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Aim: To determine the reliability of hospital discharge codes for heart failure (HF), acute myocardial infarction (AMI) and stroke compared with adjudicated diagnosis, and to pilot a scalable approach to adjudicate records on a population‐based sample. Methods: A population‐based sample of 685 people with diabetes admitted (1274 admissions) to one of three Australian hospitals during 2018–2020 were randomly selected for this study. All medical records were reviewed and adjudicated. Results: Cardiovascular diseases were the most common primary reason for hospitalisation in people with diabetes, accounting for ~17% (215/1274) of all hospitalisations, with HF as the leading cause. ICD‐10 codes substantially underestimated HF prevalence and had the lowest agreement with the adjudicated diagnosis of HF (Kappa = 0.81), compared with AMI and stroke (Kappa ≥ 0.91). While ICD‐10 codes provided suboptimal sensitivity (72%) for HF, the performance was better for AMI (sensitivity 84%; specificity 100%) and stroke (sensitivity 85%; specificity 100%). A novel approach to screen possible HF cases only required adjudicating 8% (105/1274) of records, correctly identified 78/81 of HF admissions and yielded 96% sensitivity and 98% specificity. Conclusions: While ICD‐10 codes appear reliable for AMI or stroke, a more complex diagnosis such as HF benefits from a two‐stage process to screen for suspected HF cases that need adjudicating. The next step is to validate this novel approach on large multi‐centre studies in diabetes. [ABSTRACT FROM AUTHOR]

Background: Post‐acute sequelae of COVID‐19 (PASC or 'long COVID') reflect ongoing symptoms, but these are non‐specific and common in the wider community. Few reports of PASC have been compared with a control group. Aims: To compare symptoms and objective impairment of functional capacity in patients with previous COVID‐19 infection with uninfected community controls. Methods: In this community‐based, cross‐sectional study of functional capacity, 562 patients from Western Melbourne who had recovered from COVID‐19 infections in 2021 and 2022 were compared with controls from the same community and tested for functional capacity pre‐COVID‐19. Functional impairment (<85% of the predicted response) was assessed using the Duke Activity Status Index (DASI) and 6‐min walk distance (6MWD) test. A subgroup underwent cardiopulmonary exercise testing before and after exercise training. Results: Of 562 respondents (age 54 ± 12 years, 69% women), 389 were symptomatic. Functional impairment (<85% predicted metabolic equivalent of tasks) was documented by DASI in 149 participants (27%), and abnormal 6MWD (<85% predicted) was observed in 14% of the symptomatic participants. Despite fewer risk factors and younger age, patients with COVID‐19 had lower functional capacity by 6MWD (P < 0.001) and more depression (P < 0.001) than controls. In a pilot group of seven participants (age 58 ± 12 years, two women, VO2 18.9 ± 5.7 mL/kg/min), repeat testing after exercise training showed a 20% increase in peak workload. Conclusions: Although most participants (69%) had symptoms consistent with long COVID, significant subjective functional impairment was documented in 27% and objective functional impairment in 14%. An exercise training programme might be beneficial for appropriately selected patients. [ABSTRACT FROM AUTHOR]

The article discusses the need for a risk stratification strategy for heart failure with preserved ejection fraction (HFpEF), a condition that is increasing in prevalence and poses challenges for healthcare systems. The authors evaluate various prognostic models for HFpEF and find that the analytical quality of the studies was suboptimal, leading to an increased risk of bias. They suggest that better predictive tools are needed, including clinical, exercise, biomarker, and big data approaches. The article also highlights the potential of artificial intelligence and machine learning in improving prognostic assessment for HFpEF. [Extracted from the article]

Background: Screening for atrial fibrillation is recommended for patients > 65 years on current guidelines. Targeted screening may be more efficient, however the appropriate location for screening programs has not been well defined. Our aim was to compare the cost‐effectiveness of unselected electrocardiographic (ECG) screening for atrial fibrillation (AF), and selective screening based on an abnormal echocardiogram. Methods: Two strategies of portable ECG screening for AF were compared in the base case of a hypothetical asymptomatic 65‐year‐old man (CHA2DS2‐VASC = 3 based on hypertension and diabetes mellitus) with previous echocardiography but without a cause for AF (e.g. mitral valve disease, left ventricular (LV) dysfunction). With age‐based screening (AgeScreen; 3% AF detection rate) all patients underwent ECG. With imaging‐guided screening (ImagingScreen; 5% detection rate), only patients with left atrial (LA) volume ≥34 mL/m2 and LA reservoir strain <34% or LV global longitudinal strain > −18% underwent ECG screening. A Markov model was informed by published transition probabilities, costs and quality‐adjusted life years (QALY). Costs, effects and incremental cost‐effectiveness ratio were assessed for each screening strategy over a 20‐year period. The willingness‐to‐pay threshold was $53 000/QALY. Results: ImagingScreen dominated AgeScreen, with a lower cost ($54 823 vs $57842) and better outcome (11.56 vs 11.52 QALY over 20 years). Monte Carlo simulation demonstrated that 61% of observations were more efficacious with ImagingScreen, with cost below willingness to pay. The main cost determinants were annual costs of stroke or heart failure and AF detection rates. ImagingScreen was more cost‐effective for AF detection rates up to 14%, and more cost‐effective across a range of annual stroke ($24 000–$102 000) and heart failure ($4000–$12 000) costs. Conclusion: In patients with a previous echocardiogram, AF screening of those with baseline clinical and imaging risk parameters is more cost‐effective than age‐based screening. [ABSTRACT FROM AUTHOR]

