Left ventricular hypertrophy and cognitive function: a systematic review.

Cognitive impairment is common in patients with hypertension. Left ventricular hypertrophy (LVH) is recognised as a marker of hypertension-related organ damage and is a strong predictor of coronary artery disease, heart failure and stroke. There is evidence that LVH is independently associated with cognitive impairment, even after adjustment for the presence of hypertension. We conducted a systematic review that examined cognitive impairment in adults with LVH. Independent searches were performed in Ovid MEDLINE, Ovid psycInfo and PubMed with the terms left ventricular hypertrophy and cognition. Seventy-three studies were identified when both searches were combined. After limiting the search to studies that were: (1) reported in English; (2) conducted in humans; (3) in adults aged 50 years and older; and (4) investigated the relationship between LVH and cognitive performance, nine papers were included in this systematic review. The majority of studies found an association between LVH and cognitive performance. Inspection of results indicated that individuals with LVH exhibited a lower performance in cognitive tests, when compared to individuals without LVH. Memory and executive functions were the cognitive domains that showed a specific vulnerability to the presence of LVH. A possible mechanism for the relationship between LVH and cognition is the presence of cerebral white matter damage. White matter lesions occur frequently in patients with LVH and may contribute to cognitive dysfunction. Together, the results of this review suggest that memory impairment and executive dysfunction are the cognitive domains that showed a particular association with the presence of LVH.

Clopidogrel, prasugrel or ticagrelor in patients with acute coronary syndromes undergoing percutaneous coronary intervention.

BACKGROUND: Guidelines recommend prasugrel or ticagrelor instead of clopidogrel in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary interventions (PCI). AIM: We sought to describe the trends in uptake of the newer agents and analyse the clinical characteristics and short-term outcomes of patients treated with clopidogrel, prasugrel or ticagrelor. METHODS: We analysed the temporal trends of antiplatelet use since the availability of prasugrel (2009-2013) in patients with ACS from the Melbourne Interventional Group registry. To assess clinical characteristics and outcomes, we included 1850 patients from 2012 to 2013, corresponding to the time all three agents were available. The primary outcome was major adverse cardiovascular events (MACE). The safety end-point was in-hospital bleeding. RESULTS: For the period of 2009-2013, the majority of patients were treated with clopidogrel (72%) compared with prasugrel (14%) or ticagrelor (14%). There was a clear trend towards ticagrelor by the end of 2013. Patients treated with clopidogrel were more likely to present with non-ST-elevation ACS, be older, and have more comorbidities. There was no difference in unadjusted 30-day mortality (0.9 vs 0.5 vs 1.0%, P = 0.76), myocardial infarction (2 vs 1 vs 2%, P = 0.52) or MACE (3 vs 3 vs 4%, P = 0.57) between the three agents. There was no difference in in-hospital bleeding (3 vs 2 vs 2%, P = 0.64). CONCLUSION: Prasugrel and ticagrelor are increasingly used in ACS patients treated with PCI, predominantly in a younger cohort with less comorbidity. Although antiplatelet therapy should still be individualised based on the thrombotic and bleeding risk, our study highlights the safety of the new P2Y12 inhibitors in contemporary Australian practice.

Appropriate use of echocardiography in an Australian regional centre.

BACKGROUND: The 2011 Appropriate Use Criteria (AUC) were developed by the American Society of Echocardiography (ASE) to provide guidance for referring physicians in response to growing concerns about unnecessary transthoracic echocardiogram (TTE) requests. When applied in multiple centres overseas, the rate of inappropriate referrals was as high as 22%. AIM: To assess the applicability of, and the level of adherence to the 2011 AUC in an Australian regional hospital where the AUC have not been tested systematically. METHODS: A retrospective analysis of 1000 inpatient and outpatient TTE referrals was conducted between January 2014 and June 2014 at Bendigo Hospital, a major regional referral hospital. RESULTS: Ninety-eight percent of the TTE referrals were classifiable. The most common indication for ordering TTE was to evaluate symptoms potentially related to a cardiac aetiology. Of the classifiable referrals, 77% were appropriate, 20.3% were inappropriate and 2.7% were uncertain. The most common inappropriate indications were routine surveillance of the left ventricular (LV) function in stable chronic cardiac conditions and routine perioperative evaluation of the LV function with no symptoms or signs of cardiovascular disease. Inappropriate referrals were significantly more frequent in outpatients compared with inpatients (24.4% vs 9.6%, P < 0.001). CONCLUSION: This study provides a novel insight into the ordering of TTEs in regional Australia. In this study, one in five referrals had an inappropriate indication and could be avoided. This may have significant implications for healthcare resources in regional centres, and strategies to reduce inappropriate echocardiography ordering need to be implemented.