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Catheter induced coronary dissection is an uncommon but potentially catastrophic complication of coronary angiography. We report a case of a 48-year-old female with normal coronary arteries on angiography complicated by extensive catheter induced spiral dissection. Wiring into the true lumen was a formidable challenge as a consequence of the large false lumen obliterating the true lumen. We present management strategies and in particular, highlight the important role of intravascular ultrasound (IVUS) imaging.Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Background: Inappropriate cardiac telemetry use is associated with reduced patient flow and increased healthcare costs. Aim(s): To evaluate the outcomes of guideline-based application of cardiac telemetry. Method(s): Phase I involved a prospective audit (March to August 2011) of telemetry use at a tertiary hospital. Data were collected on indication for telemetry and clinical outcomes. Phase II prospectively included patients more than 18 years under general medicine requiring ward-based telemetry. As phase II occurred at a time remotely from phase I, an audit similar to phase I (phase II - baseline) was completed prior to a 3-month intervention (May to August 2015). The intervention consisted of a daily telemetry ward round and an admission form based on the American Heart Association guidelines (class I, telemetry indicated; class II, telemetry maybe indicated; class III, telemetry not indicated). Patient demographics, telemetry data, and clinical outcomes were studied. Primary endpoint was the percentage reduction of class III indications, while secondary endpoint included telemetry duration. Result(s): In phase I (n = 200), 38% were admitted with a class III indication resulting in no change in clinical management. A total of 74 patients was included in phase II baseline (mean +/- standard deviation (SD) age 73 years +/- 14.9, 57% male), whilst 65 patients were included in the intervention (mean +/- SD age 71 years +/- 18.4, 35% male). Both groups had similar baseline characteristics. There was a reduction in class III admissions post-intervention from 38% to 11%, P < 0.001. Intervention was associated with a reduction in median telemetry duration (1.8 +/- 1.8 vs 2.4 +/- 2.5 days, P = 0.047); however, length of stay was similar in both groups (P > 0.05). Conclusion(s): Guideline-based telemetry admissions and a regular telemetry ward round are associated with a reduction in inappropriate telemetry use.Copyright © 2017 Royal Australasian College of Physicians

An 80-year-old woman initially presented with an episode of pleuritic chest pain 10 days after implantation of a dual chamber permanent pacemaker. She returned to hospital a day later with vomiting and fever. She was found to have new atrial fibrillation in addition to right-sided weakness and dysarthria. An infarct in the left anterior inferior cerebellar artery territory was later confirmed on CT. She continued to have recurrent febrile episodes associated with vomiting and dyspnoea. Extensive investigations for infection were negative, and her symptoms were initially attributed to aspiration pneumonia. The patient gradually deteriorated despite antibiotics and became progressively short of breath, with development of large pleural and pericardial effusions. A diagnosis of postcardiac injury syndrome was made after exclusion of other differentials. The patient recovered well after pleurocentesis, pericardiocentesis and a pericardial window, with resolution of symptoms without further medical therapy.Copyright © 2017 BMJ Publishing Group Ltd (unless otherwise stated in the text of the article). All rights reserved.

Objective: Evaluate the first 1013 Basic Echo in Life Support (BELS) scans performed in the 3 Emergency Departments across Monash Health. Method(s): 1013 BELS, performed between September 2015 and December 2016, were stratified by indication into Clinical and Training. Further analysis was carried out on the Clinical group alone. Data was extracted on presentation/reason for BELS, physician interpretation and impact on formal sonography services due to re-call. Result(s): Of the 1013 scans, 679 (67%) were for clinical reasons. The three most common reasons for performing a BELS were chest pain 251 (37%), shortness of breath 158 (23%) and arrhythmia 48 (7%). There were 262 (39%) scans with abnormal findings. In 631 (93%) cases, the scan answered the physician's clinical question. Left ventricular dilatation and reduced function were noted in 130 (19%) and 168 (24%) patients, respectively. Right ventricular dilation and reduced function were noted in 105 (15%) and 126 (19%), respectively. Sonographer recall was avoided in 152 cases with an estimate saving of $21 000 in paid recall and forced leave, as well as prevention of cancellation of 73 out-patient echoes. Conclusion(s): Early assessment of the BELS programme indicates that its primary use is in the assessment of patients presenting with chest pain, shortness of breath and arrhythmia. BELS scans have high-clinical utility for the performing emergency department physician, and lead toareduction ofsonographerrecall for urgent formal scans.

