In Hospital Outcomes for High-Risk Percutaneous Coronary Intervention (PCI) in Patients Referred From a Rural Centre to Metropolitan Sites.

BACKGROUND: Cardiac Society of Australia and New Zealand (CSANZ) guidelines recommend elective high-risk percutaneous coronary intervention (PCI) is not performed in sites greater than 1 hour from cardiac surgery. METHODS: In hospital outcomes for all patients from Orange Health Service (OHS) from January 2017 to January 2020 who were transferred electively to tertiary centres in Sydney for high risk PCI were examined. RESULTS: One hundred and fourteen (114) patients were identified, with 1,259 PCIs performed at OHS over the same period without transfer. The mean age of these 114 patients was 71 years, with 74.6% male. Receiving hospitals were Royal Prince Alfred Hospital, Sydney, NSW (66.7%), Concord Repatriation General Hospital, Concord, NSW (19.3%) and Strathfield Private Hospital, Strathfield, NSW (14%). The definition of high risk and indication for transfer included at least one of: moderate or greater calcification of the target lesion or proximal segment (34%), single or multiple target lesions that in aggregate jeopardised over 50% of remaining viable myocardium (27%), degenerated saphenous vein grafts (14.8%), chronic total occlusions (7.0%) and severe left ventricular (LV) impairment (3.9%). American Heart Society/American College of Cardiology (AHA/ACC) lesion types were A (1%), B1 (4.2%), B2 (40.2%), and C (54.6%). PCI was performed via the femoral route in 96.2%. The mean procedure duration was 72 minutes, mean combined fluoroscopy time was 19 minutes and mean radiation dose as defined by Reference Air Kerma was 1,630 mGy. Complications occurred in 13 patients and were: acute vessel dissection requiring stenting (4), perforation (2), acute vessel closure (4), puncture site related (1), and life-threatening arrhythmia (2). There were no cases of emergent coronary artery bypass graft (CABG) or death. CONCLUSION: This contemporary cohort of high-risk patients transferred electively from a regional PCI centre to a tertiary cardiac unit underwent lengthy PCI procedures, with high radiation doses, and a modest rate of peri-procedural complications, but had otherwise excellent procedural and clinical outcomes.

Cardiovascular disease and COVID-19: Australian and New Zealand consensus statement.

INTRODUCTION: The coronavirus 2019 disease (COVID-19) pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Pre-existing cardiovascular disease (CVD) increases the morbidity and mortality of COVID-19, and COVID-19 itself causes serious cardiac sequelae. Strategies to minimise the risk of viral transmission to health care workers and uninfected cardiac patients while prioritising high quality cardiac care are urgently needed. We conducted a rapid literature appraisal and review of key documents identified by the Cardiac Society of Australia and New Zealand Board and Council members, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, and key cardiology, surgical and public health opinion leaders. MAIN RECOMMENDATIONS: Common acute cardiac manifestations of COVID-19 include left ventricular dysfunction, heart failure, arrhythmias and acute coronary syndromes. The presence of underlying CVD confers a five- to tenfold higher case fatality rate with COVID-19 disease. Special precautions are needed to avoid viral transmission to this population at risk. Adaptive health care delivery models and resource allocation are required throughout the health care system to address this need. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: Cardiovascular health services and cardiovascular health care providers need to recognise the increased risk of COVID-19 among CVD patients, upskill in the management of COVID-19 cardiac manifestations, and reorganise and innovate in service delivery models to meet demands. This consensus statement, endorsed by the Cardiac Society of Australia and New Zealand, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, the National Heart Foundation of Australia and the High Blood Pressure Research Council of Australia summarises important issues and proposes practical approaches to cardiovascular health care delivery to patients with and without SARS-CoV-2 infection.

Rural and Remote Cardiology During the COVID-19 Pandemic: Cardiac Society of Australia and New Zealand (CSANZ) Consensus Statement.