Objectives: To compare the cost‐effectiveness of coronary artery calcium (CAC) score‐guided statin therapy criteria and American College of Cardiology/American Heart Association (ACC/AHA) guidelines (10‐year pooled cohort equation [PCE] risk ≥ 7.5%) with selection according to Australian guidelines (5‐year absolute cardiovascular disease risk [ACVDR] ≥ 10%), for people with family histories of premature coronary artery disease. Study design, setting: Markov microsimulation state transition model based on data from the Coronary Artery calcium score: Use to Guide management of Hereditary Coronary Artery Disease (CAUGHT‐CAD) trial and transition probabilities derived from published statin prescribing and adherence outcomes and clinical data. Participants: 1083 people with family histories of premature coronary artery disease but no symptomatic cardiovascular disease. Main outcome measures: Relative cost‐effectiveness over fifteen years, from the perspective of the Australian health care system, compared with usual care (Australian guidelines), assessed as incremental cost‐effectiveness ratios (ICERs), with a notional willingness‐to‐pay threshold of $50 000 per quality‐adjusted life‐year (QALY) gained. Results: Applying the Australian guidelines, 77 people were eligible for statin therapy (7.1%); with ACVDR 5‐year risk ≥ 2% and CAC score > 0, 496 people (46%); with ACVDR 5‐year risk ≥ 2% and CAC score ≥ 100, 155 people (14%); and with the ACC/AHA guidelines, 256 people (24%). The ICERs for CAC‐guided selection were $33 108 (CAC ≥ 100) and $53 028 per QALY gained (CAC > 0); the ACC/AHA guidelines approach (ICER, $909 241 per QALY gained) was not cost‐effective. CAC score‐guided selection (CAC ≥ 100) was cost‐effective for people with 5‐year ACVDR of at least 5%. Conclusion: Expanding the number of people at low to intermediate CVD risk eligible for statin therapy should selectively target people with subclinical atherosclerosis identified by CAC screening. This approach can be more cost‐effective than simply lowering treatment eligibility thresholds. [ABSTRACT FROM AUTHOR]

Insulin infusion increases skeletal muscle microvascular blood flow (MBF) in healthy people but is impaired during insulin resistance. However, we have shown that eliciting insulin secretion via oral glucose loading in healthy people impairs muscle MBF, whilst others have demonstrated intravenous glucose infusion stimulates MBF. We aimed to show that the route of glucose administration (oral versus intravenous) influences muscle MBF, and explore potential gut‐derived hormones that may explain these divergent responses. Ten healthy individuals underwent a 120 min oral glucose tolerance test (OGTT; 75 g glucose) and on a subsequent occasion an intravenous glucose tolerance test (IVGTT, bypassing the gut) matched for similar blood glucose excursions. Femoral artery and thigh muscle microvascular (contrast‐enhanced ultrasound) haemodynamics were measured at baseline and during the OGTT/IVGTT. Plasma insulin, C‐peptide, glucagon, non‐esterified fatty acids and a range of gut‐derived hormones and incretins (gastric inhibitory polypeptide (GIP) and glucagon‐like peptide‐1(GLP‐1)) were measured at baseline and throughout the OGTT/IVGTT. The IVGTT increased whereas the OGTT impaired MBF (1.3‐fold versus 0.5‐fold from baseline, respectively, P = 0.0006). The impairment in MBF during the OGTT occurred despite producing 2.8‐fold higher plasma insulin concentrations (P = 0.0001). The change in MBF from baseline (ΔMBF) negatively correlated with ΔGIP concentrations (r = −0.665, P < 0.0001). The natural log ratio of incretins GLP‐1:GIP was positively associated with ΔMBF (r = 0.658, P < 0.0001), suggesting they have opposing actions on the microvasculature. Postprandial hyperglycaemia per se does not acutely determine opposing microvascular responses between OGTT and IVGTT. Incretins may play a role in modulating skeletal muscle MBF in humans. Key points: Insulin or mixed nutrient meals stimulate skeletal muscle microvascular blood flow (MBF) to aid in the delivery of nutrients; however, this vascular effect is lost during insulin resistance.Food/drinks containing large glucose loads impair MBF in healthy people; however, this impairment is not observed when glucose is infused intravenously (bypassing the gut).We investigated skeletal muscle MBF responses to a 75 g oral glucose tolerance test and intravenous glucose infusion and aimed to identify potential gut hormones responsible for glucose‐mediated changes in MBF.Despite similar blood glucose concentrations, orally ingested glucose impaired, whereas intravenously infused glucose augmented, skeletal muscle MBF. The incretin gastric inhibitory polypeptide was negatively associated with MBF, suggestive of an incretin‐mediated MBF response to oral glucose ingestion.This work provides new insight into why diets high in glucose may be detrimental to vascular health and provides new avenues for novel treatment strategies targeting microvascular dysfunction. [ABSTRACT FROM AUTHOR]

