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Aims: This study aims to evaluate if pre-hospital heparin administration by paramedics is safe and improves clinical outcomes., Methods and Results: Using the multicentre Victorian Cardiac Outcomes Registry, linked with state-wide ambulance records, we identified consecutive patients undergoing primary percutaneous coronary intervention for STEMI between January 2014 and December 2018. Information on thrombolysis in myocardial infarction (TIMI) flow at angiography was available in a subset of cases. Patients receiving pre-hospital heparin were compared to those who did not receive heparin. Findings at coronary angiography and 30-day clinical outcomes were compared between groups. Propensity-score matching was performed for risk adjustment. We identified a total of 4720 patients. Of these, 1967 patients had TIMI flow data available. Propensity-score matching in the entire cohort yielded 1373 matched pairs. In the matched cohort, there was no observed difference in 30-day mortality (no-heparin 3.5% vs. heparin 3.0%, P = 0.25), MACCE (no-heparin 7% vs. heparin 6.2%, P = 0.44), and major bleeding (no-heparin 1.9% vs. heparin 1.4%, P = 0.64) between groups. Propensity-score analysis amongst those with TIMI data produced 552 matched pairs. The proportion of cases with TIMI 0 or 1 flow in the infarct-related artery (IRA) was lower among those receiving pre-hospital heparin (66% vs. 76%, P < 0.001) compared to those who did not., Conclusion: In this multicentre, propensity-score matched study, the use of pre-hospital heparin by paramedics was safe and is associated with fewer occluded IRAs in patients presenting with STEMI., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Objectives: In this study, we sought to evaluate the costs of percutaneous coronary intervention (PCI) across a variety of indications in Victoria, Australia, using a direct per-person approach, as well as to identify key cost drivers., Design: A cost-burden study of PCI in Victoria was conducted from the Australian healthcare system perspective., Setting: A linked dataset of patients admitted to public hospitals for PCI in Victoria was drawn from the Victorian Cardiac Outcomes Registry (VCOR) and the Victorian Admitted Episodes Dataset. Generalised linear regression modelling was used to evaluate key cost drivers. From 2014 to 2017, 20 345 consecutive PCIs undertaken in Victorian public hospitals were captured in VCOR., Primary Outcome Measures: Direct healthcare costs attributed to PCI, estimated using a casemix funding method., Results: Key cost drivers identified in the cost model included procedural complexity, patient length of stay and vascular access site. Although the total procedural cost increased from $A55 569 740 in 2014 to $A72 179 656 in 2017, mean procedural costs remained stable over time ($A12 521 in 2014 to $A12 185 in 2017) after adjustment for confounding factors. Mean procedural costs were also stable across patient indications for PCI ($A9872 for unstable angina to $A15 930 for ST-elevation myocardial infarction) after adjustment for confounding factors., Conclusions: The overall cost burden attributed to PCIs in Victoria is rising over time. However, despite increasing procedural complexity, mean procedural costs remained stable over time which may be, in part, attributed to changes in clinical practice., Competing Interests: Competing interests: PL is supported by an Australian Government Research Training Program (RTP) scholarship (Award/Grant number is not applicable). EZ has received grants from Amgen, Astra Zeneca, Pfizer, Shire and Zoll Medical Corporation outside of the submitted work. DL has received honoraria or study grants from Abbvie, Amgen, Astellas, AstraZeneca, Bohringer Ingelheim, Bristol Myers Squibb, Novartis, Pfizer, Sanofi, Shire and Zoll Medical Corporation, outside the submitted work. DS is supported by the National Heart Foundation Fellowship and Viertel Foundation Award. CMR is supported by a National Health and Medical Research Council Principal Research Fellowship (GNT1136372). All other authors have no conflicts of interest to disclose., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To compare short- and long-term outcomes after transcatheter aortic valve implantation (TAVI) in the public and private hospital setting., Design: Propensity-matched, retrospective analysis of a prospective registry., Setting and Participants: Patients with severe aortic stenosis who underwent TAVI at a tertiary public hospital (n=507) and an experienced private hospital (n=436)., Main Outcome Measures: The primary endpoint was all-cause mortality., Results: Patients that underwent TAVI in the public hospital were younger than patients in the private hospital (82±8 years vs 84±6 years, p<0.001), with lower estimated short-term mortality risk (Society of Thoracic Surgeons Predicted Risk of Mortality [STS-PROM] score >4.0%: 43% vs 56%, p<0.001). There was no difference between public and private hospitals in 30-day mortality (1.5% vs 1.2%, p=1.0), and the rate of complications was similar. Long-term survival was similar in propensity-matched public (n=344) and private (n=344) patient cohorts. The 1-year, 2-year, 5-year and 7-year survival rates were 95%, 90%, 67% and 47% in public patients, and 92%, 86%, 67% and 51% in private patients (p=0.94). In multivariable analysis, the hospital setting was not a predictor of mortality., Conclusion: Despite increased age and predicted mortality in private hospital patients, short- and long-term outcomes after TAVI were comparable between public and private hospital settings. This study demonstrates the feasibility of performing TAVI in a private hospital with a dedicated and experienced team and questions the current restricted access to TAVI in the private sector., (Copyright © 2021 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: We sought to determine if an association exists between prehospital chest pain severity and markers of myocardial injury., Methods and Results: Patients with confirmed ST elevation myocardial infarction (STEMI) treated by emergency medical services were included in this retrospective cohort analysis of the AVOID study. The primary endpoint was the association of pre-hospital initial chest pain severity, cardiac biomarkers and infarct size based on cardiac magnetic resonance imaging. Groups were categorized based on moderate to severe chest pain (numerical rating scale pain ≥ 5/10) or less than moderate severity to compare procedural and clinical outcomes. 414 patients were included in the analysis. There was a weak correlation between initial pre-hospital chest pain severity and peak creatine kinase (r = 0.16, p = 0.001) and peak cardiac troponin I (r = 0.14, p = 0.005). Both were no longer significant after adjusting for known confounders. There was no association between moderate to severe chest pain on arrival and major adverse cardiac events at 6 months (20% vs. 14%, p=0.12). There was a weak correlation between history of ischemic heart disease (r = 0.16, p = 0.001), percutaneous coronary intervention (r = 0.16, p = 0.001), left anterior descending artery (r = 0.12, p = 0.012) as the culprit vessel and a weak negative correlation between age (r = -0.14, p = 0.039) and chest pain., Conclusion: Only a weak association between pre-hospital chest pain severity and markers of myocardial injury was identified, supporting more judicious use of opioid analgesia with a focus on patient comfort., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 Published by Elsevier B.V.)