Objectives: To evaluate the impact of comprehensive public awareness campaigns by the National Heart Foundation of Australia on emergency medical service (EMS) use by people with chest pain. Design, setting and participants: A retrospective analysis of 253 428 emergency ambulance attendances for non-traumatic chest pain in Melbourne, January 2008 e December 2013. Time series analyses, adjusted for underlying trend and seasonal effects, assessed the impact of mass media campaigns on EMS use. Main Outcome Measure(s): Monthly ambulance attendances. Result(s): The median number of monthly ambulance attendances for chest pain was 3609 (IQR, 3011e3891), but was higher in campaign months than in non-campaign months (3880 v 3234, P < 0.001). After adjustments, campaign activity was associated with a 10.7% increase (95% CI, 6.5e14.9%; P < 0.001) in monthly ambulance use for chest pain, and a 15.4% increase (95% CI, 10.1e20.9%; P < 0.001) when the two-month lag periods were included. Clinical presentations for suspected acute coronary syndromes, as determined by paramedics, increased by 11.3% (95% CI, 6.9e15.9%; P < 0.001) during campaigns. Although the number of patients transported to hospital by ambulance increased by 10.0% (95% CI, 6.1e14.2%; P < 0.001) during campaign months, the number of patients not transported to hospital also increased, by 13.9% (95% CI, 8.3e19.8%; P < 0.001). Conclusion(s): A public awareness campaign about responding to prodromal acute myocardial infarction symptoms was associated with an increase in EMS use by people with chest pain and suspected acute coronary syndromes. Campaign activity may also lead to increased EMS use in low risk populations.Copyright © 2017 AMPCo Pty Ltd. Produced with Elsevier B.V. All rights reserved.

Objective: We report a case of suspected metal fume fever after prolonged domestic exposure to lead vapors. Case report: A 26-year-old, unemployed, man presented to hospital complaining of headache, fever, retrosternal chest pain, generalized muscle aches, nausea, vomiting (x1) and diarrhoea (x6). Ten hours earlier, he melted and poured lead to make fishing sinkers, for 2 hours, in an unventilated shed without the use of personal protective equipment. He had performed the same task twice recently without any sequelae. On examination he had global headache, generalized myalgia, pulse 138 bpm, BP 138/80 mmHg, tachypnoea (respiratory rate 22/min), temperature 38.6degreeC and oxygen saturation 99% (room-air). Lungs were clear to auscultation and neurological examination was normal. Hemoglobin was 156 g/L, leucocytes 8.8 x 109/L (normal 4.0-11 x 109/L), electrolytes and liver function tests were unremarkable. A 12-lead electrocardiogram (ECG) showed sinus tachycardia. C-reactive protein was initially 33mg/L and 88 mg/L (normal <5) the following day. Metal fume fever was suspected, however, given the presence of headache, and concern for inhalational lead toxicity, succimer was commenced until a whole blood lead could be performed the next day. This was less than 0.10 mumol/L and succimer was ceased after 4 doses. Chest X-ray was normal. He remained febrile and tachycardic for 24 hours. Blood and urine cultures were all negative. Symptoms fully resolved after 24 hours. The patient remains well post-discharge. Conclusion(s): Metal fume fever presents as a transient, flu-like illness after prolonged exposure to metal oxide fumes. Zinc oxide fume inhalation during industrial welding is the most common cause [1]. The precise pathophysiology is unknown. Theories include delayed hypersensitivity from repeated exposure to fumes and direct pulmonary inflammatory mediator-release. Lead has been suggested as a potential cause [1,2], but currently there are no documented cases repor

The infectious etiology of myocarditis often remains unidentified. We report a case of myocarditis associated with human parechovirus (HPeV) infection in an adult. HPeV is an emerging pathogen that can cause serious illness, including myocarditis, in adults. Testing for HPeV should be considered in differential diagnosis of myocarditis.Copyright © 2017, Centers for Disease Control and Prevention (CDC). All rights reserved.