Aims: Subclinical left ventricular dysfunction (LVD) is a prelude to symptomatic heart failure (HF). We hypothesised that screening‐guided treatment with spironolactone would prevent incident HF in at‐risk patients. Methods and results: We randomised asymptomatic, community‐dwelling subjects aged ≥65 years old, with at least one non‐ischaemic HF risk factor (hypertension, type 2 diabetes mellitus or obesity) to echocardiography‐guided therapy or usual care. Spironolactone therapy was triggered by the detection of subclinical LVD (global longitudinal strain [GLS] ≤16%) or diastolic abnormalities (at least one of E/e′ >15, E/e′ >10 with left atrial enlargement [LAE] or impaired relaxation [E/A < 0.8, IR], LAE with IR), or borderline GLS (17%) with IR or borderline GLS with LAE. The primary outcome was incident HF at 24 months. Secondary outcomes were change in 6‐min walk test (6MWT) and change in left ventricular function. LVD was identified in 161 (46%) of 349 participants (age 70 [68–73] years, 201 [58%] women). The trial was stopped because of a 55% rate of spironolactone discontinuation, due primarily to decline in renal function. Incident HF developed in 11 (3.5%) of 310 participants completing follow‐up, with no difference between usual care and intervention (4 [2.5%] vs. 7 [4.7%], p = 0.29), decline in 6MWT distance (p = 0.28), persistent or new LVD (p = 0.58), nor change in GLS with intervention (p = 0.15). A per‐protocol analysis of 131 patients with baseline LVD and a follow‐up echocardiogram, showed resolution of LVD with spironolactone therapy (59% vs. 33%, p = 0.01). Conclusion: The study was underpowered to determine whether screening‐guided spironolactone therapy reduced incident HF because spironolactone was frequently discontinued due to renal function criteria. However, LVD resolved in more patients treated with spironolactone than in untreated patients. Future trials should use less conservative renal criteria for spironolactone discontinuation. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to determine the relationship of low birth weight (LBW) with adult cardiac structure and function and investigate potential causal pathways. Methods and results: A population‐based sample of 925 Australians (41.3% male) were followed from childhood (aged 7–15 years) to young adulthood (aged 26–36 years) and mid‐adulthood (aged 36–50 years). Left ventricular (LV) global longitudinal strain (GLS, %), LV mass index (LVMi, g/m2.7), LV filling pressure (E/e′), and left atrial volume index (g/m2) were measured by transthoracic echocardiography in mid‐adulthood. Birth weight category was self‐reported in young adulthood and classified as low (≤5 lb or ≤2270 g), normal (5–8 lb or 2271–3630 g), and high (>8 lb or >3630 g). Of the 925 participants, 7.5% (n = 69) were classified as LBW. Compared with participants with normal birth weight, those with LBW had 2.01‐fold (95% confidence interval: 1.19, 3.41, P = 0.009) higher risks of impaired GLS (GLS > −18%) and 2.63‐fold (95% confidence interval: 0.89, 7.81, P = 0.08) higher risks of LV hypertrophy (LVMi > 48 g/m2.7 in men or >44 g/m2.7 in women) in adulthood, independent of age, sex, and any socio‐economic factors. Participants with LBW significantly increased body fat from childhood to adulthood relative to their peers and had greater levels of triglycerides, fasting glucose, and arterial stiffness in adulthood. These risk factors were the strongest mediators and explained 54% of the LBW effect size on adult GLS and 33% of the LBW effect size on LVMi. The remaining of these associations was independent of any of the measured risk factors. Conclusions: Low birth weight was associated with impaired cardiac structure and function in mid‐adulthood. This association was only partially explained by known risk factors. [ABSTRACT FROM AUTHOR]

Aims Fluid congestion is a leading cause of hospital admission, readmission, and mortality in heart failure (HF). We performed a systematic review and meta-analysis to determine the effectiveness of an advanced fluid management programme (AFMP). The AFMP was defined as an intervention providing tailored diuretic therapy guided by intravascular volume assessment, in hospitalized patients or after discharge. The AFMP group was compared with patients who received standard care treatment. The aim of this systematic review and meta-analysis was to determine the effectiveness of an AFMP in improving patient outcomes. Methods and results A systematic review of randomized controlled trials, case–control studies, and crossover studies using the terms ‘heart failure’, ‘fluid management’, and ‘readmission’ was conducted in PubMed, CINAHL, and Scopus up until November 2020. Studies reporting the association of an AFMP on readmission and/or mortality were included in our metaanalyses. Risk of bias was assessed in non-randomized studies using the Newcastle–Ottawa Scale. From 232 retrieved studies, 12 were included in the data synthesis. The 6040 patients in the included studies had a mean age of 72 ± 4 years and mean left ventricular ejection fraction of 39 ± 8%, there were slightly more men (n = 3022) than women, and the follow-up period was a mean of 4.8 ± 3.1 months. Readmission data were available in 5362 patients; of these, 1629 were readmitted. Mortality data were available in 5787 patients; of these, 584 died. HF patients who had an AFMP in hospital and/or after discharge had lower odds of all-cause readmission (odds ratio—OR 0.64 [95% confidence interval—CI 0.44, 0.92], P = 0.02) with moderate heterogeneity (I 2 = 46.5) and lower odds of all-cause mortality (OR 0.82 [95% CI 0.69, 0.98], P = 0.03) with low heterogeneity (I 2 = 0). The use of an AFMP was equally effective in reducing readmission and mortality regardless of age and follow-up duration. Effective pre-discharge diuresis was associated with significantly lower readmission odds (OR 0.43 [95% CI 0.26, 0.71], P = 0.001) compared with a fluid management plan as part of post-discharge follow-up. Conclusions An effective AFMP is associated with improving readmission and mortality in HF. Our results encourage attainment of optimal volume status at discharge and prescription of optimal diuretic dose. Ongoing support to maintain euvolaemia and effective collaboration between healthcare teams, along with effective patient education and engagement, may help to reduce adverse outcomes in HF patients. [ABSTRACT FROM AUTHOR]

