Contribution of general medicine to perioperative and consultative care: an Australian metropolitan teaching hospital experience.

Little is known about the contribution of general medicine to perioperative and consultative care in Australia. A descriptive observational study was undertaken at a quaternary institution to evaluate the characteristics of perioperative and nonoperative consultations undertaken by general medicine. Results demonstrated patterns of engagement within a 'traditional' model of perioperative care and highlighted several opportunities for a redesign to a more proactive and collaborative cross-disciplinary model.

Comparison of 2 Smart Watch Algorithms for Detection of Atrial Fibrillation and the Benefit of Clinician Interpretation: SMART WARS Study.

BACKGROUND: Smart watches and wearable technology capable of heart rhythm assessment have increased in use in the general population. The Apple Watch Series 4 (AW4) and KardiaBand (KB) are devices capable of obtaining single-lead electrocardiographic recordings, presenting a novel opportunity for the detection of paroxysmal arrhythmias. OBJECTIVES: The aim of this study was to assess the diagnostic utility of the AW4 and KB in an elderly outpatient population. METHODS: Consecutive recordings were taken from patients attending cardiology outpatient clinic from the AW4 and KB concurrently with 12-lead electrocardiography. Automated diagnoses and blinded single-lead electrocardiographic tracing interpretations by 2 cardiologists were analyzed. Analysis was also conducted to assess the effect of combined device and clinician interpretation. RESULTS: One hundred twenty-five patients were prospectively recruited (mean age 76 ± 7 years, 62% men). The accuracy of the automated rhythm assessment was higher with the KB than the AW4 (74% vs 65%). For the detection of atrial fibrillation, the sensitivity and negative predictive value of the KB were 89% and 97%, respectively, and of the AW4 were 19% and 82%, respectively. Using hybrid automated and clinician interpretation, the overall accuracy of the KB and AW4 was 91% and 87%, respectively. CONCLUSIONS: The KB automated algorithm outperformed the AW4 in its accuracy and sensitivity for detecting atrial fibrillation in the outpatient setting. Clinician assessment of the single-lead electrocardiogram improved accuracy. These findings suggest that although these devices' tracings are of sufficient quality, automated diagnosis alone is not sufficient for making clinical decisions about atrial fibrillation diagnosis and management.

Diabetes in ischaemic stroke in a regional Australian hospital: uncharted territory.

BACKGROUND: Stroke and diabetes mellitus (DM) are significant interrelated healthcare issues but there is a dearth of data on the prevalence of DM among Australia's regional stroke population. AIMS: We aimed to determine the prevalence of DM in stroke patients at a large regional centre, including subanalyses on stroke subtypes, glycaemic control and renal function in ischaemic stroke (IS). METHODS: We conducted a retrospective analysis of all patients (n = 323) with IS or transient ischaemic attack (TIA) admitted to Ballarat Base Hospital from January 2015 to December 2016. Demographic data, cardiovascular risk factors, aetiology/territory of IS, pre-morbid DM status, indicators of glycaemic control and renal impairment were recorded. RESULTS: DM was present in 28.5% of IS and TIA patients, including 4% being newly diagnosed. Among diabetic IS patients, 45.3% had poor glycaemic control (HbA1c ≥7.0%) while 16% had moderate to severe renal impairment (estimated glomerular filtration rate of <30). The majority of IS were partial anterior circulation stroke (53.4%) and cardioembolism was the commonest mechanism (43.5%). We found no significant association between DM and a specific stroke location or mechanism. CONCLUSIONS: Almost one-third of IS/TIA patients had DM, with a significant proportion showing poor glycaemic control. The DM prevalence in our cohort was comparable with reported rates from other developed countries. Although we found no association between DM and a particular stroke type or mechanism, it is likely a reflection of our cohort size. Our study demonstrated that DM, as a significant risk factor in IS, warrants early detection and better management strategies.

Totally Occluded Culprit Coronary Artery in Patients with Non-ST-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention.