Learning Objectives: 1 Although uncommon, emphasis that therapeutic dose warfarin does not exclude a pulmonary embolism. 2 Appreciate the importance of the role of the radiologist in diagnosing pulmonary embolism. 3 Warfarin inefficacy is rare, highlight the need for prompt, thorough investigation (in this case suspected pulmonary embolism with a CTPA or V/Q scan). 4 Consider interventional radiology, such as inferior vena caval umbrella catheter, in patients with ineffective or contraindicated anticoagulant therapy. Background(s): A 48-year-old gentleman presented to the emergency department with a one week history of pleuritic sounding chest pain who has been taking warfarin for protein S deficiency and a previous pulmonary embolism. All vital signs were within normal parameters, examination was unremarkable, electrocardiogram and chest x-ray were within normal limits and a troponin was negative. His INR was 2.4 (therapeutic dose), believed to effectively exclude a pulmonary embolism and discharged back into the community. Two days later represented with worsening chest pain with an INR of 2.1. A computer tomography pulmonary angiogram confirmed pulmonary emboli within segmental branches of the right lower lobe. Imaging Findings OR Procedure Details: Occlusive and nonocclusive filling defects in keeping with pulmonary emboli are noted within segmental branches of the right lower lobe. Conclusion(s): Pulmonary embolism is a life-threatening condition that can result in death if left undiagnosed. It is well documented in the literature that a therapeutic warfarin dose does not exclude a pulmonary embolism. The only reliable way to completely exclude a pulmonary embolism is to perform diagnostic imaging. In patients with ineffective anticoagulant therapy, the placement of an inferior vena cava filters maybe as effective, or safer in preventing recurrent thromboembolism.

A single dose of the apolipoprotein (apo)A-I mimetic peptide D-4F rendered high-density lipoprotein (HDL) less inflammatory, motivating the first multiple-dose study. We aimed to assess safety/tolerability, pharmacokinetics, and pharmacodynamics of daily, orally administered D-4F. High-risk coronary heart disease (CHD) subjects added double-blinded placebo or D-4F to statin for 13 days, randomly assigned 1:3 to ascending cohorts of 100, 300, then 500 mg (n = 62; 46 men/16 women). D-4F was safe and well-tolerated. Mean ± SD plasma D-4F area under the curve (AUC, 0-8h) was 6.9 ± 5.7 ng/mL*h (100 mg), 22.7 ± 19.6 ng/mL*h (300 mg), and 104.0 ± 60.9 ng/mL*h (500 mg) among men, higher among women. Whereas placebo dropped HDL inflammatory index (HII) 28% 8 h postdose (range, 1.25-0.86), 300-500 mg D-4F effectively halved HII: 1.35-0.57 and 1.22-0.63, respectively (P < 0.03 vs. placebo). Oral D-4F peptide dose predicted HII suppression, whereas plasma D-4F exposure was dissociated, suggesting plasma penetration is unnecessary. In conclusion, oral D-4F dosing rendered HDL less inflammatory, affirming oral D-4F as a potential therapy to improve HDL function.

Management of acute thrombotic occlusion of coronary artery aneurysms is challenging with a lack of randomized trial evidence. We report an unusual case of a 30-year-old Indian Australian male who presented with an extensive anterior STEMI because of very large thrombus burden in a dilated proximal left anterior descending artery. A relatively conservative treatment approach comprising emergency aspiration thrombectomy and ongoing infusion of glycoprotein IIb/IIIa inhibitor, guided by surveillant inpatient angiography and intravascular ultrasound, helped achieve a satisfactory outcome in a complex setting in which percutaneous coronary angioplasty and stenting were not desirable. © 2014 Wiley Periodicals, Inc.Copyright © 2014 Wiley Periodicals, Inc.