Aims: Cognitive impairment (CI) is highly prevalent in heart failure (HF), and increases patients' risks of readmission. This study sought to determine whether the presence and degree of CI could identify patients most likely to benefit from a HF disease management programme (DMP) to reduce readmissions.Methods and Results: A total of 1152 consecutive Australian patients admitted with HF (2014-2017) were prospectively followed up for 12 months. Of these, 324 patients who received DMP (1-month duration, including post-discharge home visits, medication reconciliation, exercise guidance and early clinical review) were matched (1:2 ratio) with 648 usual care patients. Cognitive function was assessed either on the day of or one day before discharge using the Montreal Cognitive Assessment (MoCA). Outcomes included readmission or death at 1, 3 and 12 months, and days at home within 12 months of discharge. Poorer cognitive function was associated with all adverse outcomes. Compared with usual care, DMP was associated with lower odds of 30-day [odds ratio (OR) 0.60, 95% confidence interval 0.40, 0.91] and 90-day (OR 0.53, 95% confidence interval 0.36, 0.77) readmission or death, and with 19 more days at home within 12 months, independent of HF therapy. The effect sizes of these associations were greater for patients with diminished cognition than those with normal cognition (interaction P = 0.036), and might have been more pronounced among those with mild CI compared with those with more severe CI (MoCA score 17-22; OR 0.42, 95% confidence interval 0.21, 0.87) at 30 days (OR 0.31, 95% confidence interval 0.16, 0.60 at 90 days). Patients with normal cognition had fewer events, irrespective of DMP.Conclusions: Cognitive function may determine how HF patients respond to a DMP. Cognitive screening before implementation of a DMP may allow personalized plans for patients with different levels of cognitive function. [ABSTRACT FROM AUTHOR]

Objectives: To assess the efficacy of a pro‐active, absolute cardiovascular risk‐guided approach to opportunistically modifying cardiovascular risk factors in patients without coronary ischaemia attending a chest pain clinic. Design: Prospective, randomised, open label, blinded endpoint study. Setting: The rapid access chest pain clinic of Royal Hobart Hospital, a tertiary hospital. Participants: Patients who presented to the chest pain clinic between 1 July 2014 and 31 December 2017 who had intermediate to high absolute cardiovascular risk scores (5‐year risk ≥ 8%). Patients with known cardiac disease or from groups with clinically determined high risk of cardiovascular disease were excluded. Main outcome measures: The primary endpoint was change in 5‐year absolute risk score (Australian absolute risk calculator) at follow‐up (at least 12 months after baseline assessment). Secondary endpoints were changes in lipid profile, blood pressure, smoking status, and body mass index, and major adverse cardiovascular events. Results: The mean change in risk at follow‐up was +0.4 percentage points (95% CI, –0.8 to 1.5 percentage points) for the 98 control group patients and –2.4 percentage points (95% CI, –1.5 to –3.4 percentage points) for the 91 intervention group patients; the between‐group difference in change was 2.7 percentage points (95% CI, 1.2–4.1 percentage points). Mean changes in lipid profile, systolic blood pressure, and smoking status were larger for the intervention group, but not statistically different from those for the control group. Conclusions: An absolute cardiovascular risk‐guided, pro‐active risk factor management strategy employed opportunistically in a chest pain clinic significantly improved 5‐year absolute cardiovascular risk scores. Trial registration: Australia New Zealand Clinical Trial Registry, ACTRN12617000615381 (retrospective). [ABSTRACT FROM AUTHOR]

Aims: Several different diagnostic parameters can be used to assess left ventricular (LV) longitudinal systolic function, but no studies comparing their predictive value have been conducted. We sought to compare the prognostic value of LV long‐axis function parameters at rest and exercise using the population with heart failure with preserved ejection fraction (HFpEF). Methods and results: Clinical and biochemical variables were collected at baseline in 201 patients with HFpEF. Echocardiography was performed at rest and immediately after exercise, with measurement of mitral annular plane systolic excursion, systolic tissue velocity (s′), global longitudinal strain (GLS), and global longitudinal strain rate (GLSR). Participants were followed for 48 (24–60) months for heart failure hospitalization and cardiovascular death. Seventy‐four patients (36.8%) met the study endpoint. Cox regression analysis revealed that after adjustment for Meta‐Analysis Global Group in Chronic Heart Failure risk score, brain natriuretic peptide (BNP), and peak VO2, heart failure hospitalization and cardiovascular death were significantly associated with GLS at rest [hazard ratio (HR) 0.91; 95% confidence interval (CI) 0.84–0.98; P = 0.016], GLS after exercise (HR 0.84; 95% CI 0.77–0.91; P < 0.001), and GLSR after exercise (HR 0.13; 95% CI 0.04–0.48; P = 0.002). The addition of each of the following: exercise GLS and GLSR and resting GLS to the base model including Meta‐Analysis Global Group in Chronic Heart Failure, BNP, and peak VO2 improved predictive power for the study endpoint [net reclassification improvement (NRI) = 49%, P < 0.001; NRI = 42%, P = 0.004; and NRI = 38%, P = 0.009, respectively]. Exercise GLS was the only longitudinal parameter significantly improving c‐statistics of the base model (0.68 vs. 0.73; P = 0.047). Conclusions: Echocardiographic parameters of LV longitudinal function are not equipotential in predicting adverse outcomes in HFpEF. LV deformation indices, especially assessed with exercise, show the highest predictive utility independent from and incremental to clinical data and BNP. [ABSTRACT FROM AUTHOR]