The short- and long-term implications of identifying totally occluded culprit coronary arteries (TOCCA) in patients presenting with non-ST-elevation myocardial infarction (NSTEMI) have not been well studied. This study compares clinical characteristics, short- and long-term outcomes of patients with NSTEMI identified with TOCCA to that of patients with non-TOCCA undergoing percutaneous coronary intervention (PCI). We analyzed data from patients with NSTEMI undergoing single-vessel PCI within the Melbourne Interventional Group multi-center registry between 2005 and 2017. Those with TOCCA were compared to those with non-TOCCA. The primary endpoint was 30-day major adverse cardiac events (MACE). Secondary endpoints included 12-month MACE and long-term mortality. A total of 6,829 patients with NSTEMI had single-vessel PCI of which 954 (14%) had TOCCA. Most TOCCA were non-left anterior descending (right coronary artery 39% versus circumflex 33% versus left anterior descending 26%; p <0.001). Cardiogenic shock and left ventricular dysfunction were higher in the TOCCA group, but non-TOCCA patients had more baseline comorbidities. Thirty-day MACE was higher in the TOCCA group (6.7% versus 3.8%; p <0.001). Long-term mortality with an average follow-up of 4.9 years was higher in the non-TOCCA group (12% versus 18%, p <0.01). Multivariable Cox-proportional hazards regression identified TOCCA as an independent predictor of 30-day MACE (HR = 1.93; 95%CI: 1.4-2.6), but not long-term mortality, which was predicted by baseline comorbidities. In conclusion, while patients with NSTEMI with TOCCA undergoing PCI represent a more unstable subgroup early on, long-term outcomes appear more dependent on baseline comorbidities.

Prevalence and risk factors of ischaemic stroke in the young: a regional Australian perspective.

BACKGROUND: There is no universally accepted age cut-off for defining young strokes. AIMS: We aimed to determine, based on the profile of young stroke patients in our regional centre, an appropriate age cut-off for young strokes. METHODS: A retrospective analysis of all ischaemic stroke patients admitted to our centre from 2015 to 2017. We identified 391 ischaemic stroke patients; 30 patients between the ages of ≤50, 40 between 51-60 inclusive and 321 ≥ 61 years of age. We collected data on demographic profiles, risk factors and stroke classification using the Trial of Org 10 172 in Acute Stroke Treatment criteria. RESULTS: We found significant differences between the ≤50 and ≥61 age groups for most of the risk factors and similarities between the 51-60 inclusive and ≥ 61 age groups. At least one of the six risk factors assessed in the study was present in 86.7% of the youngest group, 97.5% of the intermediate age group and 97.2% in the oldest group. In terms of the mechanisms of stroke, the youngest and oldest age groups in our study differed in the prevalence of cryptogenic, cardioembolic and other causes of stroke. The middle and older age groups had similar mechanisms of stroke. CONCLUSIONS: The prevalence of vascular risk factors and mechanisms of stroke likewise differed significantly across age groups. This study suggests that 50 years is an appropriate age cut-off for defining young strokes and reinforces the importance of primary prevention in all age groups.

Ticagrelor-associated ventricular pauses: a case report and literature review.

BACKGROUND: Ticagrelor is an oral anti-platelet agent that is a reversible and direct inhibitor of the adenosine diphosphate P2Y12 receptor. Ticagrelor's brady-arrhythmic potential was investigated in a sub-study of the PLATO trial, which concluded that the effects were transient and not clinically significant beyond the acute initiation phase. Since then, there have been emerging reports of ticagrelor-associated high-degree heart block, requiring drug discontinuation and pacemaker insertion. We present a case of symptomatic ventricular pauses in a patient loaded with ticagrelor post-percutaneous coronary intervention (PCI) for non-ST elevation acute coronary syndrome (NSTEACS) and review the literature relating to ticagrelor and its brady-arrhythmic potential. CASE SUMMARY: A 59-year-old female presented to our hospital with NSTEACS and received an oral load of ticagrelor 180 mg following PCI to her mid-left circumflex coronary artery. Three hours after, four pauses were observed on telemetry over a 20 min period, the longest being 18.5 s in duration. Ticagrelor was ceased and clopidogrel commenced in place. No arrhythmic events were recorded on loop recorder interrogation following ticagrelor discontinuation. DISCUSSION: The exact mechanism of ticagrelor-induced brady-arrhythmia is unclear, although inhibition of adenosine reuptake is proposed as likely due to structural similarities between ticagrelor and adenosine. In the setting of acute coronary syndrome treated with ticagrelor, extracellular adenosine concentrations are amplified by the ischaemic milieu with myocardial adenosine release and blunted cellular reuptake. This leads to enhanced agonism of adenosine A1 receptors, causing negative chronotropy and dromotropy. This case report highlights ticagrelor's brady-arrhythmic potential even in the absence of baseline conduction disease or concurrent confounding medications.