Recovery Rates of Diagnostic Cardiac Procedural Volume in Oceania 1 Year Into COVID-19: The IAEA Non-Invasive Cardiology Protocol Survey on COVID-19 (INCAPS COVID 2).

AIM: The aim of this study was to assess the recovery rates of diagnostic cardiac procedure volumes in the Oceania Region, midway through the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A survey was performed comparing procedure volumes between March 2019 (pre-pandemic), April 2020 (during first wave of COVID-19 pandemic), and April 2021 (1 year into the COVID-19 pandemic). A total of 31 health care facilities within Oceania that perform cardiac diagnostic procedures were surveyed, including a mixture of metropolitan and regional, hospital and outpatient, public and private sites, as well as teaching and non-teaching hospitals. A comparison was made with 549 centres in 96 countries in the rest of the world (RoW) outside of Oceania. The total number and median percentage change in procedure volume were measured between the three timepoints, compared by test type and by facility. RESULTS: A total of 11,902 cardiac diagnostic procedures were performed in Oceania in April 2021 as compared with 11,835 pre-pandemic in March 2019 and 5,986 in April 2020; whereas, in the RoW, 499,079 procedures were performed in April 2021 compared with 497,615 pre-pandemic in March 2019 and 179,014 in April 2020. There was no significant difference in the median recovery rates for total procedure volumes between Oceania (-6%) and the RoW (-3%) (p=0.81). While there was no statistically significant difference in percentage recovery been functional ischaemia testing and anatomical coronary testing in Oceania as compared with the RoW, there was, however, a suggestion of poorer recovery in anatomical coronary testing in Oceania as compared with the RoW (CT coronary angiography -16% in Oceania vs -1% in RoW, and invasive coronary angiography -20% in Oceania vs -9% in RoW). There was no statistically significant difference in recovery rates in procedure volume between metropolitan vs regional (p=0.44), public vs private (p=0.92), hospital vs outpatient (p=0.79), or teaching vs non-teaching centres (p=0.73). CONCLUSIONS: Total cardiology procedure volumes in Oceania normalised 1 year post-pandemic compared to pre-pandemic levels, with no significant difference compared with the RoW and between the different types of health care facilities.

Cardiac Computed Tomography to exclude left atrial appendage thrombus in atrial arrhythmias prior to electrical cardioversion during the COVID-19 pandemic.

Nil.

Multisystem inflammatory syndrome following mild COVID-19 in an unvaccinated Tongan adult.

Multisystem inflammatory syndrome in adults (MIS-A), is a rare post-infectious complication of COVID-19. We describe an illustrative case of MIS-A in an otherwise well, SARS-CoV-2 unvaccinated 25-year-old Tongan man who presented to hospital 30 days after mild COVID-19 illness. We highlight the progression of his illness, including treatment in the Intensive Care Unit (ICU) for cardiogenic shock, and detail temporal evolution of clinical, laboratory and radiographic features of his illness. Clinicians should be alert for possible MIS-A in the weeks after a surge in COVID-19 cases.

Impact of COVID-19 on Diagnostic Cardiac Procedural Volume in Oceania: The IAEA Non-Invasive Cardiology Protocol Survey on COVID-19 (INCAPS COVID).