Importance: The practice of pretreatment with oral P2Y12 inhibitors in non-ST elevation acute coronary syndromes (NSTEACS) remains common; however, its association with improved cardiovascular outcomes is unclear., Objective: To assess the association between oral P2Y12 inhibitor pretreatment and cardiovascular and bleeding outcomes in patients with NSTEACS., Data Sources: On March 20, 2021, PubMed, MEDLINE, Embase, Scopus, Web of Science, Science Direct, clinicaltrials.gov, and the Cochrane Central Register for Controlled Trials were searched from database inception., Study Selection: Randomized clinical trials of patients with NSTEACS randomized to either oral P2Y12 inhibitor pretreatment (defined as prior to angiography) or no pretreatment (defined as following angiography, once coronary anatomy was known) among patients undergoing an invasive strategy., Data Extraction and Synthesis: This study followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data on publication year, sample size, clinical characteristics, revascularization strategy, P2Y12 inhibitor type and dosage, time from pretreatment to angiography, and end point data were independently extracted by 2 authors. A random-effects model was used, including stratification by (1) P2Y12 inhibitor type, (2) revascularization strategy, and (3) access site., Main Outcomes and Measures: The primary end point was 30-day major adverse cardiac events (MACEs). Secondary end points were 30-day myocardial infarction (MI) and cardiovascular death. The primary safety end point was 30-day major bleeding (defined according to individual studies)., Results: A total of 7 trials randomizing 13 226 patients to either pretreatment (6603 patients) or no pretreatment (6623 patients) were included. The mean age of patients was 64 years and 3598 (27.2%) were female individuals. Indication for P2Y12 inhibitors was non-ST elevation myocardial infarction in 7430 patients (61.7%), radial access was used in 4295 (32.6%), and 10 945 (82.8%) underwent percutaneous coronary intervention. Pretreatment was not associated with a reduction in 30-day MACE (odds ratio [OR], 0.95; 95% CI, 0.78-1.15; I2 = 28%), 30-day MI (OR, 0.90; 95% CI, 0.72-1.12; I2 = 19%), or 30-day cardiovascular death (OR, 0.79; 95% CI, 0.49-1.27; I2 = 0%). The risk of 30-day major bleeding was increased among patients who underwent pretreatment (OR, 1.51; 95% CI, 1.16-1.97; I2 = 41%). The number needed to harm to bring about 1 major bleeding event with oral P2Y12 inhibitor pretreatment was 63 patients., Conclusions and Relevance: In this study, pretreatment with oral P2Y12 inhibitors among patients with NSTEACS prior to angiography, compared with treatment once coronary anatomy is known, was associated with increased bleeding risk and no difference in cardiovascular outcomes. Routine pretreatment with oral P2Y12 inhibitors in patients with NSTEACS receiving an early invasive strategy is not supported by this study.

Identifying acute MI in the setting of left bundle branch block (LBBB) is challenging because ST-segment elevation is often found at baseline. When faced with LBBB and ischemic symptoms, identifying which patients require urgent reperfusion therapy is critical. Sgarbossa et al. derived three criteria that can be used to help identify these patients, Smith et al. refined these criteria creating the Smith-modified Sgarbossa criteria. We present a case of LBBB meeting the Smith-modified Sgarbossa criteria, recognized by paramedics and used to activate the catheterization laboratory after normal business hours. The patient was found with 95% stenosis of the left anterior descending artery and received stenting.

Aims: We assessed the impact of intravenous fentanyl and lignocaine on the pharmacokinetics and pharmacodynamics of ticagrelor in patients with unstable angina and non-ST-elevation myocardial infarction and their procedural analgesic efficacy and safety., Methods and Results: Seventy patients undergoing coronary angiography with ticagrelor loading were included in the pharmacokinetic and pharmacodynamic analyses of this randomized trial. Plasma ticagrelor levels 2 h post-loading dose were significantly lower in the fentanyl arm than in the lignocaine treatment arm (598 vs. 1008 ng/mL, P = 0.014). The area under the plasma-time curves for ticagrelor (1228 vs. 2753 ng h/mL, P < 0.001) and its active metabolite (201 vs. 447 ng h/mL, P = 0.001) were both significantly lower in the fentanyl arm. Expression of activated platelet glycoprotein IIb/IIIa receptor (2829 vs. 1426 mean fluorescence intensity, P = 0.006) and P-selectin (439 vs. 211 mean fluorescence intensity, P = 0.001) was significantly higher at 60 min in the fentanyl arm. A higher proportion of patients had high on-treatment platelet reactivity in the fentanyl arm at 60 min using the Multiplate Analyzer (41% vs. 9%, P = 0.002) and 120 min using the VerifyNow (30% vs. 3%, P = 0.003) and VASP (37% vs. 6%, P = 0.002) assays. Both drugs were well tolerated with a high level of patient satisfaction., Conclusions: Unlike fentanyl, lignocaine does not impair the bioavailability or delay the antiplatelet effect of ticagrelor. Both drugs were well tolerated and effective with a high level of patient satisfaction for procedural analgesia. Routine procedural analgesia during percutaneous coronary intervention should be reconsidered and if performed, lignocaine is a beneficial alternative to fentanyl., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Aim: Cardiac arrest (CA) survival has diverse psychosocial outcomes for both survivors and their close family, with little known regarding long-term adjustment and recovery experiences. We explored the psychological adjustment and experiential perspectives of survivors and families in the second year after out-of-hospital cardiac arrest (OHCA)., Methods: A prospective, mixed-methods study of adult OHCA survivors in Victoria, Australia was conducted. Eighteen survivors and 12 family members completed semi-structured interviews 14-19 months post-arrest. Survivors' cognition, anxiety, depression and post-traumatic stress symptoms were measured using a battery of psychological assessments. A thematic content analysis approach was applied to qualitative interview data by two independent investigators, with data coded and categorised into themes and sub-themes., Results: Survivors' cognition, depression, anxiety and post-traumatic stress symptoms were not clinically elevated in the second year post-arrest. Subjective cognitive failures were associated with increased anxiety but not with mental state. Depression was significantly correlated with post-traumatic symptoms. Six primary themes emerged from survivors' recovery stories, focused on: awakening and realisation, barriers to adjustment, psychosocial difficulties, integration, protective factors and unmet needs. Family perspectives revealed four primary themes focused on trauma exposure, survivor adjustment problems, family impact, and areas for service improvement., Conclusion: Survivors and their family members describe complex recovery journeys characterised by a range of psychosocial adjustment challenges, which are not adequately captured by common psychological measures. Post-arrest care systems are perceived by survivors and their families as inadequate due to a lack of accurate information regarding post-arrest sequalae, limited follow-up and inconsistent access to allied health care., (Copyright © 2021 Elsevier B.V. All rights reserved.)