Introduction: A third of patients undergoing elective angiography have chest pain without obstructive coronary artery disease (NoCAD), with many having persistent symptoms. The objective of the study is to identify the clinical and coronary haemodynamic determinants of persistent chest pain at 1 month in NoCAD patients. Method(s): Patients with NoCAD underwent invasive coronary haemodynamic testing including: (1) Microvascular function assessment using coronary flow reserve (CFR) and hyperaemic microvascular resistance (hMR) measured by a combined pressure/Doppler wire at peak hyperaemia induced by intravenous adenosine infusion (140mcg/kg/min), (2) Coronary endothelial function assessment with low dose intracoronary acetylcholine (IC-ACh) infusions (0.18mcg/min & 1.8mcg/min over 2 min respectively), and (3) Spasm provocation testing by IC-ACh boluses (25, 50 and 100mcg). Health status (symptoms, physical limitations and quality of life) was assessed at baseline and 1 month. Result(s): Of the 40 recruited patients (77% female, 54+/-11 years), 30 (75%) continued to experience chest pain. Univariate analysis revealed frequent chest pain prior to angiography (93% vs 50% P=0.004), prior unstable angina admission (73% vs 33% P=0.014) and microvascular dysfunction defined as hMR >1.9 (67% vs 30% P= 0.042) were determinants of persistent symptoms at 1 month.Onmultivariate logistic regression analysis, only abnormal hMR was an independent determinant of persistent chest pain (odd ratio, 4.83; 95% confidence interval, 0.91-25.71; P=0.06). Conclusion(s): Two-thirds of patients with NoCAD have persistent chest pain one month following elective angiography. An abnormal hMR is an independent predictor of this outcome and therapies targeting the microvascular dysfunction may alleviate the symptoms.

Pain is recognized as a clinical complication in cystic fibrosis (CF), but the prevalence, characteristics and clinical associations of this co-morbidity have not been systematically reviewed. Electronic searches of six databases were performed. For inclusion in phase 1, studies reported a pain prevalence rate in CF and/or its clinical associations. For phase 2, included studies reported the measurement properties of validity, reliability and responsiveness of an instrument assessing pain in CF. Two independent reviewers rated the quality of evidence (phase 1) and the measurement properties using the 4-point COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist (phase 2). Of the 400 studies identified in the literature, 16 met the inclusion criteria for phase 1 and 5 for phase 2. The mean (SD) quality score (of 16) was 11.8 (2.3). The pooled prevalence of pain in adults with CF was 77% (95% confidence interval (CI): 57%-92%) and in children was 42% (95% CI: 0%-91%). Common regions of pain included back, abdomen, chest and limbs. In children and adults, pain was associated with a poorer quality of life (QOL) and significant interference with treatments. Measurement properties of three instruments (Brief Pain Inventory, Multidimensional Pain Inventory, Daily Pain Assessment-CF) were construct validity and criterion-predictive validity, with variable findings based on 'fair' to 'good' quality studies. Pain is a common problem in both children and adults with CF. It has negative clinical associations with QOL and the ability to successfully undertake treatment. Further research exploring the measurement properties of instruments assessing pain is required.Copyright © 2016 The Author(s).

Background: There is limited data on age and gender based reference ranges for 24-h ambulatory electrocardiography in children, with no published Australian data. Patients and Methods: All 24-h Holter recordings from patients <=18 years performed between December 2010 and December 2012, for clinical indications of palpitations, chest pain or suspected paroxysmal arrhythmia were retrospectively evaluated. Exclusion criteria included structural heart disease, known or demonstrated arrhythmia or use of antiarryhthmic medications. Males and females were analysed using SPSS 20. Best-fit non-linear (logarithmic) regressions were derived for minimum and mean heart rates. Age and gender specific reference ranges were constructed according to the method of Altman and compared with published data. Result(s): 253 subjects (males = 138, females = 115) were included. Minimum heart rate (male: R2 = 0.69, female: R2 = 0.58), and mean heart rate (male: R2 = 0.69, female: R2 = 0.73) decreased with age (all p < 0.001). Males had lower mean and minimum heart rates by seven and five beats per minute respectively (both p < 0.05). These reference ranges are similar to previously published data. Conclusion(s): Heart rate was related to age and gender in our population and gender-specific reference ranges are required.