Aims: Heart failure (HF) readmission commonly arises owing to insufficient patient knowledge and failure of recognition of the early stages of recurrent fluid congestion. In previous work, we developed a score to predict short‐term hospital readmission and showed that higher‐risk patients benefit most from a disease management programme (DMP) that included enhancing knowledge and education by a nurse. We aim to evaluate the effectiveness of a novel, nurse‐led HF DMP in selected patients at high risk of short‐term hospital readmission, using ultrasound‐guided diuretic management and artificial intelligence to enhance HF knowledge in an outpatient setting. Methods and results: Risk‐HF is a prospective multisite randomized controlled trial that will allocate 404 patients hospitalized with acute decompensated HF, and ≥33% risk of readmission and/or death at 30 days, into risk‐guided nurse intervention (DMP‐Plus group) compared with usual care. Intervention elements include (i) fluid management with a handheld ultrasound (HHU) device at point of care; (ii) post‐discharge follow‐up; (iii) optimal programmed drug titration; (iv) better transition of care; (v) intensive self‐care education via an avatar‐based 'digital health coach'; and (vi) exercise guidance through the digital coach. Usual care involves standard post‐discharge hospital care. The primary outcome is reduced death and/or hospital readmissions at 30 days post‐discharge, and secondary outcomes include quality of life, fluid management efficacy, and feasibility and patient engagement. Assuming that our intervention will reduce readmissions and/or deaths by 50%, with a 1:1 ratio of intervention vs. usual care, we plan to randomize 404 patients to show a difference at a statistical power of 80%, using a two‐sided alpha of 0.05. We anticipate this recruitment will be achieved by screening 2020 hospitalized HF patients for eligibility. An 8 week pilot programme of our digital health coach in 21 HF patients, age > 75 years, showed overall improvements in quality of life (13 of 21), self‐care (12 of 21), and HF knowledge (13 of 21). A pilot of the use of HHU by nurses showed that it was feasible and accurate. Conclusions: The Risk‐HF trial will evaluate the effectiveness of a risk‐guided intervention to improve HF outcomes and will evaluate the efficacy of trained HF nurses delivering a fluid management protocol that is guided by lung ultrasound with an HHU at point of care. [ABSTRACT FROM AUTHOR]

Objectives: To assess the predictive value of the Australian absolute cardiovascular disease risk (ACVDR) calculator and other assessment tools for identifying Australians with family histories of early onset coronary artery disease (CAD) who have coronary artery calcification.Design, Setting, Participants: People without known CAD were recruited at seven Australian hospitals, October 2016 - January 2019. Participants were aged 40-70 years, had a family history of early onset CAD, and a 5-year ACVDR of 2-15%.Main Outcome Measures: CT coronary artery calcium score greater than zero (any coronary calcification) or greater than 100 (calcification warranting lipid therapy).Results: 1059 participants were recruited; 477 (45%) had non-zero coronary artery calcium scores (median 5-year ACVDR, 4.8% [IQR, 2.9-7.6%]; median coronary artery calcium score, 41.7 [IQR, 8-124]); 582 (55%) did not (median 5-year ACVDR, 3.2% [IQR, 2.0-4.6%]). Of 151 participants with calcium scores of 100 or more, 116 (77%) were deemed to be at low cardiovascular risk by Australian guidelines, while 14 of 75 participants at intermediate risk (19%) had zero calcium scores. The sensitivity of the ACVDR calculator for identifying people with non-zero calcium scores (area under receiver operator curve [AUC], 0.674) was lower than that of the pooled cohort equation (AUC, 0.711; P < 0.001). ACVDR (10-year)- and Multi-Ethnic Study of Atherosclerosis (MESA)-predicted risk categories concurred for 511 participants (48%); classifications were concordant for 925 participants (87%) when the ACVDR was supplemented by calcium scores.Conclusions: Coronary artery calcium scoring should be considered as part of the heart health check for patients at intermediate ACVDR risk and with family histories of early onset CAD. Alternative risk calculators may better select such patients for further diagnostic testing and primary prevention therapy.Trial Registration: Australian New Zealand Clinical Trials Registry, ACTRN 12614001294640; 11 December 2014 (prospective). [ABSTRACT FROM AUTHOR]

Objective: Epicardial atherosclerosis and heart failure while distinct clinical entities share common pathophysiological features including endothelial dysfunction and inflammation. Presence of subclinical disease could lead to early diagnosis and intervention in the other. The aim of our study was to assess the association between coronary calcium score (CCS), conventional cardiovascular risk factors, and echocardiographic markers of subclinical left ventricular dysfunction (S‐LVD). Methods: One hundred and fifty‐nine participants aged 40–70 years with intermediate risk of coronary artery disease (5‐year risk of 2%–15%) were identified. Computed tomography (CT) CCS and 2‐D transthoracic echocardiography were performed. Main outcomes included presence of subclinical left ventricular dysfunction defined by reduced average global longitudinal strain, left atrial volume enlargement, and elevated E/e'. Results: Fifteen participants had evidence of subclinical LV dysfunction (8 with systolic dysfunction and 7 with diastolic dysfunction) and 85 participants had CCS > 0. CCS > 0 was present in 10 participants with S‐LVD compared to 75 participants without S‐LVD (67% vs 53%, P =.47). There was no significant difference between in mean GLS (19.2 vs 19.5, P =.14), E/e' (7.2 vs 7.5 P =.33) in those without or with coronary artery calcium. Elevated CCS was also not associated with a higher tertiles of indexed LV mass (OR 1.15, P =.49) or index left atrial volume (OR 1.15, P =.49). Conclusions: In an asymptomatic, low‐intermediate‐risk group, mechanistic processes that lead to atherosclerosis are not directly associated with subclinical LV dysfunction. [ABSTRACT FROM AUTHOR]