The short- and long-term implications of identifying totally occluded culprit coronary arteries (TOCCA) in patients presenting with non-ST-elevation myocardial infarction (NSTEMI) have not been well studied. This study compares clinical characteristics, short- and long-term outcomes of patients with NSTEMI identified with TOCCA to that of patients with non-TOCCA undergoing percutaneous coronary intervention (PCI). We analyzed data from patients with NSTEMI undergoing single-vessel PCI within the Melbourne Interventional Group multi-center registry between 2005 and 2017. Those with TOCCA were compared to those with non-TOCCA. The primary endpoint was 30-day major adverse cardiac events (MACE). Secondary endpoints included 12-month MACE and long-term mortality. A total of 6,829 patients with NSTEMI had single-vessel PCI of which 954 (14%) had TOCCA. Most TOCCA were non-left anterior descending (right coronary artery 39% versus circumflex 33% versus left anterior descending 26%; p <0.001). Cardiogenic shock and left ventricular dysfunction were higher in the TOCCA group, but non-TOCCA patients had more baseline comorbidities. Thirty-day MACE was higher in the TOCCA group (6.7% versus 3.8%; p <0.001). Long-term mortality with an average follow-up of 4.9 years was higher in the non-TOCCA group (12% versus 18%, p <0.01). Multivariable Cox-proportional hazards regression identified TOCCA as an independent predictor of 30-day MACE (HR = 1.93; 95%CI: 1.4-2.6), but not long-term mortality, which was predicted by baseline comorbidities. In conclusion, while patients with NSTEMI with TOCCA undergoing PCI represent a more unstable subgroup early on, long-term outcomes appear more dependent on baseline comorbidities., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Clinical trials have shown that radial access percutaneous coronary intervention (PCI) is associated with improved patient outcomes compared to femoral artery access. However, few studies have evaluated the cost-effectiveness of radial access PCI. This analysis sought to evaluate the cost-effectiveness of transradial versus transfemoral access PCI for patients with acute coronary syndrome (ACS) using data from the Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox (MATRIX) trial. A decision analytic Markov model was constructed from an Australian health care perspective with a 2 year time horizon. The model simulated recurrent cardiovascular disease and death post PCI among a hypothetical cohort of 1000 individuals with ACS. Population and efficacy data were based on the MATRIX trial. Cost and utility data were drawn from published sources. Over a 2-year time horizon, radial access was predicted to save 12 (discounted) quality adjusted life years (QALYs) compared with femoral access PCI. Cost savings (discounted) amounted to AUD $51,305. Hence from a health economic point of view, radial access PCI was dominant over femoral access PCI. Sensitivity analyses supported the robustness of these findings. Radial access PCI is likely to be associated with both better outcomes and lower costs compared to femoral access PCI over 2 years post procedure. In conclusion, these findings support radial access being the preferred approach in PCI for ACS., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Between 2009 and 2013, the National Heart Foundation of Australia ran mass media campaigns to improve Australian's awareness of acute coronary syndrome (ACS) symptoms and the need to call emergency medical services (EMS). This study examined the impact of this campaign on emergency department (ED) presentations and EMS use in Victoria, Australia., Methods: The Victorian Department of Health and Human Services provided data for adult Victorian patients presenting to public hospitals with an ED diagnosis of ACS or unspecified chest pain (U-CP). We modelled changes in the incidence of ED presentations, and the association between the campaign period and (1) EMS arrival and (2) referred to ED by a general practitioner (GP). Models were adjusted for increasing population size, ACS subtype and demographics., Results: Between 2003 and 2015, there were 124 632 eligible ED presentations with ACS and 536 148 with U-CP. In patients with ACS, the campaign period was associated with an increase in ED presentations (incidence rate ratio: 1.11; 95% CI 1.07 to 1.15), a decrease in presentations via a GP (adjusted OR (AOR): 0.77; 95% CI 0.70 to 0.86) and an increase in EMS use (AOR: 1.10; 95% CI 1.05 to 1.17). Similar, but smaller associations were seen in U-CP., Conclusions: The Warning Signs Campaign was associated with improvements in treatment seeking in patients with ACS-including increased EMS use. The increase in ACS ED presentations corresponds with a decrease in out-of-hospital cardiac arrest over this time. Future education needs to focus on improving EMS use in ACS patient groups where use remains low., Competing Interests: Competing interests: JEB and JF have provided unpaid consultancy assistance to the NHFA. The NHFA was not involved in this study beyond providing campaign information., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: National cardiac registries are increasingly used for informing health policy, improving the quality and cost-effectiveness of patient care, clinical research, and monitoring the safety of novel treatments. However, the quality of registries is variable. We aimed to assess the characteristics and quality of national cardiac registries across all subspecialties of cardiac care., Methods: Publications relating to national cardiac registries across six cardiac subspecialty domains were identified by searching MEDLINE and the Google advanced search function with 26 438 citations and 4812 full-text articles reviewed., Results: A total of 155 registries, representing 49 countries, were included in the study. Of these, 45 related to coronary disease or percutaneous coronary intervention, 28 related to devices, arrhythmia, and electrophysiology, 24 related to heart failure, transplant, and mechanical support, 21 related to structural heart disease, 21 related to congenital heart disease, and 16 related to cardiac surgery. Enrollment was procedure-based in 60% and disease-based in 40%. A total of 73.10 million patients were estimated to have been enrolled in cardiac registries. Quality scoring was performed using a validated registry grading system, with registries performing best in the use of explicit variable definitions and worst in assessment of data reliability. Higher quality scores were associated with government funding, mandated enrollment, linkage to other registries, and outcome risk adjustment. Quality scores and number of registries within a country were positively correlated with each other and with measures of national economic output, health expenditure, and urbanization., Conclusions: There has been remarkable growth in the uptake of national cardiac registries across the last few decades. However, the quality of processes used to ensure data completeness and accuracy remain variable and few countries have integrated registries covering multiple subspecialty domains. Clinicians, funders, and health policymakers should be encouraged to focus on the range, quality, and integration of these registries. Registration: URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42020204224.

Background: The emergency department (ED) plays an important role in out-hospital-cardiac arrest (OHCA) management. However, ED outcomes are not widely reported. This study aimed to (1) describe OHCA ED outcomes and reasons for ED deaths, and (2) whether these differed between hospitals., Methods: Data were obtained from the Victorian Ambulance Cardiac Arrest Registry and 12 hospitals for adult, non-traumatic OHCA cases transported to ED between 2014 and 2016. Multivariable logistic regression was used to examine the association of level of cardiac arrest centre on ED survival in a subset of cases (non-paramedic witnessed OHCA who were unconscious on ED arrival with ROSC)., Results: Of 1547 eligible OHCA cases, 81% (N = 1254) survived ED, varying between 57% to 88% between EDs. Among non-survivors, the majority had either: cessation of resuscitation after presenting with CPR in progress (27%); withdrawal of life-sustaining treatment for non-neurological (n = 65, 22%) or neurological (16%) reasons; or a unsuccessful resuscitation following a rearrested in ED (20%). These causes of ED deaths varied between the different levels of cardiac arrest centres, and in our subset of interest (n = 952) ED survival was associated with transportation to centres with high annual OHCA volumes and with 24-hour cardiac intervention capabilities (AOR = 3.43, 95% CI 1.89-6.21)., Conclusion: Our study found wide variation in survival between EDs, which was associated with hospital characteristics. Such data suggests the need for a detailed review of ED deaths, particularly in non-cardiac arrest centres, and potentially the need for monitoring ED survival as a measure of quality., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Data on the patient characteristics and health outcomes of Indigenous Australians having revascularisation for treatment of coronary artery disease are scarce. The aim of this study was to assess differences in patient characteristics, presentations, and outcomes among Indigenous and non-Indigenous Australians having percutaneous coronary intervention (PCI) in urban and larger regional centres in Victoria, Australia., Methods: In this multicentre, prospective, observational cohort study, data were prospectively collected from six government-funded tertiary hospitals in the state of Victoria, Australia. The Melbourne Interventional Group PCI registry was used to identify patients having PCI at Victorian metropolitan and large regional hospitals between Jan 1, 2005, and Dec 31, 2018. The primary outcome was long-term mortality. Secondary outcomes were 30 day mortality and 30 day major adverse cardiovascular events (MACE), defined as a composite endpoint of death, myocardial infarction, and target-vessel revascularisation. Regression analyses, adjusted for clinically relevant covariates and geographical and socioeconomic indices, were used to establish the influence of Indigenous status on these study outcomes., Findings: 41 146 patient procedures were entered into the registry, of whom 179 (0·4%) were recorded as identifying as Indigenous Australian, 39 855 (96·9%) were not Indigenous Australian, and 1112 (2·7%) had incomplete data regarding ethnicity and were excluded. Compared with their non-Indigenous counterparts, Indigenous patients were younger, more often women, and more likely to have comorbidities. Indigenous Australians were also more likely to live in a regional community and areas of socioeconomic disadvantage. Procedural success and complication rates were similar for Indigenous and non-Indigenous patients having PCI. At 30 day follow-up, Indigenous Australians were more likely to be taking optimal medical therapy, although overall follow-up rates were lower and prevalence of persistent smoking was higher. Multivariable analysis showed that Indigenous status was independently associated with increased risk of long-term mortality (hazard ratio 2·49, 95% CI 1·79-3·48; p<0·0001), 30 day mortality (odds ratio 2·78, 95% CI 1·09-7·12; p=0·033), and 30-day MACE (odds ratio 1·87, 95% CI 1·03-3·39; p=0·039)., Interpretation: Indigenous Australians having PCI in urban and larger regional centres are at increased risk of mortality and adverse cardiac events. Clinically effective and culturally safe care pathways are urgently needed to improve health outcomes among Indigenous Australians who are having PCI., Funding: National Health and Medical Research Council, National Heart Foundation., Competing Interests: Declaration of interests LPD is supported by the National Health and Medical Research Council of Australia (NHMRC) and National Heart Foundation postgraduate scholarships. SJD is supported by a NHMRC grant (reference number 1111170). CMR is supported by a NHMRC Principal Research Fellowship (reference number 1136972). DS is supported by National Heart Foundation grants. All author authors declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

