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Spontaneous coronary artery dissection (SCAD) is an under-recognised cause of acute coronary syndrome (ACS) with a strong female predominance. There are currently limited prospective studies and no randomised controlled trials that inform on SCAD's best clinical care. Little is also known about predictors of acute SCAD deterioration or recurrence. We describe the study design of a multi-centre prospective and historical cohort study recruiting patients with SCAD across 15-20 sites in Australia/New Zealand (NZ). The primary aim is to describe the clinical presentation, management and outcomes along with predictors of acute deterioration and recurrence in a large Australian/NZ SCAD cohort, with international data pooling.Consented patients diagnosed with SCAD during a hospital admission for an ACS will be prospectively followed at 30 days then yearly, for up to 5 years. Each recruiting site will also retrospectively identify historical cases of SCAD from the proceeding 10 years, with a waiver of consent. For historical cases, data will be collected in a de-identified manner with date of last follow-up or death obtained from the medical records. All cases undergo core laboratory adjudication of coronary angiography and any accompanying imaging to confirm SCAD diagnosis. The primary endpoint will be occurrence of major adverse cardiovascular events; a composite of all-cause mortality, recurrent myocardial infarction (including SCAD recurrence), stroke/transient ischaemic attack, heart failure, cardiogenic shock, cardiac arrest/ventricular arrhythmia, heart transplantation and, repeat/unplanned revascularisation. Secondary endpoints will include each individual primary outcome as well as acute SCAD extension and quality of life/Seattle Angina Score in prospectively recruited participants. Endpoints will be assessed at the end of the hospital admission and at 30-days, 1 year, and median long-term follow-up.Multicentre ethics approval has been granted from the Western Sydney Local Health District Human Research Ethics Committee (2021/ETH00040).The analysed results will be published in peer-reviewed journals on completion of the historical data collection and then on completion of the prospective data collection.The ANZ-SCAD registry has been prospectively registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12621000824864).

BACKGROUND: Countries who suffered large COVID-19 outbreaks reported a decrease in acute coronary syndrome (ACS) presentations and percutaneous coronary intervention (PCI). The impact of the pandemic in countries like Australia, with relatively small outbreaks yet significant social restrictions, is relatively unknown. There is also limited and conflicting data regarding the impact on clinical outcomes, symptom-to-door time (STDT) and door-to-balloon time (DTBT). METHODS: Consecutive ACS patients treated with PCI were prospectively recruited from a tertiary hospital network in Melbourne, Australia. The pre-pandemic period (11 March 2019-10 March 2020) was compared to the pandemic period (11 March 2020-10 May 2020) using an interrupted time series analysis with a primary endpoint of number PCI-treated ACS per day. Secondary endpoints included STDT, DTBT, total mortality and major adverse cardiac events (MACE). RESULTS: A total 984 ACS patients (14.8% during the pandemic period) received PCI. Mean number of PCI-treated ACS per day did not differ between the two periods (2.3 vs 2.4, p=0.61) with no difference in STDT [+51.3 mins, 95% confidence interval (CI) -52.4 to 154.9, p=0.33], 30-day mortality (5% vs 5.3%, p=0.86) or MACE (5.2% vs 6.1%, p=0.68). DTBT was significantly longer during the pandemic versus the pre-pandemic period (+18.1 mins, 95% CI 1.6-34.5, p=0.03) and improved with time (slope estimate: -0.76, 95% CI -1.62 to 0.10). CONCLUSIONS: Despite significant social restrictions imposed in Melbourne, numbers of ACS treated with PCI and 30-day outcomes were similar to pre-pandemic times. DTBT was significantly longer during the COVID-19 pandemic period, likely reflecting infection control measures, which reassuringly improved with time.