Background: Low socioeconomic status is associated with cardiovascular diseases, and an association with atrial fibrillation (AF) could guide screening. Aim: To investigate if indices of advantage/disadvantage (IAD), index of education/occupation (IEO) and index of economic resources were associated with incident AF, independent of risk factors and cardiac function. Methods: We studied community‐based participants aged ≥65 years with AF risk factors (n = 379, age 70 ± 4 years, 45% men). The CHARGE‐AF score (a well validated AF risk score) was used to assess 5‐year risk of developing AF. Participants also had baseline echocardiograms. IAD, IEO and index of economic resources were obtained from the 2011 Socio‐Economic Indexes for Areas score, in which higher decile ranks indicate more advantaged areas. Patients were followed up for incident AF (median 21 (range 5–31) months), with AF diagnosed by clinical review, including 12‐lead electrocardiogram (ECG), as well as single‐lead portable ECG monitoring used to record 60 s ECG tracings five times/day for 1 week. Cox proportional hazards models were used to assess the association between socioeconomic status and incident AF. Results: Subjects with AF (n = 50, 13%) were more likely to be male (64 vs 42%, P = 0.003) and had higher CHARGE‐AF score (median 7.1% (5.2–12.8%) vs 5.3% (3.3–8.6%), P < 0.001). Areas with lower socioeconomic status (IAD and IEO) had a higher risk of incident AF independent of LV function and CHARGE‐AF score (hazard ratio for IAD 1.16, 95% confidence interval 1.05–1.29, P = 0.005 and hazard ratio for IEO 1.18, 95% confidence interval 1.07–1.30, P = 0.001). Conclusion: Regional socioeconomic status is associated with risk of incident AF, independent of LV function and clinical risk. This association might permit better regional targeting of prevention. [ABSTRACT FROM AUTHOR]

Aims: This study aims to determine if traditional markers of disadvantage [female sex, low socio‐economic status (SES), and remoteness] are associated with lower prescription of evidence‐based therapy and higher mortality among patients with moderate–severe heart failure with reduced ejection fraction. Methods and results: We recruited 452 consecutive class II–III heart failure with reduced ejection fraction patients. Baseline clinical data were recorded prospectively. The primary outcome was the association of female sex on overall survival. Secondary outcomes included association between evidence‐based therapy delivery and sex and association of SES and remoteness on heart failure therapy and survival. The Australian Bureau of Statistics generated all indices. Median follow‐up was 37.9 months. One hundred and nine patients (24.3%) were women. There was no difference in overall survival based on sex (hazard ratio = 1.19, 95% confidence interval: 0.74–1.92, 0.48). There was no difference in prescription of beta‐blockers [χ2(1) = 0.91, 0.66], angiotensin‐converting enzyme inhibitors [χ2(1) = 0.001, 0.97], nor aldosterone antagonists [χ2(1) = 2.71, 0.10]. There was no difference in rates of primary prevention implantable cardioverter‐defibrillator implantation in men compared with women [χ2(1) = 0.35, 0.56]. Neither higher SES nor inner city residence conferred an overall survival benefit. Conclusions: In this Australian cohort of heart failure patients, delivery of care and likelihood of death are comparable between the sexes, SES groups, and rural vs. city residents. [ABSTRACT FROM AUTHOR]

Background: Elevated left atrial (LA) pressure, particularly during exercise, is associated with symptomatic status and survival in patients with heart failure with preserved ejection fraction (HFpEF). We aimed to characterize the contribution of abnormal LA mechanical properties to exercise haemodynamics in HFpEF.Methods and Results: Simultaneous echocardiography and right heart catheterization were performed in 71 subjects with left ventricular ejection fraction ≥ 50% referred for assessment of exertional dyspnoea. According to haemodynamic evaluation, 49 patients were diagnosed with HFpEF [pulmonary capillary wedge pressure (PCWP) ≥ 15 mmHg at rest and/or ≥ 25 mmHg at maximal exertion] and 22 as non-cardiac dyspnoea. Apical two- and four-chamber views were used for blinded two-dimensional LA speckle tracking analysis. HFpEF was characterized by impaired LA reservoir (24.3 ± 9.6 vs. 36.7 ± 8.4%, P < 0.001) and pump strain (-11.5 ± 3.2 vs. -17.0 ± 3.4%, P < 0.001); and increased stiffness (0.8 ± 0.7 vs. 0.2 ± 0.1 mmHg/%, P < 0.001). Reservoir and pump strain correlated with exercise PCWP (r = -0.64 and r = 0.72, P < 0.001), and remained independent predictors after adjusting for left ventricular mass index, LA volume index, mean E/e' and systolic blood pressure (B = -0.66 and B = 1.41, respectively, P < 0.001). LA stiffness was strongly related to B-type natriuretic peptide levels (r = 0.73, P < 0.001; B = 173.0, P < 0.001). Reservoir strain at cut-off of ≤ 33% predicted invasively verified HFpEF diagnosis with 88% sensitivity and 77% specificity, providing a net reclassification improvement of 12% in comparison to the 2016 European Society of Cardiology criteria for non-invasive diagnosis of HFpEF.Conclusions: Impaired LA reservoir and pump function and increased stiffness are associated with abnormal exercise haemodynamics in HFpEF. These markers provide significant HFpEF diagnostic utility in elderly ambulatory patients with dyspnoea. [ABSTRACT FROM AUTHOR]