There is paucity of data examining long-term outcomes of premature coronary artery disease (CAD). We aimed to investigate the short- and long-term clinical outcomes of patients with premature CAD treated by percutaneous coronary intervention (PCI) compared to older cohorts. We analyzed data from 27,869 patients who underwent PCI from 2005-2017 enrolled in a multicenter PCI registry. Patients were divided into three age groups: young group (≤ 45 years), middle-age group (46-65 years) and older group (>65 years). There were higher rates of current smokers in the young (n = 1,711) compared to the middle-age (n = 12,830) and older groups (n = 13,328) (54.2% vs 34.6% vs 11%) and the young presented more frequently with acute coronary syndrome (ACS) (78% vs 66% vs 62%), all p <0.05. There were also greater rates of cardiogenic shock (CS), out-of-hospital cardiac arrest (OHCA) and ST-elevation myocardial infarction (STEMI) in the young, all p <0.05. The young cohort with STEMI had higher rates of in-hospital, 30-day death, and long-term mortality (3.8% vs 0.2%, 4.3% vs 0.2% and 8.6% vs 3.1%, all p <0.05, respectively) compared to the non-STEMI subgroup. There was a stepwise increase in long-term mortality from the young, to middle-age, to the older group (6.1% vs 9.9% vs 26.8%, p <0.001). Younger age was an independent predictor of lower long-term mortality (HR 0.66, 95% CI 0.52-0.84, p = 0.001). In conclusion, younger patients presenting with STEMI had worse prognosis compared to those presenting with non-STEMI. Despite higher risk presentations among young patients, their overall prognosis was favorable compared to older age groups., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background Women with ST-segment-elevation myocardial infarction experience delays in reperfusion compared with men with little data on each time component from symptom onset to reperfusion. This study analyzed sex discrepancies in patient delays, prehospital system delays, and hospital delays. Methods and Results Consecutive patients with ST-segment-elevation myocardial infarction treated with percutaneous coronary intervention across 30 hospitals in the Victorian Cardiac Outcomes Registry (2013-2018) were analyzed. Data from the Ambulance Victoria Data warehouse were used to perform linkage to the Victorian Cardiac Outcomes Registry for all patients transported via emergency medical services (EMS). The primary end point was EMS call-to-door time (prehospital system delay). Secondary end points included symptom-to-EMS call time (patient delay), door-to-device time (hospital delay), 30-day mortality, major adverse cardiovascular events, and major bleeding. End points were analyzed according to sex and adjusted for age, comorbidities, cardiogenic shock, cardiac arrest, and symptom onset time. A total of 6330 (21% women) patients with ST-segment-elevation myocardial infarction were transported by EMS. Compared with men, women had longer adjusted geometric mean symptom-to-EMS call times (47.0 versus 44.0 minutes; P <0.001), EMS call-to-door times (58.1 versus 55.7 minutes; P <0.001), and door-to-device times (58.5 versus 54.9 minutes; P =0.006). Compared with men, women had higher 30-day mortality (odds ratio [OR], 1.38; 95% CI, 1.06-1.79; P =0.02) and major bleeding (OR, 1.54; 95% CI, 1.08-2.20; P =0.02). Conclusions Female patients with ST-segment-elevation myocardial infarction experienced excess delays in patient delays, prehospital system delays, and hospital delays, even after adjustment for confounders. Prehospital system and hospital delays resulted in an adjusted excess delay of 10 minutes compared with men.

Objectives: To evaluate the effect of age in an all-comers population undergoing percutaneous coronary intervention (PCI)., Background: Age is an important consideration in determining appropriateness for invasive cardiac assessment and perceived clinical outcomes., Methods: We analysed data from 29,012 consecutive patients undergoing PCI in the Melbourne Interventional Group (MIG) registry between 2005 and 2017. 25,730 patients <80 year old (78% male, mean age 62±10 years; non-elderly cohort) were compared to 3,282 patients ≥80 year old (61% male, mean age 84±3 years; elderly cohort)., Results: The elderly cohort had greater prevalence of hypertension, diabetes and previous myocardial infarction (all p<0.001). Elderly patients were more likely to present with acute coronary syndromes, left ventricular ejection fraction <45% and chronic kidney disease (p<0.0001). In-hospital, 30-day and long-term all-cause mortality (over a median of 3.6 and 5.1 years for elderly and non-elderly cohorts, respectively) were higher in the elderly cohort (5.2% vs. 1.9%; 6.4% vs. 2.2%; and 43% vs. 14% respectively, all p<0.0001). In multivariate Cox regression analysis, estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m 2 (HR 3.8, 95% CI: 3.4-4.3), cardiogenic shock (HR 3.0, 95% CI: 2.6-3.4), ejection fraction <30% (HR 2.5, 95% CI: 2.1-2.9); and age ≥80 years (HR 2.8, 95% CI: 2.6-3.1) were independent predictors of long-term all-cause mortality (all p<0.0001)., Conclusion: The elderly cohort is a high-risk group of patients with increasing age being associated with poorer long-term mortality. Age, thus, should be an important consideration when individualising treatment in elderly patients., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