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome (ACS) that affects women disproportionately. Previous case series have found that patients with SCAD undergoing cardiac catheterisation have high rates of iatrogenic coronary damage. We formally compared the rate of iatrogenic coronary artery dissection in women with and without SCAD undergoing cardiac catheterisation over a 11-year period.Women with SCAD were identified by a search of the cardiac catheterisation database 2007-2017 for the keywords 'SCAD', 'spontaneous coronary artery dissection', 'spontaneous coronary dissection', and 'spontaneous dissection'. For each identified case, the medical record and the coronary angiogram images were reviewed to confirm spontaneous coronary dissection. For cases of recurrent SCAD, duplicates were removed so that each patient was included only once in this analysis. For each identified case of SCAD, a control case was chosen from women aged70 years, without SCAD, undergoing cardiac catheterisation for an ACS during the same 10-year period. One control case was chosen to match each SCAD patient as closely as possible for age and year of cardiac catheterisation. Iatrogenic coronary dissection was defined as new, proximal, flow limiting coronary artery dissection in a different coronary segment to the presenting spontaneous coronary dissection.Eighty-five (85) cases of women with SCAD were identified. Mean age was not different between SCAD and non-SCAD women (51±11 and 51±10 years, respectively). The SCAD group had lower rates of ST elevation myocardial infarction, lower rises in serum creatine kinase (CK) and troponin levels, lower rates of diabetes and smoking, and far less placement of stents during the procedure than the control group. The rate of additional iatrogenic dissection relating to the cardiac catheterisation procedure was 4 of 85 (4.7%) versus 0 of 85 (0%), p=0.04 in SCAD and control groups, respectively, despite a much lower rate of percutaneous coronary intervention in the SCAD group. No common factors could be identified regarding particular equipment or procedural factors associated with iatrogenic dissection.The rate of iatrogenic dissection in women with SCAD during cardiac catheterisation is confirmed to be high and significantly higher than a contemporaneous age-matched group of women without SCAD. This observation likely indicates generalised coronary fragility in this disease, and emphasises the importance of the utmost care in the engagement, injection and intervention involving the coronary arteries in this disease. Development of a non-invasive coronary imaging modality or biomarker able to diagnose SCAD non-invasively would be a great advance in the care of patients with this condition, because it would avoid the need for invasive coronary angiography for diagnosis.

Background Women who experience vascular complications of pregnancy, including pre-eclampsia, hypertension and diabetes, are at increased risk of coronary artery disease (CAD). Yet patients and their medical providers have low awareness of the significance of these ‘non-traditional’ cardiovascular risk factors. We aimed to determine the prevalence and medical provider awareness of pregnancy-related cardiovascular risk factors in women with CAD. Methods Women aged 18–70 years treated with percutaneous coronary intervention (PCI) across three tertiary hospitals were invited to participate in a pregnancy-related telephone interview at 12 months post-PCI. Electronic medical records (EMR) were retrospectively reviewed for documentation of pregnancy-related cardiovascular risk factors in the 12 months prior to, and including, the PCI admission. Results A total of 102 women (mean age 59.8±7.7 years) underwent PCI for CAD and completed the pregnancy history questionnaire. Approximately three-quarters (73.5%, 75/102) of women had been pregnant, of which 25.3% (19/75) had experienced vascular complications consisting of pre-eclampsia 31.5% (6/19), gestational diabetes 36.8% (7/19), and gestational hypertension 73.6% (14/19). Documentation of traditional CVD risk factors occurred in 209/211 episodes of emergency or cardiology contact (99.1%), while documentation of ‘non-traditional’ pregnancy-related cardiovascular risk factors occurred in 0/211 episodes of emergency or cardiology contact. Conclusion More than a quarter of women treated with PCI for CAD had experienced a past pregnancy-related vascular complication. Despite vascular complications of pregnancy predicting future CAD, medical providers were not obtaining a history of these ‘non-traditional’ cardiovascular risk factors.