Background: With improved cancer survivorship, cardiovascular disease (CVD) and other noncancer events compete with cancer as the underlying cause of death, but the risks of mortality in competing-risk settings have not been well characterized.Methods: The authors identified 21,637 individuals who had a first cancer registered between 2006 and 2013, with follow-up to 2015, in the Australian population-based Tasmanian Cancer Registry. The cumulative incidence of deaths from specific competing events was assessed in competing-risk analyses. Standardized mortality ratios (SMRs) and absolute excess risks (AERs) for deaths from noncancer causes were calculated for comparison with the general population.Results: Overall, 8844 deaths were observed, with 1946 (22%) from competing events. The cumulative incidence of deaths from CVD increased significantly with age at first cancer diagnosis and exceeded other competing events at age ≥65 years. The risk of death from CVD was more common than expected in the first year of follow-up (SMR, 1.44 [95% confidence interval, 1.26-1.64]; AER, 36.8 per 10,000 person-years). The SMR and AER for CVD deaths varied by first cancer site, indicating increased risks after a first diagnosis of lung cancer, hematologic malignancy, and urinary tract cancer. For other noncancer events, the SMRs increased significantly for deaths from infectious disease and respiratory disease and were highest in the first year of follow-up.Conclusions: CVD was the leading cause of competing mortality among Tasmanian patients with cancer who were diagnosed from 2006 to 2013. The higher than expected occurrence of death from CVD and other noncancer events during the first year after a cancer diagnosis highlights the importance of early preventive interventions. [ABSTRACT FROM AUTHOR]

Objectives: To investigate whether enrolment of patients in management programs after hospitalisation for heart failure (HF) reduces the likelihood of post-hospital adverse outcomes. Design: Cohort study in which associations between adverse outcomes at 30 and 90 days for people hospitalised for HF and baseline clinical, socio-demographic and blood pathology factors, and with post-discharge management strategies, were assessed. Setting, participants: 906 patients with HF were prospectively enrolled in five Australian states at cardiology departments with expertise in treating people with HF. Main outcome measures: All-cause re-admissions and deaths at 30 and 90 days after discharge from the index admission. Results: 58% of patients were men; the mean age was 72.5 years (SD, 13.9 years). By hospital, 30-day re-admission rates ranged from 17% to 33%, and 90-day rates from 40% to 55%; 30-day mortality rates were 0e13%, 90-day rates 4e24%. Factors associated with increased odds of re-admission or death at 30 or 90 days included living alone, cognitive impairment, depression, NYHA classification, left atrial volume index, and Charlson index score. Nurse-led disease management programs and reviews within 7 days were associated with reduced odds of re-admission (but not of death) at 30 and 90 days; exercise programs were associated with reduced odds at 90 days. Significant between-hospital differences in re-admission rates were reduced after adjustment for post-discharge management programs, and abolished by further adjustment for echocardiography findings. Between-hospital differences in mortality were largely explained by differences in echocardiographic findings. Conclusions: Differences in early re-admission rates after hospitalisation for HF are primarily explained by differences in post-discharge management. [ABSTRACT FROM AUTHOR]

Abstract: Aims: The detection of non‐ischaemic (mainly hypertension, diabetes, and obesity) stage B heart failure (SBHF) may facilitate the recognition of those at risk of progression to overt HF and HF prevention. We sought the relationship of specific electrocardiographic (ECG) markers of SBHF to echocardiographic features of SBHF and their prognostic value for development of HF. The ECG markers were Cornell product (Cornell‐P), P‐wave terminal force in lead V1 (PTFV1), ST depression in lead V5 V6 (minSTmV5V6), and increased heart rate. Echocardiographic assessment of SBHF included left ventricular hypertrophy (LVH), impaired global longitudinal strain (GLS), and diastolic dysfunction (DD). Method and results: Asymptomatic subjects ≥65 years without prior cardiac history, but with HF risks, were recruited from the local community. At baseline, they underwent clinical assessment, 12‐lead ECG, and comprehensive echocardiography. New HF was assessed clinically at mean follow‐up of 14 ± 4 months, and echocardiography was repeated in subjects with HF. Of the 447 study subjects (age 71 ± 5, 47% men) with SBHF, 13% had LVH, 32% impaired GLS, and 65% ≥grade I DD (10% ≥grade II DD). Forty were lost to follow‐up. Clinical HF developed in 47 of 407, of whom 20% had echocardiographic LVH, 51% abnormal GLS, and 76% DD at baseline. Baseline LVH and abnormal GLS (not grade I DD) were independently associated with outcomes (clinical HF and cardiovascular death). Cornell‐P and heart rate (not minSTmV5V6 nor PTFV1) were independently associated with LVH, impaired GLS, and DD. Cornell‐P and minSTV5V6 (not heart rate nor PTFV1) were independently associated with outcomes. More ECG abnormalities improved sensitivity, but ECG‐markers were not independent of or incremental to echocardiographic markers to predict HF in SBHF. Conclusions: In this elderly study population, ECG markers showed low diagnostic sensitivity for non‐ischaemic SBHF and low prognostic value for outcomes. Cornell‐P and minSTmV5V6 had predictive value for outcomes in non‐ischaemic SBHF independent of age, gender, and common comorbidities but were not incremental to echocardiography. [ABSTRACT FROM AUTHOR]