Objective: Acute coronary syndrome (ACS) encompasses unstable angina (UA), non ST elevation myocardial infarction (NSTEMI) and ST segment elevation myocardial infarction (STEMI). In 2007-2008 in Australia there were 95,000 hospitalisations for ACS. There is limited data about the level of agreement between the emergency department (ED) and hospital discharge diagnosis. The objective of this study is to describe the proportion of ED patients with a concordant ACS hospital discharge diagnosis and determine factors associated with this. Method(s): This study was a retrospective case series of consecutive presentations of patients with acute coronary syndrome to the EDs of Southern Health, Victoria, Australia, during a six-month period between August 2011 and January 2012. Result(s): 1028 patients diagnosed with ACS in the ED were identified. Hospital discharge diagnosis was recorded for 704 cases. The mean age was 63 years (SD 14.5) and 69% were male. 119 patients (16.9%) were diagnosed with a STEMI, 322 (45.7%) with a NSTEMI and 263 (37.4%) with UA. 68.3% had a concordant discharge diagnosis of ACS. An ED diagnosis of STEMI (87.4%), English as the primary language (OR 1.81 (1.13 - 2.89) and chest pain as the presenting complaint [OR 2.70 (1.72-4.23) were associated with a concordant diagnosis of ACS. Conclusion(s): Almost one third of patients who are admitted to the hospital with ACS have a different hospital discharge diagnosis. English language, chest pain and STEMI ECG changes are associated with a more concordant diagnosis. Further research needs to be performed to better understand these findings.

Background: The significance of pre-arrest factors in out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical services (EMS) is not well established. Objective(s): The purpose of this study was to assess the association between prodromal symptoms and pre-arrest clinical observations on the arresting rhythm and survival in EMS witnessed OHCA. Method(s): Between 1st January 2003 and 31st December 2011, 1,056 adult EMS witnessed arrests of a presumed cardiac aetiology were identified from the Victorian Ambulance Cardiac Arrest Registry. Pre-arrest prodromal features and clinical characteristics were extracted from the patient care record. Backward elimination logistic regression was used to identify pre-arrest factors associated with an initial shockable rhythm and survival to hospital discharge. Result(s): The median age was 73.0 years, 690 (65.3%) were male, and the rhythm of arrest was shockable in 465 (44.0%) cases. The most commonly reported prodromal symptoms prior to arrest were chest pain (48.8%), dyspnoea (41.8%) and altered consciousness (37.8%). An unrecordable systolic blood pressure was observed in 34.4%, a respiratory rate <13 or >24/min was present in 43.1%, and 45.5% had a Glasgow coma score <15. In the multivariable analysis, the following pre-arrest factors were significantly associated with survival: age, public location, aged care facility, chest pain, arm or shoulder pain, dyspnoea, dizziness, vomiting, ventricular tachycardia, pulse rate, systolic blood pressure, respiratory rate, Glasgow coma score, aspirin and inotrope administration. Conclusion(s): Pre-arrest factors are strongly associated with the arresting rhythm and survival following EMS witnessed OHCA. Potential opportunities to improve outcomes exist by way of early recognition and management of patients at risk of OHCA.

Background: Failure of left ventricular (LV) contractile reserve or reduced ejection fraction (EF) post-exercise represents an abnormal stress echocardiography (ESE) response. The aetiology of this response in the absence of obstructive coronary disease in patients with normal resting LVEF is unclear.We sought to determine whether patients with this response have subclinical LVmyocardial dysfunction. Method(s): Of 4542 consecutive patients who underwent ESE between January 2009 and January 2012, 521 underwent either CT or invasive angiography within three months. Having excluded those with obstructive (>=50%) coronary disease, hypertensive response to exercise, failure to achieve target heart rate, resting LVEF < 50% and >mild valvular disease, we identified 89 patients who demonstrated an abnormal LV contractile response to exercise. Resting early diastolic mitral annular velocity (e'), left atrial (LA) volume and transmitral Doppler were measured. Result(s): Of 89 included patients (age 61+/-10, 83% female, BMI 30+/-6), 78 underwent ESE to investigate chest pain and/or dyspnoea. Mean Bruce treadmill time was 7.1+/-2.7 min. LVEF decreased post-exercise in 77 (75%) patients andwas unchanged in 22 (25%). Mean resting calculated LVEF 60.0+/-6.5% fell to 54.7+/-8.2% post-exercise (p < 0.01). Resting echocardiography findings included: LV mass index 78+/-21 g/m2, septal e' 6.1+/-2.0 cm/s, lateral e' 8.1+/-2.9 cm/s, septal E/e' 11.9+/-4.0, LA volume 36.8+/-10.7 ml/m2. Septal and lateral e' velocities were abnormally reduced in 68 (76%) and 43 (48%) patients respectively (defined as >2 SDs below age-predicted mean). Based on ASE criteria, 76 patients (85%) had LA dilatation. Conclusion(s): An abnormal LV contractile response to exercise, in the absence of obstructive coronary disease or a hypertensive response, is associated with subclinical LV myocardial dysfunction and predominantly occurs in middle-aged females.