THE CHALLENGES: Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors. The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations, and people with known CVD have increased morbidity and mortality from coronavirus disease 2019 (COVID-19). In addition, COVID-19 is associated with serious cardiac manifestations, potentially placing additional demand on limited regional services at a time of diminished visiting metropolitan support with restricted travel. Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity. Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic. MAIN RECOMMENDATIONS: Health districts, cardiologists and government agencies need to minimise impacts on the already vulnerable cardiovascular health of regional and remote Australians and New Zealanders throughout the COVID-19 pandemic. Changes in management should include.

COVID-19 - Does This Disease Kill Due to Imbalance of the Renin Angiotensin System (RAS) Caused by Genetic and Gender Differences in the Response to Viral ACE 2 Attack?

Debate continues in the medical literature on the role of the renin angiotensin system (RAS) in Coronavirus disease 2019 (COVID-19) pathophysiology and the implications for the use of cardiovascular drugs acting on the RAS. Could these drugs - which include angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptors blockers (ARBs) - be harmful or potential key therapeutic agents in COVID-19? And, could potentially helpful measures be available and in plain view on the pharmacy shelf?

A preliminary study of spiritual self-schema (3-S(+)) therapy for reducing impulsivity in HIV-positive drug users.

The purpose of this study was twofold. First, pretreatment correlations are presented among impulsivity, intoxicant use, HIV risk behavior, spirituality, and motivation in a sample of 38 HIV-positive drug users. Second, treatment outcomes are presented from a preliminary study of spiritual self-schema (3-S(+)) therapy - a manual-guided psychotherapy integrating cognitive and Buddhist psychologies - for increasing motivation for abstinence, HIV prevention, and medication adherence. Impulsivity was negatively correlated with spiritual practices and motivation for recovery, and was positively related to intoxicant use and HIV risk behavior. Relative to a standard care comparison condition, patients completing 3-S(+) therapy reported greater decreases in impulsivity and intoxicant use, and greater increases in spiritual practices and motivation for abstinence, HIV prevention, and medication adherence.

Reflections by inner-city drug users on a Buddhist-based spirituality-focused therapy: a qualitative study.

A manual-guided, spirituality-focused intervention--spiritual self-schema (3-S) therapy--for the treatment of addiction and HIV-risk behavior was developed as part of a Stage I behavioral therapies development project. It is theoretically grounded in cognitive and Buddhist psychologies and may be suitable for individuals of diverse faiths. The therapy development process began with focus groups to assess addicted clients' perceived need for a spirituality-focused intervention. The therapy was then codified in manual format, and a controlled clinical trial was conducted. Here the authors report on inner-city, methadone-maintained clients' personal experiences that were recorded in semistructured interviews following completion of the therapy. Findings from this qualitative study support the value of integrating spirituality-focused interventions into addiction treatment for the purpose of increasing motivation for drug abstinence and HIV prevention.

Potent and selective xanthine-based inhibitors of phosphodiesterase 5.

Inhibitors of PDE5 are useful therapeutic agents for treatment of erectile dysfunction. A series of novel xanthine derivatives has been identified as potent inhibitors of PDE5, with good levels of selectivity against other PDE isoforms, including PDE6. Studies in the dog indicate excellent oral bioavailability for compound 21.

Acupuncture and spirituality-focused group therapy for the treatment of HIV-positive drug users: a preliminary study.

In this study, 40 HIV-seropositive, cocaine abusing, methadone maintained drug users were randomized to either the standard five-needle National Acupuncture Detoxification Association (NADA) protocol or to a reduced, escalating dose (one to three needle) protocol. In addition to receiving their assigned acupuncture treatments, the last 15 patients also received a spirituality-focused group therapy intervention. Acupuncture treatments were offered five days per week for eight weeks. Urine samples were collected twice weekly and were analyzed for the presence of cocaine and heroin. Depression and anxiety were assessed pre- and post-treatment. Results showed no difference between the two acupuncture conditions on the number of weeks in which urine samples tested negative for illicit opiate and cocaine use. However, patients who received the spirituality-focused group therapy in addition to their assigned acupuncture treatment were abstinent from heroin and cocaine for significantly longer, and had greater reductions in depression and anxiety than did those patients not receiving spirituality-focused psychotherapy. These preliminary findings suggest that acupuncture and a spirituality-focused psychotherapy may be a synergistic combination worthwhile investigating in larger scale, controlled studies.