OBJECTIVES: The INCAPS COVID Oceania study aimed to assess the impact caused by the COVID-19 pandemic on cardiac procedure volume provided in the Oceania region. METHODS: A retrospective survey was performed comparing procedure volumes within March 2019 (pre-COVID-19) with April 2020 (during first wave of COVID-19 pandemic). Sixty-three (63) health care facilities within Oceania that perform cardiac diagnostic procedures were surveyed, including a mixture of metropolitan and regional, hospital and outpatient, public and private sites, and 846 facilities outside of Oceania. The percentage change in procedure volume was measured between March 2019 and April 2020, compared by test type and by facility. RESULTS: In Oceania, the total cardiac diagnostic procedure volume was reduced by 52.2% from March 2019 to April 2020, compared to a reduction of 75.9% seen in the rest of the world (p<0.001). Within Oceania sites, this reduction varied significantly between procedure types, but not between types of health care facility. All procedure types (other than stress cardiac magnetic resonance [CMR] and positron emission tomography [PET]) saw significant reductions in volume over this time period (p<0.001). In Oceania, transthoracic echocardiography (TTE) decreased by 51.6%, transoesophageal echocardiography (TOE) by 74.0%, and stress tests by 65% overall, which was more pronounced for stress electrocardiograph (ECG) (81.8%) and stress echocardiography (76.7%) compared to stress single-photon emission computerised tomography (SPECT) (44.3%). Invasive coronary angiography decreased by 36.7% in Oceania. CONCLUSION: A significant reduction in cardiac diagnostic procedure volume was seen across all facility types in Oceania and was likely a function of recommendations from cardiac societies and directives from government to minimise spread of COVID-19 amongst patients and staff. Longer term evaluation is important to assess for negative patient outcomes which may relate to deferral of usual models of care within cardiology.

ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome): A Study of Cross-System Implementation of a National Clinical Pathway.

BACKGROUND: Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. METHODS: This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation RESULTS: There were 11 529 participants in the preimplementation phase (range, 284-3465) and 19 803 in the postimplementation phase (range, 395-5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%-37.7%) to 18.4% (6.8%-43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3-2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4-3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P=0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. CONCLUSIONS: Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. CLINICAL TRIAL REGISTRATION: URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.

Cardiac Society of Australia and New Zealand Position Statement: Coronary Artery Calcium Scoring.

Coronary Artery Calcium Scoring (CAC) is a non-invasive quantitation of coronary artery calcification using computed tomography (CT). It is a marker of atherosclerotic plaque burden and an independent predictor of future myocardial infarction and mortality. Coronary Artery Calcium Scoring provides incremental risk information beyond traditional risk calculators (eg. Framingham Risk Score). Its use for risk stratification is confined to primary prevention of cardiovascular events, and can be considered as "individualised coronary risk scoring" for those not considered to be of high or low risk. Medical practitioners should carefully counsel patients prior to CAC. Coronary Artery Calcium Scoring should only be undertaken if an alteration in therapy including embarking on pharmacotherapy is being considered based on the test result. Patient Groups to Consider Coronary Calcium Scoring: Patient Groups in Whom Coronary Calcium Scoring Should Not be Considered: Coronary Artery Calcium Scoring is not recommended for patients who are: Interpretation of CAC CAC=0 A zero score confers a very low risk of death, <1% at 10 years. CAC=1-100 Low risk, <10% CAC=101-400 Intermediate risk, 10-20% CAC=101-400 & >75th centile. Moderately high risk, 15-20% CAC >400 High risk, >20% Management Recommendations Based on CAC Optimal diet and lifestyle measures are encouraged in all risk groups and form the basis of primary prevention strategies. Patients with moderately-high or high risk based on CAC score are recommended to receive preventative medical therapy such as aspirin and statins. The evidence for pharmacotherapy is less robust in patients at intermediate levels of CAC 100-400, with modest benefit for aspirin use; though statins may be reasonable if they are above 75th centile. Aspirin and statins are generally not recommended in patients with CAC <100. Repeat CAC Testing In patients with a CAC of 0, a repeat CAC may be considered in 5 years but not sooner. In patients with positive calcium score, routine re-scanning is not currently recommended. However, an annual increase in CAC of >15% or annual increase of CAC >100 units are predictive of future myocardial infarction and mortality. Cost Effectiveness of CAC Based Primary Prevention Recommendations: There is currently no data in Australia and New Zealand that CAC is cost-effective in informing primary prevention decisions. Given the cost of testing is currently borne entirely by the patient, discussion regarding the implications of CAC results should occur before CAC is recommended and undertaken.

The value of CT cardiac angiography and CT calcium score testing in a modern cardiology service in New Zealand: a report of a single centre eight-year experience from 5,237 outpatient procedures.