Several studies have estimated that 25-40% of all tests sent to the pathology laboratory are unnecessary. This may be due to inexperienced staff, poor understanding of test characteristics, or a perceived need for "completeness". Recently, ACEM and the RCPA (Royal College of Pathologists of Australasia) released a guideline on pathology testing in the emergency department. To date, there are no papers comparing current practice to these guidelines. This paper will present the findings of a three-month retrospective audit of all ED electronic medical records of pathology testing for a number of commonly encountered conditions from three Victorian hospital EDs in south east Melbourne (one tertiary ED, and two urban district EDs). The conditions reviewed included Chest pain (? STEMI and? Pulmonary embolism); Chest infection/pneumonia; COPD exacerbation; gastrointestinal bleeding; bleeding in early pregnancy; stroke/TIA; syncope; fractured neck of femur; renal colic; and deliberate self-poisoning. The results of the study will be used to develop a quality improvement programme to address unnecessary/inappropriate practice variance and lead to improved quality, safety and efficiency.

Clonidine is a central alpha(2)-agonist antihypertensive used widely for opioid/alcohol withdrawal, attention deficit hyperactivity disorder and chronic pain management. We describe a case of clonidine withdrawal causing life-threatening hypertensive crisis and stress-induced cardiomyopathy. A 47-year-old man with chronic back pain, treated with clonidine for many years via intrathecal pump (550 mcg/24 h), presented following a collapse and complaining of sudden worsening of back pain, severe headache, diaphoresis, nausea and vomiting. A few hours prior to presentation, his subcutaneous pump malfunctioned. On presentation, vital signs included pulse 100 bpm, BP 176/103 mmHg, temperature 37.8 degreeC and O2 saturation 100 % (room air). Acute clonidine withdrawal with hypertensive crisis was suspected. Intravenous clonidine loading dose and a 50 mcg/h infusion were commenced. Five hours later, severe chest pain, dyspnoea, tachycardia, hypoxia, with BP 180/120 mmHg and pulmonary edema ensued. ECG showed sinus tachycardia with no ST elevation. Repeated intravenous clonidine doses were given (25 mcg every 5-10 min), with ongoing clonidine infusion to control blood pressure. Glyceryl trinitrate infusion, positive pressure ventilation and intravenous benzodiazepines were added. Bedside echocardiogram showed stress-induced cardiomyopathy pattern. Serum troponin-I was markedly elevated. His coronary angiography showed minor irregularities in the major vessels. Over the next 3 days in the ICU, drug infusions were weaned. Discharge was 12 days later on oral clonidine, metoprolol, perindopril, aspirin and oxycodone-SR. Two months later, his echocardiogram was normal. The intrathecal pump was removed. We report a case of stress-induced cardiomyopathy resulting from the sudden cessation of long-term intrathecal clonidine. This was managed by re-institution of clonidine and targeted organ-specific therapies.Copyright © 2015, American College of Medical Toxicology.