Spiritual beliefs, world assumptions, and HIV risk behavior among heroin and cocaine users.

The relationship between spirituality and HIV risk behavior in a sample of 34 inner-city cocaine-using methadone-maintained patients was examined. Spirituality was operationally defined in terms of "life meaningfulness" and included the Santa Clara Strength of Religious Faith (T. G. Plante & M. T. Boccaccini, 1997b) and the World Assumptions Scale (R. Janoff-Bulman, 1989; assessing benevolence, meaningfulness, and worthiness of the self). Hierarchical multiple regression analyses of self-reported drug- and sex-related risk behavior were conducted with sex and race entered as control variables. The full models accounted for 23% and 42% of the variance in drug- and sex-related risk behavior, respectively. Strength of spiritual/religious faith (B = .37) and belief in a benevolent (beta = .50) and meaningful (beta = .46) world were independent predictors of sex-related, but not drug-related, HIV preventive behavior.

Tolerability of carvedilol in patients with heart failure and concomitant chronic obstructive pulmonary disease or asthma.

BACKGROUND: A substantial proportion of the population with congestive heart failure (CHF) has concomitant airway disease. Little information exists on the tolerability of carvedilol in patients with chronic obstructive pulmonary disease (COPD). In this study, we assessed the tolerability and efficacy of carvedilol in patients with CHF and concomitant COPD or asthma. METHODS: Between 1996 and 2000, a total of 487 patients began receiving open-label carvedilol. Forty-three (9%) had COPD (n = 31) or asthma (n = 12). Spirometry supported clinical diagnosis in all, and full pulmonary function testing supported diagnosis in 71%. Sixty percent began carvedilol therapy in the hospital and underwent measurement of peak expiratory flow rates (PEFR) before and after dosing. RESULTS: In patients with COPD, mean forced expiratory volume in one second (FEV(1)) was 62% +/- 13% predicted, reversibility was 4% +/- 4% with bronchodilators, and FEV(1)/FVC was 62% +/- 8%. Mean PEFR was 325 +/- 115 liter/min before the dose and increased by 17% 2 hours after the carvedilol dose (p = 0.04). In patients with asthma, mean FEV(1) was 80% +/- 17% predicted, reversibility was 13% +/- 7%, and FEV(1)/FVC was 74% +/- 11%. Mean PEFR was 407 +/- 161 liter/min before the dose with no significant change 2 hours after the dose. Carvedilol was introduced safely in 84% of patients with COPD, with only 1 patient withdrawn from therapy for wheezing. In contrast, only 50% of patients with asthma tolerated carvedilol. Survival at 2.5 years was 72%. In survivors, left ventricular end-diastolic diameter decreased from 76 +/- 11 mm to 72 +/- 14 mm (p = 0.01), left ventricular end-systolic diameter decreased from 65 +/- 13 mm to 60 +/- 15 mm (p = 0.01), and fractional shortening increased from 14% +/- 7% to 17% +/- 7% (p = 0.05) at 12 months. CONCLUSIONS: Patients with CHF and COPD tolerated carvedilol well with no significant reversible airflow limitation, but patients with CHF and asthma tolerated carvedilol poorly. The effect of carvedilol on left ventricular dimensions and function in patients with concomitant airway diseases was similar to that seen in our general group of patients. Asthma remains a contraindication to beta-blockade.

8-Aryl xanthines potent inhibitors of phosphodiesterase 5.

In clinical studies, several inhibitors of phosphodiesterase 5 (PDE5) have demonstrated utility in the treatment of erectile dysfunction. We describe herein a series of 8-aryl xanthine derivatives which function as potent PDE5 inhibitors with, in many cases, high levels of selectivity versus other PDE isoforms.