BACKGROUND: Computed tomographic (CT) cardiac angiography is of increasing value in several areas of patient management in cardiology. We assessed the ability of CT cardiac angiography to effectively 'rule out' severe coronary stenoses in patients presenting with 'atypical' symptoms and/or an equivocal stress test, which offers a new approach to the management of coronary artery disease. We also examined the use of the CT calcium score test in cardiovascular (CVS) risk assessment. METHODS: From a large single centre (Mercy Hospital) in Auckland, using a prospectively acquired, comprehensive database, we audited the entire eight-year experience of 5,169 patients (7/8/06 to 31/1/14) who underwent 5,237 64-slice computed tomographic (CT) cardiac angiogram or CT calcium score tests (GE Lightspeed scanner). RESULTS: From 5,169 patients there were 5,237 CT procedures. The mean patient age was 57 (SD 10) years; 42% patients were female. Of the 3,603 (69%) full CT cardiac angiogram scans, 3,509 (67%) included a calcium score test. One thousand four hundred and eighty-three (28%) of scans were a calcium score test only. Of the 3,603 (69%) full CT cardiac angiogram scans, it was possible to 'rule out' significant coronary atheroma (stenosis ≥50%) in 2,947 (82%) of these procedures. Of the 4,903 (94%) patients who had a CT calcium score test, in whom we could calculate the NZ Framingham-based CVS risk, it was possible to reassign 532 (22%) of these patients who were previously thought to be at 'low risk' to be at a higher CVS risk. CONCLUSION: CT cardiac angiography has become established in the modern management of cardiology patients. It has particular value as a tool to 'rule out' severe coronary stenoses, and as a tool to give a more accurate assessment of CVS risk. It adds significant value to the care of many patients within an established cardiology practice.

Plasma brain natriuretic peptide concentrations in patients with valvular heart disease.

OBJECTIVE: Plasma brain natriuretic peptide (BNP) concentrations predict prognosis in patients with valvular heart disease (VHD), but it is unclear whether this directly relates to disease severity. We assessed the relationship between BNP and echocardiographic measures of disease severity in patients with VHD. METHODS: Plasma BNP concentrations were measured in patients with normal left ventricular (LV) systolic function and isolated VHD (mitral regurgitation (MR), n=33; aortic regurgitation (AR), n=39; aortic stenosis (AS), n=34; mitral stenosis (MS), n=30), and age-matched and sex-matched controls (n=39) immediately prior to exercise stress echocardiography. RESULTS: Compared with controls, patients with VHD had elevated plasma BNP concentrations (MR median 35 (IQR 23-52), AR 34 (22-45), AS 31 (22-60), MS 58 (34-90); controls 24 (16-33) pg/mL; p<0.01 for all). LV end diastolic volume index varied by valve lesion; (MR (mean 77±14), AR (91±28), AS (50±17), MS (43±11), controls (52±13) mL/m(2); p<0.0001). There were no associations between LV volume and BNP. Left atrial (LA) area index varied (MR (18±4 cm(2)/m(2)), AR (12±2), AS (11±3), MS (19±6), controls (11±2); p<0.0001), but correlated with plasma BNP concentrations: MR (r=0.42, p=0.02), MS (r=0.86, p<0.0001), AR (r=0.53, p=0.001), AS (r=0.52, p=0.002). Higher plasma BNP concentrations were associated with increased pulmonary artery pressure and reduced exercise capacity. Despite adverse cardiac remodelling, 81 (60%) patients had a BNP concentration within the normal range. CONCLUSIONS: Despite LV remodelling, plasma BNP concentrations are often normal in patients with VHD. Conversely, mild elevations of BNP occur with LA dilatation in the presence of normal LV. Plasma BNP concentrations should be interpreted with caution when assessing patients with VHD.

Evaluation of Previously Cannulated Radial Arteries as Patent Coronary Artery Bypass Conduits.