Objective: Clonidine is a central alpha(2)-agonist antihypertensive used widely for indications such as opioid/alcohol withdrawal, Attention Deficit Hyperactivity Disorder and the management of chronic pain. In recent times, clonidine withdrawal has not been commonly reported. We describe an unusual case of clonidine withdrawal causing life-threatening sympathetic storm and takotsubo cardiomyopathy. Case report: A 47-year-old man with chronic back pain, treated with clonidine for many years via intrathecal pump (550 mcg/24hours), presented to our emergency department following collapse and complaining of sudden worsening of back pain, severe headache, diaphoresis, malaise, nausea and vomiting. A few hours prior to presentation, his subcutaneous pump beeped, suggesting malfunction. On presentation his vital signs were pulse 100 bpm, BP 176/103, temperature 37.8degreeC and O2 saturations 100% (room air). Acute clonidine withdrawal with hypertensive crisis was suspected. An intravenous clonidine loading-dose of 150 mcg was given, followed by 150 mcg/hour infusion. Despite this, 5 hours later, severe chest pain, dyspnoea, tachycardia (150 bpm), hypoxia (SpO2 82%), with BP 180/120 ensued. CXR showed pulmonary oedema. ECG showed sinus tachycardia with no ST elevation. The toxicology service was consulted and advised repeated boluses of clonidine 25 mcg every 5-10 minutes, with ongoing clonidine infusion to control his blood pressure with addition of glyceryl trinitrate (GTN) infusion, positive pressure ventilation and intravenous benzodiazepines. Bedside echocardiogram showed takotsubo-type stress-induced cardiomyopathy pattern. Serum troponin-I was markedly elevated. Subsequent in-patient coronary angiography showed minor irregularities in the major vessels. Over the next 3 days in ICU, GTN and clonidine infusions were weaned. Discharge was 12-days later on oral clonidine, metoprolol, perindopril, aspirin and oxycodone SR. Two months later an echocardiogram was normal. T

Background: The significance of pre-arrest factors in out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical services (EMS) is not well established. The purpose of this study was to assess the association between prodromal symptoms and pre-arrest clinical observations on the arresting rhythm and survival in EMS witnessed OHCA. Method(s): Between 1st January 2003 and 31st December 2011, 1056 adult EMS witnessed arrests of a presumed cardiac aetiology were identified from the Victorian Ambulance Cardiac Arrest Registry. Pre-arrest prodromal features and clinical characteristics were extracted from the patient care record. Backward elimination logistic regression was used to identify pre-arrest factors associated with an initial shockable rhythm and survival to hospital discharge. Result(s): The median age was 73.0 years, 690 (65.3%) were male, and the rhythm of arrest was shockable in 465 (44.0%) cases. The most commonly reported prodromal symptoms prior to arrest were chest pain (48.8%), dyspnoea (41.8%) and altered consciousness (37.8%). An unrecordable systolic blood pressure was observed in 34.4%, a respiratory rate <13 or >24min-1 was present in 43.1%, and 45.5% had a Glasgow coma score <15. In the multivariable analysis, the following pre-arrest factors were significantly associated with survival: age, public location, aged care facility, chest pain, arm or shoulder pain, dyspnoea, dizziness, vomiting, ventricular tachycardia, pulse rate, systolic blood pressure, respiratory rate, Glasgow coma score, aspirin and inotrope administration. Conclusion(s): Pre-arrest factors are strongly associated with the arresting rhythm and survival following EMS witnessed OHCA. Potential opportunities to improve outcomes exist by way of early recognition and management of patients at risk of OHCA.Copyright © 2014.

An 81 year-old female with severe aortic stenosis was admitted electively to determine her anatomic suitability for trans-catheter aortic valve implantation (TAVI). Transthoracic echocardiogram prior to referral confirmed critical aortic stenosis with a mean transaortic valve gradient of 106mmHg, aortic valve area (AVA) 0.6cm2 and dimensionless index (DI) 0.18. She reported a significant symptom burden with New York Heart Association Class III dyspnoea, four episodes of syncope in the month prior to admission and exertional chest pain.Copyright © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).