Aims Incident heart failure (HF) continues to pose a common and serious problem. We sought to examine the value of echocardiographic predictors of new HF in a community-based elderly population at risk for HF, independent of and incremental to clinical evaluation. Methods and results Asymptomatic patients ≥65 years old, with ≥1 HF risk factor (hypertension, type 2 diabetes, or obesity) were recruited from the community; patients with valve disease, reduced ejection fraction (EF), and atrial fibrillation (AF) were excluded. Patients underwent standard clinical evaluation including calculation of the Charlson co-morbidity score and a comprehensive echocardiography including global longitudinal strain (GLS). Functional capacity was assessed by 6 min walk test. New HF and cardiovascular death were assessed after a mean follow-up of 14±4months by three independent cardiologists using Framingham criteria. Of 410 subjects (median age 70 years; 48% men), the prevalence of stage B HF was 13% [by LV hypertrophy (LVH)], 12% (by abnormal E/e'), 33% (by impaired GLS), and 31% [by left atrial enlargement (LAE)]. New HF symptoms developed in 49, and 2 died of cardiovascular causes, giving an event rate of 104/1000 person-years. These patients were older (P = 0.012), had a higher Charlson co-morbidity score (P < 0.001), larger LV mass and left atrium, higher E/e', and lower GLS (P < 0.05). LAE, LVH, abnormal GLS, and E/e' were independent predictors of new HF. In sequential models, LV mass and GLS added incremental information to clinical parameters. GLS significantly reclassified individuals (P = 0.002), but no reclassification improvement was identified using LV mass index, E/e', and left atrial volume index. Conclusion Echocardiographic assessment (especially GLS and LV mass) provides incremental value in predicting incident HF. [ABSTRACT FROM AUTHOR]

Aims: Incident heart failure (HF) continues to pose a common and serious problem. We sought to examine the value of echocardiographic predictors of new HF in a community-based elderly population at risk for HF, independent of and incremental to clinical evaluation.Methods and Results: Asymptomatic patients ≥65 years old, with ≥1 HF risk factor (hypertension, type 2 diabetes, or obesity) were recruited from the community; patients with valve disease, reduced ejection fraction (EF), and atrial fibrillation (AF) were excluded. Patients underwent standard clinical evaluation including calculation of the Charlson co-morbidity score and a comprehensive echocardiography including global longitudinal strain (GLS). Functional capacity was assessed by 6 min walk test. New HF and cardiovascular death were assessed after a mean follow-up of 14 ± 4 months by three independent cardiologists using Framingham criteria. Of 410 subjects (median age 70 years; 48% men), the prevalence of stage B HF was 13% [by LV hypertrophy (LVH)], 12% (by abnormal E/e'), 33% (by impaired GLS), and 31% [by left atrial enlargement (LAE)]. New HF symptoms developed in 49, and 2 died of cardiovascular causes, giving an event rate of 104/1000 person-years. These patients were older (P = 0.012), had a higher Charlson co-morbidity score (P < 0.001), larger LV mass and left atrium, higher E/e', and lower GLS (P < 0.05). LAE, LVH, abnormal GLS, and E/e' were independent predictors of new HF. In sequential models, LV mass and GLS added incremental information to clinical parameters. GLS significantly reclassified individuals (P = 0.002), but no reclassification improvement was identified using LV mass index, E/e', and left atrial volume index.Conclusion: Echocardiographic assessment (especially GLS and LV mass) provides incremental value in predicting incident HF. [ABSTRACT FROM AUTHOR]

Background Longitudinal strain of right ventricle ( RV) can be used to determine RV systolic function. This study compared RV longitudinal strain values of two different speckle tracking software technologies, velocity vector imaging ( VVI) and two-dimensional speckle tracking echocardiography (2 DSTE), and longitudinal strain by cardiac magnetic resonance ( CMR). Methods We studied 36 patients (28 men, 63 ± 11 years) with ischemic cardiomyopathy ( ICM) who underwent echocardiography with GE machines and CMR. Longitudinal strain of RV analyzed with 2 DSTE and VVI in same DICOM files. Longitudinal RV strain analyzed with 2 DSTE and VVI in same raw data. These values were compared with RVEF and longitudinal strain by CMR. Results VVI strain showed significant correlations with RVEF by CMR (global RV: r = −0.56, P < 0.01, free wall: r = −0.52, P < 0.01, and septum: r = −0.49, P < 0.01). 2 DSTE strain also revealed significant correlations (global RV: r = −0.40, P = 0.02, and septum: r = −0.35, P = 0.04). 2 DSTE strain had significant bias with wide limits of agreement in global RV and septum compared with CMR strain. 2 DSTE strain had significantly lower intra-observer variability than VVI (P = 0.03) or CMR strain (P = 0.04) in RV-free wall. Conclusions RV longitudinal strains by VVI and 2 SDTE demonstrated relatively good correlations with RVEF and longitudinal strain by CMR. However, when compared to CMR-derived strain, 2 DSTE-derived strain underestimates longitudinal strain of RV septum and of global right ventricle. 2 DSTE strain had significantly lower intra-observer variability compared with VVI or CMR strain analysis. [ABSTRACT FROM AUTHOR]

Assessment of mechanical dyssynchrony can improve the prognostic value of guideline-based patient selection for cardiac resynchronization therapy. Why mechanical dyssynchrony remains relevant to cardiac resynchronization therapy. Letter regarding the article 'Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: a joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology'. [Extracted from the article]