There are conflicting data on whether patients with insulin-treated diabetes mellitus (ITDM) have poorer outcomes compared with non-insulin treated diabetic (non-ITDM) patients following percutaneous coronary intervention (PCI). We therefore compared clinical outcomes following PCI in ITDM versus non-ITDM patients. We prospectively collected data on 4,579 patients with diabetes underwent PCI between 2005 and 2014 in a large multicenter registry and dichotomized them as having ITDM (n = 1,111) or non-ITDM (n = 3,468). The non-ITDM group was further divided into diet control only (diet-DM; n = 786) and those taking oral hypoglycemic agents (OHG-DM; n = 2,639), and clinical outcomes were compared with ITDM patients. Median follow-up for long-term mortality was 4.2 years (IQR 2.0 to 6.6 years). ITDM patients were more likely to be female, obese, and have severe renal impairment (all p <0.001). Procedural characteristics were similar other than a greater use of drug-eluting stents in ITDM patients. On multivariable analysis, ITDM was an independent predictor of 12-month major adverse cardiovascular and cerebrovascular events (MACCE; OR 1.26, 95% CI 1.02 to1.55, p = 0.03). Dividing the non-ITDM group further by treatment, a progressively higher rate of 12-month MACCE across the 3 groups was observed (13.5% vs 17.9% vs 21.8%; p <0.001). Long-term mortality was similar in the diet-DM and OHG-DM groups, but significantly higher in the ITDM group on Kaplan-Meier analysis (log-rank p <0.001). In conclusion, there is a clear gradient of adverse outcomes with escalation of therapy from diet control to OHGs to insulin., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background There is increasing evidence that opioids interfere with the oral bioavailability of P2Y 12 inhibitors leading to delayed onset of antiplatelet effects. Several strategies have been proposed to mitigate this interaction including utilizing alternative analgesic agents in the management of ischemic chest pain. Methods The lidocAine Versus Opioids In MyocarDial Infarction (AVOID-2) study is a phase II, pre-hospital, open-label, non-inferiority, randomized controlled trial conducted by Ambulance Victoria and Monash University in metropolitan Melbourne, Victoria, Australia. The purpose of the study is to compare the analgesic effect (reduction in pain by arrival to hospital) and safety (e.g. adverse drug reactions) (co-primary endpoints) of intravenous lidocaine versus intravenous fentanyl in 300 adult patients attended by ambulance with suspected ST-elevation myocardial infarction (STEMI). Secondary endpoints and a cardiac magnetic resonance imaging (MRI) sub-study will also compare infarct size between these two groups. Conclusions The evaluation of alternative analgesic agents in the management of acute coronary syndromes is urgently needed to manage the opioid-P2Y 12 inhibitor interaction. The results of this trial will have significant implications on the emergency management of acute coronary syndromes internationally., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Many emergency medical service (EMS) agencies are implementing programmes to improve the quality and performance of resuscitation. We sought to examine the impact of a resuscitation quality improvement programme on outcomes following OHCA., Methods: An interrupted time-series analysis of adult OHCA patients of medical aetiology. Patients treated after the implementation of a high-performance cardiopulmonary resuscitation (CPR) intervention between February 2019 and January 2020 were compared to historical controls between January 2015 and January 2019. The effect of the intervention on the risk-adjusted odds of survival were examined using logistic regression models, with and without adjustment for temporal trends., Results: A total of 8270 and 2330 patients were treated in the control and intervention periods, respectively. Patients in the intervention period were older and less likely to arrest in public, present with an initial shockable rhythm, and receive mechanical CPR. After adjustment for arrest factors and temporal trends, there was a significant increase in the level of monthly survival to hospital discharge (AOR 1.50; 95% CI: 1.10, 2.04; p = 0.01), event survival (AOR 1.34; 95% CI: 1.09, 1.65; p = 0.006) and return of spontaneous circulation (AOR 1.38; 95% CI: 1.14, 1.65; p = 0.001). After removing the non-significant temporal trend, there was a 33% increase (AOR 1.33; 95% CI: 1.11, 1.58; p = 0.002) in the risk-adjusted odds of survival over the 12-month intervention period. The average marginal effect of the intervention resulted in 8.7 (95% CI: 3.2, 14.1) additional survivors per million population., Conclusion: A resuscitation quality improvement programme consisting of high-performance CPR was associated with a significant increase in survival following OHCA., (Copyright © 2021 Elsevier B.V. All rights reserved.)

In 2019, the first multi-source registry of sudden cardiac arrest and death for patients aged 1-50 years launched in Victoria, Australia. Sudden cardiac arrest (SCA) affects approximately fifteen hundred younger Victorians per year. The End Unexplained Cardiac Death (EndUCD) Registry enrols SCA/death (D) cases aged 1-50 years, providing family screening, access to psychological support through clinical sites and creating a genetic biorepository for whole-genome sequencing. The registry will support clear pathways of cardiac assessment, epidemiological profiling and routine family screening and psychological support., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.)

Objectives: This study determined whether flow state classified by stroke volume index (SVi) or transvalvular flow rate (FR) improved risk stratification of all-cause mortality, hospitalization due to heart failure, and aortic valvular interventions for patients with severe aortic stenosis (AS)., Background: SVi is a widely accepted classification for flow state in severe low-flow, low-gradient (LFLG) AS. Recent studies suggest that FR more closely approximates true AS severity and provides more useful prognostication than SVi., Methods: Patients with severe AS over a 7-year period were subclassified by echocardiographic parameters. LFLG-AS was defined as severe AS (aortic valve area index [AVAi]: <0.6 cm 2 /m 2 ), with a mean transvalvular pressure gradient of <40 mm Hg in the setting of low flow state: SVi of <35 ml/m 2 and/or FR of <200 ml/s and subclassified into preserved (≥50%; paradoxical) or reduced (<50%; classical) left ventricular ejection fraction (LVEF)., Results: Among 621 consecutive patients with severe AS, the proportions of patients classified as LFLG-AS were different between SVi and FR (p < 0.001). Classification using SVi, FR, and LVEF was a strong predictor of the composite endpoint at the 2-year follow-up. The addition of SVi to the echocardiographic and clinical model provided significant improvement in reclassification (net reclassification improvement: 0.089; 95% confidence interval [CI]: 0.045 to 0.133; p = 0.04), whereas addition of FR did not (net reclassification improvement: 0.061; 95% CI: 0.016 to 0.106; p = 0.17). C-statistics indicated improved risk discrimination when AVAi, LVEF, and SVi or FR were added as predictive variables to the clinical model (p = 0.006)., Conclusions: Low SVi or FR was associated with adverse cardiovascular events and showed improvement in discrimination, but only SVi, not FR, significantly improved risk reclassification compared to other conventional clinical and echocardiographic predictors. This suggests that FR is not superior to SVi in distinguishing true severe from pseudosevere forms of AS and identification of patients with LFLG-AS who have worse outcomes., Competing Interests: Funding Support and Author Disclosures This work has been supported in part by a partnership grant (1149692) from the National Health and Medical Research Council, Canberra. Dr. Sen was supported by scholarships from the National Heart Foundation of Australia (identification: 102578), National Health and Medical Research Council of Australia (identification: 1191044), Baker Heart and Diabetes Institute (Bright Sparks), and the Australian Government Research Training Program. Dr. Stub is supported by a fellowship from the National Heart Foundation, Canberra. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: There is increasing evidence that use of intravascular ultrasound (IVUS) guidance during percutaneous coronary intervention (PCI) is associated with improved clinical outcomes compared with angiography guidance alone. However, concern regarding the cost-effectiveness of IVUS has limited use of this technology worldwide. In this study, we aimed to evaluate the cost-effectiveness of IVUS-guided PCI compared with angiography-guided PCI in patients undergoing drug-eluting stent implantation., Methods: A decision-analytic Markov model was constructed to compare the cost-effectiveness of IVUS to angiography guidance from the Australian healthcare system perspective. Procedure-related morbidity and mortality were estimated from the literature. Costs were obtained from Australian sources. The population of interest was all-comers undergoing PCI with drug-eluting stent. Outcomes of interest included costs, life-expectancy, and quality-adjusted life years (QALYs) for both treatment groups., Results: In the base case, IVUS guidance was cost-effective compared with angiography guidance alone. With 5% annual discounting, IVUS was associated with increased lifetime costs of Australian dollars (AUD) $823 (USD $597) per person and benefits of 0.04 life years and 0.05 QALYs compared with angiography, yielding an incremental cost-effectiveness ratio of AUD $17 539 (USD $12 730) per QALY gained. Results were robust to sensitivity analyses, with IVUS being cost-effective in 99% of 10 000 Monte Carlo iterations assuming a willingness-to-pay threshold of AUD $50 000 per QALY gained. In a worst-case scenario analysis, IVUS remained the cost-effective option, with an ICER of AUD $36 651 (USD $26 601) per QALY gained. Exploratory subgroup analysis revealed that cost-effectiveness may be greatest among patients with left main and complex coronary lesions., Conclusions: Use of IVUS guidance during PCI is likely to be cost-effective compared with angiography guidance alone among patients undergoing drug-eluting stent implantation.