In coronary artery bypass grafting, good-quality conduits are needed to maximize the potential for long-term patency. Revascularization has traditionally been achieved with use of the saphenous vein and the internal thoracic arteries. In recent years, total arterial revascularization with use of the radial arteries has been promoted. Meanwhile, use of the transradial approach for coronary angiography has also increased. The long-term effects of previous cannulation in radial artery bypass grafts are not known. Therefore, we used multidetector computed tomographic angiography to investigate radial-artery graft patency in a small series of patients who had undergone transradial angiography. We found a high patency rate, and we discuss those findings here.

Exercise stress echocardiography in patients with valvular heart disease.

Stress echocardiography is recommended for the assessment of asymptomatic patients with severe valvular heart disease (VHD) when there is discrepancy between symptoms and resting markers of severity. The aim of this study is to determine the prognostic value of exercise stress echocardiography in patients with common valve lesions. One hundred and fifteen patients with VHD (aortic stenosis (n=28); aortic regurgitation (n=35); mitral regurgitation, (n=26); mitral stenosis (n=26)), and age- and sex-matched controls (n=39) with normal ejection fraction underwent exercise stress echocardiography. The primary endpoint was a composite of death or hospitalization for heart failure. Asymptomatic VHD patients had lower exercise capacity than controls and 37% of patients achieved <85% of their predicted metabolic equivalents (METS). There were three deaths and four hospital admissions, and 24 patients underwent surgery during follow-up. An abnormal stress echocardiogram (METS <5, blood pressure rise <20 mmHg, or pulmonary artery pressure post exercise >60 mmHg) was associated with an increased risk of death or hospital admission (14% vs 1%, P<0.0001). The assessment of contractile reserve did not offer additional predictive value. In conclusion, an abnormal stress echocardiogram is associated with death and hospitalization with heart failure at 2 years. Stress echocardiography should be considered as part of the routine follow-up of all asymptomatic patients with VHD.

Two causes of ventricular tachycardia in a 26 year-old male.

We present the case of a 26 year-old man who presented to hospital with monomorphic ventricular tachycardia (VT) at a rate of 170bpm after exercising on a treadmill. Multimodality imaging with transthoracic echocardiogram (TTE), cardiac magnetic resonance imaging (CMRI) and computed tomography coronary angiogram (CTCA) demonstrated two causes for ventricular tachycardia; hypertrophic cardiomyopathy (HCM) and an anomalous right coronary artery (RCA) arising from the left coronary sinus, with a potentially malignant interarterial course. Both conditions can be associated with sudden cardiac death (SCD). We discuss the management dilemmas in this unique patient.

Renal denervation for resistant hypertension using an irrigated radiofrequency balloon: 12-month results from the Renal Hypertension Ablation System (RHAS) trial.

AIMS: Renal denervation using the point-by-point application of radiofrequency energy delivered by the first-generation Symplicity system is effective in lowering office blood pressure but may be time-consuming. The OneShot Renal Denervation System with a balloon-mounted spiral electrode potentially shortens and simplifies the procedure. This study is a hypothesis-generating first-in-human study to assess feasibility, and to provide preliminary efficacy and safety data. METHODS AND RESULTS: Eligible patients had a baseline office systolic blood pressure ≥160 mmHg (or ≥150 mmHg for diabetics) and were on two or more antihypertensive medications. Nine patients were enrolled. The primary endpoint, the insertion of the OneShot balloon into each renal artery and the delivery of radiofrequency energy, was achieved in 8/9 (89%) of patients. The one failure (the first patient) was due to generator high-impedance safety shut-off threshold set too low for humans. Adverse events were minor. No patient developed renal artery stenosis. Baseline BP was 185.67 ± 18.7 mmHg and the reductions at 1, 3, 6 and 12 months were 30.1 ± 13.6 (p=0.0004), 34.2 ± 20.2 (p=0.002), 33.6 ± 32.2 (p=0.021) and 30.6 ± 22.0 (p=0.019). CONCLUSIONS: The OneShot renal denervation system successfully delivered radiofrequency energy to the renal arteries in a short and straightforward procedure. Australian New Zealand Clinical Trials Registry - URL: anzctr.org.au. Trial identification: ACTRN12611000987965.

