to have undergone coronary angiography (odds ratio, adjusted for GRACE score quartile [aOR], 0.53 95% CI, 0.41-0.69) or revascularisation (aOR, 0.42 95% CI, 0.34-0.52) they were less likely to have received timely revascularisation (aOR, 0.72 95% CI, 0.63-0.83) or primary PCI (aOR, 0.76 95% CI, 0.61-0.95). Six months after admission, the rates of major adverse cardiovascular events (aOR, 2.68 95% CI, 1.76-4.09) and mortality (aOR, 2.17 95% CI, 1.24-3.80) were higher for women. At discharge, significantly fewer women than men received β-blockers, statins, and referrals to cardiac rehabilitation. Women with STEMI are less likely to receive invasive management, revascularisation, or preventive medication at discharge. The reasons for these persistent differences in care require investigation.
Publisher: Elsevier BV
Date: 10-2015
DOI: 10.1016/J.AHJ.2015.06.022
Abstract: Late gadolinium enhancement cardiac magnetic resonance imaging (CMRI) is the current standard for evaluation of myocardial infarct scar size and characteristics. Because post-ST-segment elevation myocardial infarction (STEMI) troponin levels correlate with clinical outcomes, we sought to determine the s ling period for high-sensitivity troponin T (hs-TnT) that would best predict CMRI-measured infarct scar characteristics and left ventricular (LV) function. Among 201 patients with first presentation with STEMI who were prospectively recruited, we measured serial hs-TnT levels at admission, peak, 24 hours, 48 hours, and 72 hours after STEMI. Indexed LV volumes, LV ejection fraction (LVEF) and infarct scar characteristics (scar size, scar heterogeneity, myocardial salvage index, and microvascular obstruction) were evaluated by CMRI at a median of 4 days post-STEMI. Peak and serial hs-TnT levels correlated positively with early indexed LV volumes and infarct scar characteristics, and negatively correlated with myocardial salvage index and LVEF. Both 48- and 72-hour hs-TnT levels similarly predicted "large" total infarct scar size (odds ratios [ORs] 3.08 and 3.53, both P < .001), myocardial salvage index (ORs 1.68 and 2.30, both P < .001), and LVEF <40% (ORs 2.16 and 2.17, both P < .001) on univariate analyses. On multivariate analyses, 48- and 72-hour hs-TnT levels independently predicted large infarct scar size (ORs 2.05 and 2.31, both P < .001), reduced myocardial salvage index (OR 1.39 [P = .031] and OR 1.55 [P = .009]), and LVEF <40% (OR 1.47 [P = .018] and OR 1.43 [P = .026]). All measured hs-TnT levels had a modest association and similar capacity to predict microvascular obstruction. Levels of hs-TnT at 48 and 72 hours, measured during the "plateau phase" post-STEMI, predicted infarct scar size, poor myocardial salvage, and LVEF. These levels also correlated with scar heterogeneity and microvascular obstruction post-STEMI. Since ascertaining peak levels after STEMI is challenging in routine practice, based on the biphasic kinetics of hs-TnT, a measurement at 48 to 72 hours (during the plateau phase) provides a useful and simple method for early evaluation of LV function and infarct scar characteristics.
Publisher: Elsevier BV
Date: 07-2018
DOI: 10.1016/J.HLC.2017.08.005
Abstract: There are continuing bed constraints in percutaneous coronary intervention centres (PCI) so efficient patient triage from referral hospitals is pivotal. To evaluate a strategy of PCI centre (PCIC) bed-sparing we examined return of patients to referral hospitals screened by the RETRIEVE (REverse TRIage EVEnts) criteria and validated its use as a tool for screening suitability for same day transfer of non-ST-elevation acute coronary syndrome (NSTEACS) patients post PCI to their referring non-PCI centre (NPCIC). From May 2008 to May 2011, 433 NSTEACS patients were prospectively screened for suitability for same day transfer back to the referring hospital at the completion of PCI. Of these patients, 212 were excluded from same day transfer using the RETRIEVE criteria and 221 patients met the RETRIEVE criteria and were transferred back to their NPCIC. Over the study period, 218 patients (98.6%) had no major adverse events. The primary endpoint (death, arrhythmia, myocardial infarction, major bleeding event, cerebrovascular accident, major vascular site complication, or requirement for return to the PCIC) was seen in only three transferred patients (1.4%). The RETRIEVE criteria can be used successfully to identify NSTEACS patients suitable for transfer back to NPCIC following PCI. Same day transfer to a NPCIC using the RETRIEVE criteria was associated with very low rates of major complications or repeat transfer and appears to be as safe as routine overnight observation in a PCIC.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-07-2022
Abstract: Patients with suspected ST‐segment–elevation myocardial infarction (STEMI) and cardiac catheterization laboratory nonactivation (CCL‐NA) or cancellation have reportedly similar crude and higher adjusted risks of death compared with those with CCL activation, though reasons for these poor outcomes are not clear. We determined late clinical outcomes among patients with prehospital ECG STEMI criteria who had CCL‐NA compared with those who had CCL activation. We identified consecutive prehospital ECG transmissions between June 2, 2010 to October 6, 2016. Diagnoses according to the Fourth Universal Definition of myocardial infarction (MI), particularly rates of myocardial injury, were adjudicated. The primary outcome was all‐cause death. Secondary outcomes included cardiovascular death/MI/stroke and noncardiovascular death. To explore competing risks, cause‐specific hazard ratios (HRs) were obtained. Among 1033 included ECG transmissions, there were 569 (55%) CCL activations and 464 (45%) CCL‐NAs (1.8% were inappropriate CCL‐NAs). In the CCL activation group, adjudicated index diagnoses included MI (n=534, 94%, of which 99.6% were STEMI and 0.4% non‐STEMI), acute myocardial injury (n=15, 2.6%), and chronic myocardial injury (n=6, 1.1%). In the CCL‐NA group, diagnoses included MI (n=173, 37%, of which 61% were non‐STEMI and 39% STEMI), chronic myocardial injury (n=107, 23%), and acute myocardial injury (n=47, 10%). At 2 years, the risk of all‐cause death was higher in patients who had CCL‐NA compared with CCL activation (23% versus 7.9%, adjusted risk ratio, 1.58, 95% CI, 1.24–2.00), primarily because of an excess in noncardiovascular deaths (adjusted HR, 3.56, 95% CI, 2.07–6.13). There was no significant difference in the adjusted risk for cardiovascular death/MI/stroke between the 2 groups (HR, 1.23, 95% CI, 0.87–1.73). CCL‐NA was not primarily attributable to missed STEMI, but attributable to “masquerading” with high rates of non‐STEMI and myocardial injury. These patients had worse late outcomes than patients who had CCL activation, mainly because of higher rates of noncardiovascular deaths.
Publisher: Springer Science and Business Media LLC
Date: 02-02-2017
No related grants have been discovered for Rohan Rajaratnam.