Objectives: To explore the relationship between emergency medical service (EMS) delay time, overall time to reperfusion and clinical outcome in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI)., Methods: This was a retrospective observational study of 2976 patients with STEMI who presented to EMS and underwent PPCI between January 2014 and December 2017. We performed multivariable logistic models to assess the relationship between EMS delay time and 30-day mortality and to identify factors associated with system delay time., Results: EMS delay time accounted for the first half of total system delay (median=59 min (IQR=48-77)). Compared with those who survived, those who died had longer median EMS delay times (59 (IQR=11-74) vs 74 (IQR=57-98), p<0.001). EMS delay time was independently associated with a higher risk of mortality (adjusted OR 1.20; 95% CI 1.02 to 1.40, for every 30 min increase), largely driven by complicated patients with cardiogenic shock or cardiac arrest. Independent predictors of longer EMS delay times were older age, women, cardiogenic shock, cardiac arrest, prehospital notification and intensive care management. Although longer EMS delay times were associated with shorter door-to-balloon times, total system delay times increased with increasing EMS delay times., Conclusion: Increasing EMS delay times, particularly those result from haemodynamic complications, increase total time to reperfusion and are associated with 30-day mortality after STEMI. All efforts should be made to monitor and reduce EMS delay times for timely reperfusion and better outcome., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There are 20,000 sudden cardiac arrests (SCAs) in Australia annually, with 90% case-fatality., Objective: The present study calculated both the health and economic impact of SCAs in Victoria, Australia., Methods: Data on all SCAs attended by Ambulance Victoria from July 2017 to June 2018 were collected regarding age, gender, and survival to hospital, discharge and 12 months. Pre-SCA employment status of all patients was modelled using age and gender-matched Australian economic data. A Markov state-transition model with a five-year horizon calculated health and economic impact in years of life lived (YLL), productivity-adjusted life years (PALYs) and gross domestic product (GDP) lost. A counterfactual Markov state-transition model assessed outcomes of an identical cohort of patients who did not experience SCA. All values were discounted by 5%., Results: In 12 months, 4637 people suffered SCAs in Victoria, of whom 1516 (32.7%) were working at the time. 695 patients (15.0%) survived to hospital, 325 (7.0%) to discharge, and 303 (6.5%) to 12 months. In five years following their SCA, the cohort lost 15,922 years of life and 2327 PALYs. Reduced productivity led to GDP losses of AUD$448 million (92.8% relative reduction). Extrapolated to the 20,000 SCAs occurring across all of Australia, total GDP losses approached AUD$2 billion., Conclusion: The health and economic burden of SCAs is high, predominantly underpinned by very high mortality. Annual national losses approach AUD$2 billion (USD$1.42 billion) and are comparable to productivity losses from all cancers combined. Prioritising research and state-of-the-art care for SCA patients appears economically sound., (Crown Copyright © 2021. Published by Elsevier B.V. All rights reserved.)

Background: Recent studies have shown that transcatheter aortic valve implantation (TAVI) is non-inferior to surgical aortic valve replacement (SAVR) for treatment of low-risk patients with severe aortic stenosis (AS). However, the cost-effectiveness of TAVI in this population is unknown. We sought to evaluate the cost-effectiveness of both balloon-expandable and self-expanding TAVI compared to SAVR in patients with severe AS at low operative risk., Methods: We developed a Markov model comparing TAVI to SAVR over a lifetime horizon. Key data inputs were drawn from the Placement of AoRTic TraNscathetER Valve (PARTNER) 3 trial for balloon-expandable TAVI and the Evolut Low-Risk trial for self-expanding TAVI. Costs were obtained from Australian sources. The perspective was that of the Australian health care system., Results: Although procedural costs were higher for TAVI compared to SAVR, these were offset by a shorter length of hospitalisation and lower acute complication costs in the TAVI group. Over a lifetime horizon, balloon-expandable TAVI was associated with increased costs of A$702 compared to SAVR, and increased quality-adjusted survival by 0.20 years, yielding an incremental cost-effectiveness ratio of A$3,521 per quality-adjusted life year (QALY) saved. Self-expanding TAVI was associated with lower lifetime costs compared to SAVR, and increased quality-adjusted survival by 0.08 years, and was therefore economically dominant. In probabilistic sensitivity analyses, balloon-expandable TAVI was cost-effective in 78% of iterations (at a cost-effectiveness threshold of A$50,000 per QALY gained) and self-expanding TAVI was cost-effective in 70% of iterations., Conclusions: Among low-risk AS patients, both balloon-expandable and self-expanding TAVI are likely to be cost-effective relative to SAVR., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Fibrinolysis is an important reperfusion strategy in the management of ST-elevation myocardial infarction (STEMI) when timely access to primary percutaneous coronary intervention (PPCI) is unavailable. Rescue PCI is generally thought to have worse outcomes than PPCI in STEMI. We aimed to determine short- and long-term outcomes of patients with rescue PCI versus PPCI for treatment of STEMI., Methods and Results: Patients admitted with STEMI (excluding out-of-hospital cardiac arrest) within the Melbourne Interventional Group (MIG) registry between 2005 and 2018 treated with either rescue PCI or PPCI were included in this retrospective cohort analysis. Comparison of 30-day major adverse cardiac events (MACE) and long-term mortality between the two groups was performed. There were 558 patients (7.1%) with rescue PCI and 7271 with PPCI. 30-day all-cause mortality (rescue PCI 6% vs. PPCI 5%, p = 0.47) and MACE (rescue PCI 10.3% vs. PPCI 8.9%, p = 0.26) rates were similar between the two groups. Rates of in-hospital major bleeding (rescue PCI 6% vs. PPCI 3.4%, p = 0.002) and 30-day stroke (rescue PCI 2.2% vs. PPCI 0.8%, p < 0.001) were higher following rescue PCI. The odds ratio for haemorrhagic stroke in the rescue PCI group was 10.3. Long-term mortality was not significantly different between the groups (rescue PCI 20% vs. PPCI 19%, p = 0.33)., Conclusions: With contemporary interventional techniques and medical therapy, rescue PCI remains a valuable strategy for treating patients with failed fibrinolysis where PPCI is unavailable and it has been suggested in extenuating circumstances where alternative revascularisation strategies are considered., Competing Interests: The Melbourne Interventional Group acknowledges funding from Abbott Vascular, Astra-Zeneca, BMS and Pfizer. These companies do not have access to data and do not have the right to review manuscripts or abstracts before publication. The authors have no conflict of interest to declare., (© 2021 The Authors.)

This study sought to explore the feasibility and utility of post-mortem coronary artery calcium (CAC) scoring in identifying patients with ischemic heart disease as cause of sudden death. 100 deceased patients aged 18-50 years underwent post-mortem examination in the setting of sudden death. At post-mortem, fifty cases were determined to have ischemic heart disease, and fifty had death attributed to trauma or unascertained causes. The CAC score was calculated in a blinded manner from post-mortem CTs performed on all cases. CAC scores were assessable in 97 non-decomposed cases (feasibility 97%). The median CAC score was 88 Agatston units [IQR 0-286] in patients deceased from ischemic heart disease vs 0 [IQR 0-0] in patients deceased from other causes (p < 0.0001). Presence of any coronary calcification differed significantly between ischemic heart disease and non-ischemic groups (adjusted odds ratio 10.7, 95% CI 3.2-35.5). All cases with a CAC score > 100 (n = 22) had ischemic heart disease as the cause of death. Fifteen cases had a CAC score of zero but severe coronary disease at post-mortem examination. Post-mortem CAC scoring is highly feasible. An elevated CAC score in cases 18-50 years old with sudden death predicts ischemic heart disease at post-mortem examination. However, a CAC score of zero does not exclude significant coronary artery disease. Post-mortem CAC score may be considered as a further assessment tool to help predict likely cause of death when there is an objection to or unavailability of post-mortem examination.