First-in-human use of the OneShot™ renal denervation system from Covidien.

Percutaneous transcatheter renal sympathetic denervation (RDN) is a promising treatment for refractory hypertension (HT). RDN was found in one series of clinical studies to reduce systolic blood pressure (SBP) by as much as a mean of 30 mmHg with 85% of subjects experiencing sustained reductions of 10 mm or more out to two years after RDN. This degree of blood pressure reduction may reduce stroke and myocardial infarction rates and is anticipated to translate into improved life expectancy. The lowering of blood pressure by RDN has been shown to improve glycaemic control and reverse left ventricular hypertrophy. Beneficial effects on renal function, sleep apnoea and heart failure are suggested as well. This report describes the first patient treated using the OneShot™ Renal Denervation System (formerly Maya Medical now Covidien, Campbell, CA, USA).

High calcium scores in patients with a low Framingham risk of cardiovascular (CVS) disease: implications for more accurate CVS risk assessment in New Zealand.

AIMS: New Zealand (NZ) patients are recommended to undergo an 'adjusted' Framingham score to assess their cardiovascular (CVS) risk. The current (2009) NZ CVS Risk Guideline does not recommend the use of a 'calcium score' as an additional risk tool, although it has been shown to be powerfully predictive of CVS events above the predictive power of traditional Framingham risk factors. Calcium scores of >400 are very strongly predictive of a future CVS event and give direct evidence of atheromatous disease in the coronary circulation. Identification of people with advanced, premature coronary atheroma would allow early treatment of those who may benefit from more vigorous preventative strategies, including statin therapy. METHODS: Using a prospectively acquired, comprehensive database we audited the first 1000 patients (7 August 2006 to 28 November 2008) to undergo a 64-slice computed tomographic (CT) cardiac angiogram (GE Light Speed), which included a scan for a 'calcium score', at the Mercy Hospital, Auckland. We excluded 58 patients who had experienced one or more of a previous myocardial infarction (MI) (n=21), coronary artery bypass graft (CABG) surgery (n=15), percutaneous coronary intervention (PCI) (n=13) or stroke (n=21) and who therefore already had definite evidence of vascular disease and would be automatically placed in a high risk strata. We calculated each patient's Framingham risk from the original 'Anderson' equation, used by the 1996 NZ CVS risk Guideline, and the 'adjusted' Framingham 5-year CVS risk using the NZ Guidelines Group 2003/2009 recommendations, and then compared this with the observed calcium scores. RESULTS: The mean patient age was 56 (SD 9) years; 364 (39%) patients were female, 82% patients were Caucasian. 41% were current (4.6%) or previous (36%) cigarette smokers, 35% had a history of hypertension, 44% hyperlipidaemia and 5.6% had diabetes mellitus. The percentage of patients at 'low' 5-Year CVS risk (0-10% 5-year risk), using the 1996 and 2003/2009 guideline methods, was 78% and 58% respectively. Of patients in these Framingham 'low-risk' groups, 10% and 8.8% had a calcium score of >400 Agatston units, indicating that they were actually at very high CVS risk, and 203 (28%) and 147 (27%) respectively had a calcium score of >100 Agatston units, indicating that they were actually at 'high risk' and not 'low risk'. CONCLUSION: Approximately 10% to 27% of patients with a low CVS risk as assessed by the established Framingham equation have a markedly increased calcium score and hence a significantly increased risk of a CVS event. Currently promoted methods of risk assessment may be inadvertently, falsely re-assuring these patients. Clinicians managing patients may consider a calcium score as an additional tool to the standard risk assessment strategies.

Prognostic value of CT coronary angiography in diabetic and non-diabetic subjects with suspected CAD: importance of presenting symptoms.