Background-Oxygen is commonly administered to patients with ST-elevation-myocardial infarction despite previous studies suggesting a possible increase in myocardial injury as a result of coronary vasoconstriction and heightened oxidative stress. Methods and Results-We conducted a multicenter, prospective, randomized, controlled trial comparing oxygen (8 L/min) with no supplemental oxygen in patients with ST-elevation-myocardial infarction diagnosed on paramedic 12-lead ECG. Of 638 patients randomized, 441 patients had confirmed ST-elevation-myocardial infarction and underwent primary endpoint analysis. The primary end point was myocardial infarct size as assessed by cardiac enzymes, troponin I, and creatine kinase. Secondary end points included recurrent myocardial infarction, cardiac arrhythmia, and myocardial infarct size assessed by cardiac magnetic resonance imaging at 6 months. Mean peak troponin was similar in the oxygen and no oxygen groups (57.4 versus 48.0 mug/L; ratio, 1.20; 95% confidence interval, 0.92-1.56; P=0.18). There was a significant increase in mean peak creatine kinase in the oxygen group compared with the no oxygen group (1948 versus 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There was an increase in the rate of recurrent myocardial infarction in the oxygen group compared with the no oxygen group (5.5% versus 0.9%; P=0.006) and an increase in frequency of cardiac arrhythmia (40.4% versus 31.4%; P=0.05). At 6 months, the oxygen group had an increase in myocardial infarct size on cardiac magnetic resonance (n=139; 20.3 versus 13.1 g; P=0.04). Conclusion-Supplemental oxygen therapy in patients with ST-elevation-myocardial infarction but without hypoxia may increase early myocardial injury and was associated with larger myocardial infarct size assessed at 6 months.Copyright © 2015 American Heart Association, Inc.

Introduction: Emergencies in radiology are infrequent, but potentially lethal. Australasian radiologists are advised to undergo resuscitation training at least every three years, however, little is known about their experience and confidence in managing common emergencies relevant to their clinical practice. This paper describes the current experience and confidence of Australasian radiologists and radiology trainees in the management of common medical emergencies. Method(s): A cross-sectional online survey of trainees and fellows of the RANZCR collected data on training and learning preferences relating to resuscitation and life-support skills, access to emergency medical care, and knowledge, confidence and ability in managing a variety of medical emergencies. Result(s): There were 602 responses to the survey (response rate 23.4%). The majority of respondents were interested in learning more about the management of contrast reactions, cardiac arrest, ischaemic chest pain, and basic life support. Self-rated knowledge, confidence and ability were higher in respondents who had completed life-support training within the previous three years. In this group, however, more than 40% rated their ability at managing contrast reactions as poor or fair, while more than 60% rated their ability as poor or fair for management of cardiac arrest, basic life support, advanced life support, and dosing of adrenaline. Preferred resuscitation training modalities included simulation, small group tutorials, and workshops. Conclusion(s): Self-reported level of skill and expertise in the management of potential emergencies in radiology is suboptimal among a large number of respondents. Consideration should be given to addressing this by improving access to specific training.

Background: Coronary computed tomography angiography (CTA) may be utilised for assessment of patients presenting to the Emergency Department (ED) with chest pain. We designed and tested a novel CTA-guided algorithm for triaging chest pain patients and sought to determine the efficacy and long-term safety of this diagnostic strategy. Method(s): We prospectively evaluated 542 consecutive patients who presented to ED between September 2008 and June 2011 with low-to-intermediate risk (TIMI 0-4) ischaemic-sounding chest pain and were evaluated with 320-row CTA after normal single or serial troponin measurements and normal electrocardiogram. Patients with known obstructive coronary stenoses or previous revascularisation were excluded. Patients without plaque or with mild stenoses on CTA were discharged without further investigation. Patients with moderate stenoses were discharged with outpatient stress echocardiogram phy. Patients with severe stenoses were admitted for invasive angiography. Discharged patients and/or their general practitioners were contacted to determine longterm MACE. Result(s): Mean age was 56.0+/-11.6 years (58% male). CTA showed no plaque or mild stenoses in 415 patients (77%) who were discharged without further investigation, moderate stenoses in 54 (10%) who were discharged with outpatient stress echocardiography and severe stenoses in 73 (13%) who were admitted. At median 23.3-month follow-up (range 8-41 months), there had been 10 chest pain readmissions (2%, 95%CI 1.2-3.9%), no revsascularisation procedures, no myocardial infarctions and no deaths (95%CI 0-0.8%). Follow-up was 100% complete. Conclusion(s): Triaging and discharging low-tointermediate risk chest pain patients from ED after investigation with a novel CTA-guided algorithm is safe with no MACE at long-term follow-up. This approach provides a paradigm for a new model of care for chest pain assessment in ED.