Objective: The purpose of this study was to identify factors associated with time delay to emergency medical services for patients with suspected ST-elevation myocardial infarction., Methods: This observational study involved 1994 suspected ST-elevation myocardial infarction patients presenting to the emergency medical services in Melbourne, Australia, between October 2011-January 2014. Factors associated with delays to emergency medical services call of >1 h and emergency medical services self-referral were analyzed using multivariable logistic regression., Results: The time of symptom onset was reported for 1819 patients (91.2%), the median symptom onset-to-call time was 52 min (interquartile range=17-176). Of all emergency medical services calls, 17% were referred by healthcare professionals. Compared to self-referred patients, patients who presented to a general practitioner or hospital had higher odds of delay >1 h to emergency medical services activation (adjusted odds ratio 7.76; 95% confidence interval 5.10-11.83; and 8.02; 3.65-17.64, respectively). The other factors associated with emergency medical services call delays of >1 h were living alone, non-English speaking background, a history of substance abuse, less severe symptoms, symptom onset at home and at rest, and self-treatment. Emergency medical services self-referred patients were more likely to be older than 75 years, have a history of ischemic heart disease or revascularization, more severe symptoms, and symptom onset at home, with activity, during the weekends and out-of-hours., Conclusion: Almost one-fifth of emergency medical services calls for suspected ST-elevation myocardial infarction were healthcare referrals, and this was associated with increased delays. A wide range of factors could influence a patient's decision to directly and rapidly seek emergency medical services. More efforts are needed to educate at-risk populations about early self-referral to the emergency medical services., (© The European Society of Cardiology 2020.)

Little research has examined the effects of high concentration, medium-duration smoke exposure on cardiovascular health. We investigated whether six weeks of exposure to smoke from the 2014 Hazelwood coal mine fire in Victoria (Australia), was associated with long-term clinical or subclinical cardiovascular disease approximately four years later, in adult residents of the towns of Morwell (exposed, n = 336) and Sale (unexposed, n = 162). The primary outcome was serum high sensitivity (hs) C-reactive protein (CRP). Blood pressure, electrocardiogram, flow mediated dilatation and serum levels of hs-troponin, N-terminal pro B-type natriuretic peptide and lipids were secondary outcomes. There was no significant difference in weighted median hsCRP levels between exposed and unexposed participants (1.9 mg/L vs. 1.6 mg/L, p = 0.273). Other outcomes were comparable between the groups. hsCRP was associated in a predictable manner with current smoking, obesity and use of lipid-lowering therapy. Four years after a 6-week coal mine fire, this study found no association between smoke exposure and markers of clinical or subclinical cardiovascular disease in exposed adults.

Background: Distinguishing the subgroup of older, comorbid patients presenting with non-ST-elevation acute coronary syndromes (NSTEACS) who will benefit from percutaneous coronary intervention (PCI) remains challenging. Identifying risk factors for major adverse cardiac or cerebrovascular events (MACCE) post PCI may help define this cohort. The objective of this study was to describe contemporary outcomes of older patients with NSTEACS undergoing PCI and identify pre-procedural risk factors for MACCE., Methods: We retrospectively reviewed data for 1,875 patients aged ≥80 years entered in the Victorian Cardiac Outcomes Registry (VCOR) who underwent PCI for NSTEACS between 1 January 2013 and 31 December 2017. MACCE was a composite outcome comprising 30-day mortality, myocardial infarction, stroke, major bleeding, target lesion revascularisation or target vessel revascularisation; in-hospital cardiogenic shock or stent thrombosis; and new requirement for dialysis. Patient demographic data and pre-procedural comorbidities were compared between the groups with and without a MACCE., Results: The rate of MACCE at 30 days was 8.0% (n=150). Thirty-day (30-day) mortality was 3.0% (n=57). Pre-procedural left ventricular ejection fraction (LVEF)<45% (OR 2.32; 95% CI 1.47-3.68; p<0.001) and eGFR≤30 mL/min/1.73m 2 or renal replacement therapy (OR 2.10; 95% CI 1.27-3.46; p<0.01) were independent predictors of a MACCE., Conclusions: Older patients presenting with NSTEACS who have left ventricular systolic dysfunction or renal impairment are at increased risk of MACCE post PCI. Randomised studies are required to determine if invasive management remains beneficial for these patents compared with medical therapy., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Despite advances in medical and interventional management of acute myocardial infarction, treatment of the associated chest pain has remained relatively unchanged since opioids were first utilized in the 1930's. This dominance can be partially attributed to initial studies suggesting hemodynamic benefits with opioid treatment. However, delayed gastrointestinal absorption of P2Y 12 inhibitors due to opioids and the consequent impairment in antiplatelet activity of this established therapy is cause for concern. Coupled with the lack of randomized clinical trial evidence to support widespread opioid use, there is now an opportunity to re-evaluate our approach to analgesia in myocardial infarction. This review characterizes the mechanism of the opioid-P2Y 12 inhibitor interaction, strategies aimed at mitigating the interaction and appraises promising alternative agents to opioid therapy in patients with myocardial infarction., Competing Interests: Declaration of competing interest The authors declare that there are no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Aims: Women at increased surgical risk have been shown to have better outcomes with transcatheter aortic valve implantation (TAVI) as compared to surgical valve replacement (SAVR). With the scope of TAVI moving into low-surgical risk patients, we aimed to update the current literature to include the new low-risk randomised controlled trial (RCT) data in investigating outcomes by sex., Methods: We systematically searched MEDLINE (Ovid), PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov and reference lists for relevant RCTs comparing TAVI to SAVR published prior to 4 May 2020. Data extraction was performed by two independent authors and included trial design details, baseline characteristics and outcome data stratified by sex. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. Quantitative synthesis of pooled data was performed using Mantel-Haenszel fixed or random effects model. Q-statistic and the I 2 test were used for assessment of heterogeneity., Results: Our search yielded eight RCTs included in the final quantitative synthesis. The overall pooled cohort was 8,040, of whom 41.4% were female. Women had significantly lower rates of one-year all-cause mortality (12.2% vs 17.7%, pooled OR 0.59, 95% CI 0.40-0.86) and one-year composite endpoint (9.7% vs 12.4%, pooled OR 0.73, 95% CI 0.58-0.92) with TAVI as compared to SAVR. The selective mortality benefit with TAVI over SAVR in women did not persist to 5 years (pooled HR 1.01, 95% CI 0.87-1.17). At 30 days, women demonstrated lower rates of major bleeding and acute kidney injury following TAVI compared to SAVR. For men, these outcomes were similar regardless of type of intervention. Both sexes were at increased risk of major vascular complications with TAVI as compared to SAVR, however women demonstrated nearly double the odds of major vascular complication with TAVI compared to men., Conclusion: Our updated meta-analysis demonstrates that at one-year women undergoing TAVI have significantly lower mortality and better safety outcomes compared to those undergoing SAVR. These benefits are not seen in men. In the new low-risk era, these results are ever more important for guiding appropriate patient selection., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Transcatheter aortic valve implantation (TAVI) is emerging as the default strategy for older patients with severe, symptomatic, and trileaflet aortic stenosis. Increased body-mass index (BMI) is associated with a protective effect in patients undergoing percutaneous coronary intervention. We assessed whether elevated BMI was associated with a similar association in TAVI. We evaluated prospectively collected data from 634 patients who underwent TAVI at 2 centers from August 2008 to April 2019. Patients were stratified as normal weight (BMI 18.5 to 24.9 kg/m 2 , n = 214), overweight (25 to 29.9 kg/m 2 , n = 234), and obese (>30 kg/m 2 , n = 185). Outcomes were reported according to VARC-2 criteria. Mortality was assessed using Cox proportional hazards regression analysis (median follow-up 2 years). Kaplan-Meier analysis was used to estimate cumulative mortality. Baseline differences were seen in age (85 vs 84 vs 82, p <0.001), STS-PROM score (4.3 vs 3.4 vs 3.6, p <0.001), sex (50% vs 36% vs 55% female, p <0.001), clinical frailty score (p = 0.02), diabetes (21% vs 29% vs 40%, p <0.001), and presence of chronic obstructive pulmonary disease (COPD) (13% vs 13% vs 23%, p = 0.009). On multivariable analysis there was no mortality difference between normal and obese patients (hazard ratio [HR] 0.70, confidence interval [CI] 0.46 to 1.1 p = 0.11), however overweight patients had significantly lower mortality (HR 0.56 CI 0.38 to 0.85, p = 0.006). Variables independently associated with increased mortality were increasing age, male sex, COPD, previous balloon valvuloplasty, and higher STS-PROM. In conclusion, overweight patients have lower long-term mortality when compared with normal weight and obese patients undergoing TAVI., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To determine if Victorian State of Emergency (SOE) measures to combat COVID-19 were associated with delayed presentations or management of acute stroke and acute myocardial infarction (AMI)., Methods: This was a retrospective, pre- and post-implementation study using data from an adult, tertiary cardiology and neurosciences centre with 24-h capacity for endovascular procedures. All primary presentations with acute stroke or AMI during the first 28 days of stage 2 and stage 3 SOE restrictions (26 March to 23 April 2020) were compared to an equivalent period without restrictions (26 March to 23 April 2019). The primary outcome variable was time from onset of symptoms to ED presentation., Results: There were 52 (1.6% of all ED presentations) patients who met inclusion criteria during the SOE period and 57 (1.0%) patients in the comparator period. Patients were equally matched for demographics, disease severity and prior history of stroke or AMI. Median time from symptom onset to presentation was 227 (93-1183) min during the SOE period and 342 (119-1220) min during the comparator period (P = 0.24). Among eligible patients with ischaemic stroke or ST-elevation AMI, median time to primary reperfusion intervention was 65 (37-78) min during SOE and 44 (39-60) min in the comparator period (P = 0.54). There were no differences in mortality at hospital discharge (9.6% vs 10.5%) and hospital length of stay (5.4 vs 4.3 days)., Conclusions: In the first 28 days, SOE measures to combat COVID-19 were not associated with delays in presentation or life-saving interventions for patients with acute stroke and AMI., (© 2020 Australasian College for Emergency Medicine.)