AIM: To assess the prognostic relevance of 64-slice computed tomography coronary angiography (CT-CA) and symptoms in diabetics and non-diabetics referred for cardiac evaluation. METHODS: We followed 210 patients with diabetes type 2 (DM) and 203 non-diabetic patients referred for CT-CA for ruling out coronary artery disease (CAD). Patients were without known history of CAD and were divided into four categories on the basis of symptoms at presentation (none, atypical angina, typical angina and dyspnoea). Clinical end points were major cardiac events (MACE): cardiac-related death, non-fatal myocardial infarction, unstable angina and cardiac revascularizations. Cox proportional hazard models, with and without adjustment for risk factors and multiplicative interaction term (obstructive CAD × DM), were developed to predict outcome. RESULTS: DM patients with dyspnoea or who were asymptomatic showed a higher prevalence of obstructive CAD than non-diabetics (p ≤ 0.01). At mean follow-up of 20.4 months, DM patients had worse cardiac event-free survival in comparison with non-DM patients (90% vs. 81%, p = 0.02). In multivariate analysis, CT-CA evidence of obstructive CAD (in DM patients: HR: 6.4; 95% CI: 2.3-17.5; p < 0.001; in non-DM patients: HR: 7.4; 95% CI: 2.1-26.7; p = 0.002) and the presence of typical angina (in DM patients: HR: 2.9; 95% CI: 1.3-6.3; p = 0.007; in non-DM patients: HR: 2.7; 95% CI: 1.1-7.1; p = 0.03) were independent predictors of MACE in both groups. Furthermore, other independent outcome predictors included dyspnoea (HR: 3.8; 95% CI: 1.7-8.5; p = 0.001), the number of segments with any CAD (HR: 1.1; 95% CI: 1.001-1.2; p = 0.04) in DM patients and coronary calcium score >100 in non-DM patients (HR: 5.6; 95% CI: 1.4-21.5; p = 0.01). In Cox regression analysis of the overall population, interaction term obstructive CAD × DM resulted in non-significance. CONCLUSIONS: Among DM patients, dyspnoea carried a high event risk with a MACE rate four times higher. CT-CA findings were strongly predictive of outcome and proved valuable for further risk stratification.

Magnetic resonance assessment of left ventricular volumes and mass using a single-breath-hold 3D k-t BLAST cine b-SSFP in comparison with multiple-breath-hold 2D cine b-SSFP.

OBJECTIVE: To assess the feasibility of single-breath-hold three-dimensional cine b-SSFP (balanced steady-state free precession gradient echo) sequence (3D-cine), accelerated with k-t BLAST (broad-use linear acquisition speed-up technique), compared with multiple-breath-hold 2D cine b-SSFP (2D-cine) sequence for assessment of left ventricular (LV) function. METHODS: Imaging was performed using 1.5-T MRI (Achieva, Philips, The Netherlands) in 46 patients with different cardiac diseases. Global functional parameters, LV mass, imaging time and reporting time were evaluated and compared in each patient. RESULTS: Functional parameters and mass were significantly different in the two sequences [3D end-diastolic volume (EDV) = 129 ± 44 ml vs 2D EDV = 134 ± 49 ml; 3D end-systolic volume (ESV) = 77 ± 44 ml vs 2D ESV = 73 ± 50 ml; 3D ejection fraction (EF) = 43 ± 15% vs 2D EF = 48 ± 15%; p < 0.05], although an excellent correlation was found for LV EF (r = 0.99). Bland-Altman analysis showed small confidence intervals with no interactions on volumes (EF limits of agreement = 2.7; 7.6; mean bias 5%). Imaging time was significantly lower for 3D-cine sequence (18 ± 1 s vs 95 ± 23 s; p < 0.05), although reporting time was significantly longer for the 3D-cine sequence (29 ± 7 min vs 8 ± 3 min; p < 0.05). CONCLUSIONS: A 3D-cine sequence can be advocated as an alternative to 2D-cine sequence for LV EF assessment in patients for whom shorter imaging time is desirable.