Radial access reduces bleeding and is associated with improved survival following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). We evaluated the association between sex, markers of body size and radial access, and its impact on bleeding and mortality following PCI for ACS.From 2013-2016, consecutive patients treated with PCI for ACS across 30 centres were prospectively entered into the Victorian Cardiac Outcomes Registry and followed for 30 days. Multivariate logistic regression was used to analyse predictors of the primary endpoint of PCI access site and secondary endpoints of major bleeding and mortality. A total of 16,330 ACS patients (40.9% ST elevation myocardial infarction [STEMI]) underwent PCI (23.5% female). Women were older with significantly lower weight and height compared to men. Women had lower radial access use (41.6% versus 51.0%, p0.001), with higher 30-day major bleeding (2.4% versus 1.4%, p0.001) and mortality (4.4% versus 3.4%, p0.001) than men. Female sex independently predicted lower radial access use (OR 0.75, 95% CI 0.68-0.83, p0.001) while body surface area, height and body mass index did not. Female sex was an independent predictor of higher 30-day major bleeding (OR 1.38, 95% CI 1.05-1.81, p=0.019) and mortality in STEMI patients (OR 1.31, 95% CI 1.01-1.70. p=0.039). Radial access was associated with lower major bleeding (OR 0.70, 95% CI 0.53-0.91, p=0.009) and mortality (OR 0.60, 95% CI 0.48-0.75, p0.001).Radial access, despite being associated with lower bleeding and mortality, was used less frequently in women, independent of co-morbidities and objective markers of body size.

Background Antithrombotic recommendations following transcatheter aortic valve replacement (TAVR) are largely based on previous trial protocols. The efficacy and risk of anticoagulation has not been systematically assessed. The aim of this study was to determine the efficacy and safety of oral anticoagulation in patients with atrial fibrillation (AF) following TAVR with the Lotus Valve System (Boston Scientific, Marlborough, MA, USA). Methods Consecutive patients with severe aortic stenosis who underwent Lotus valve implantation were prospectively recruited (n = 164). Atrial fibrillation patients prescribed oral anticoagulation (standard AF therapy) were compared to non-AF patients prescribed aspirin and clopidogrel (standard non-AF therapy). Twenty (20) of 164 patients were excluded, as they were not prescribed standard therapy. The primary endpoint was 6-month incidence of death, myocardial infarction, stroke/transient ischaemic attack (TIA) or major/life-threatening bleeding. Secondary endpoints included each component of the primary endpoint, defined according to VARC-2. Results Overall, the primary endpoint occurred in 20.8% and 17.7% of the standard AF and standard non-AF therapy groups respectively (p = 0.82). There was no statistically significant difference in bleeding (12.5% versus 9.4%, p = 0.77) or stroke/TIA (2.1% versus 8.3%, p = 0.27) between the standard AF and standard non-AF therapy groups respectively. Conclusions This study supports the safety of anticoagulation in AF patients, which did not result in excess risk of bleeding or stroke/TIA compared with dual antiplatelet therapy in non-AF patients.

Sudden Cardiac Death (SCD) is a major public health issue, accounting for half of all cardiovascular deaths world-wide. The implantable cardioverter-defibrillator (ICD) has been solidified as the cornerstone therapy in primary prevention of SCD in ischaemic and non-ischaemic cardiomyopathy. However, what has become increasingly clear is that the left ventricular ejection fraction (LVEF) is an inadequate tool to select patients for a prophylactic ICD, despite its widespread use for this purpose. Use of LVEF alone has poor specificity for arrhythmic versus non-arrhythmic death. In addition, the vast majority of sudden deaths occur in patients with more preserved cardiac function. Alternate predictors of sudden death include electrophysiology study, non-invasive markers of electrical instability, myocardial fibrosis, genetic and bio-markers. The challenge for the future is finding a risk stratification test, or combination of tests, that adequately select patients at high risk of SCD with low competing risk of non-sudden death.

Background Radial access for primary percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) is associated with reduced mortality and bleeding, when compared to femoral access. However, radial access failure may be associated with an increased door-to-device (DTD) time. Aims To identify predictors of radial access failure requiring crossover to femoral artery access during primary PCI. Methods From 2013 to 2020, 2,256 consecutive patients treated for PPCI at a single tertiary hospital were prospectively recruited into the Victorian Cardiac Outcomes Registry and followed for 30 days. Multivariable logistic regression was used to identify independent predictors of radial to femoral access crossover. Results From 2,256 STEMI patients, primary radial access was used in 1,778 (78.8%), with 171 (9.6%) experiencing radial-to-femoral crossover. Patients with failed versus successful radial access experienced longer DTD times (67 mins, interquartile range [IQR] 46–99 vs 54 mins [IQR 39-78]; p