International guidelines suggest revascularization within 24 hours in non-ST segment elevation myocardial infarction (NSTEMI). Within a large population cohort study, we aimed to explore clinical practice regarding timing targets for percutaneous coronary intervention (PCI) in NSTEMI. The Victorian Cardiac Outcomes Registry was established in 2013 as a state-wide clinical quality registry, pooling data from public and private PCI capable centers. Data were collected on 11,852 PCIs performed for NSTEMI from 2014 to 2018. Patients were divided into 3 groups by time of symptom onset to PCI (<24 hours; 24 to 72 hours; >72 hours). We performed multivariable logistic regression analysis conditional on several baseline covariates in investigating the impact of timing of PCI in NSTEMI on clinical outcomes. Patients who underwent PCI within 24 hours represented 18.4% (n = 2,178); 24 to 72 hours 45.8% (n = 5,434); >72 hours 35.8% (n = 4,240). Patients waiting longer for PCI were older (62.6 ± 12.2 vs 64.8 ± 12.6 vs 67.0 ± 12.7, p <0.001), more likely to be female (23.1% vs 24.2% vs 26.4%, p = 0.007), and have diabetes (18.6% vs 21.1% vs 27.1%, p <0.001). Multivariate logistic regression found that as compared with PCI <24 hours, PCI 24 to 72 hours and PCI >72 hours of symptom onset were associated with a decreased risk of 30-day mortality (odds ratio 0.55; 95% confidence interval 0.35 to 0.86, p = 0.008 and odds ratio 0.64; 95% confidence interval 0.35 to 1.01, p = 0.053, respectively). There was no significant difference in 30-day mortality between groups following exclusion of patients presenting with cardiogenic shock or out of hospital cardiac arrest requiring intubation. In conclusion, many registry patients undergo PCI outside the 24-hour window following NSTEMI. This delay is at odds with current guideline recommendations but does not appear to be associated with an increased mortality risk., (Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.)

Background: The benefit of emergency coronary angiography after resuscitation from out-of-hospital cardiac arrest is uncertain for patients without ST-segment elevation. The aim of this randomized trial was to evaluate the efficacy and safety of early coronary angiography and to determine the prevalence of acute coronary occlusion in resuscitated patients with out-of-hospital cardiac arrest without ST-segment elevation., Methods: Adult (>18 years) comatose survivors without ST-segment elevation after resuscitation from out-of-hospital cardiac arrest were prospectively randomized in a 1:1 fashion under exception to informed consent regulations to early coronary angiography versus no early coronary angiography in this multicenter study. Early angiography was defined as ≤120 minutes from arrival at the percutaneous coronary intervention-capable facility. The primary end point was a composite of efficacy and safety measures, including efficacy measures of survival to discharge, favorable neurologic status at discharge (Cerebral Performance Category score ≤2), echocardiographic measures of left ventricular ejection fraction >50%, and a normal regional wall motion score of 16 within 24 hours of admission. Adverse events included rearrest, pulmonary edema on chest x-ray, acute renal dysfunction, bleeding requiring transfusion or intervention, hypotension (systolic arterial pressure ≤90 mm Hg), and pneumonia. Secondary end points included the incidence of culprit vessels with acute occlusion., Results: The study was terminated prematurely before enrolling the target number of patients. A total of 99 patients were enrolled from 2015 to 2018, including 75 with initially shockable rhythms. Forty-nine patients were randomized to early coronary angiography. The primary end point of efficacy and safety was not different between the 2 groups (55.1% versus 46.0%; P =0.64). Early coronary angiography was not associated with any significant increase in survival (55.1% versus 48.0%; P =0.55) or adverse events (26.5% versus 26.0%; P =1.00). Early coronary angiography revealed a culprit vessel in 47%, with a total of 14% of patients undergoing early coronary angiography having an acutely occluded culprit coronary artery., Conclusions: This underpowered study, when considered together with previous clinical trials, does not support early coronary angiography for comatose survivors of cardiac arrest without ST elevation. Whether early detection of occluded potential culprit arteries leads to interventions that improve outcomes requires additional study., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02387398.

Background: Inflammation plays a crucial role in clinical manifestations and complications of acute coronary syndromes (ACS). Colchicine, a commonly used treatment for gout, has recently emerged as a novel therapeutic option in cardiovascular medicine owing to its anti-inflammatory properties. We sought to determine the potential usefulness of colchicine treatment in patients with ACS., Methods: This was a multicenter, randomized, double-blind, placebo-controlled trial involving 17 hospitals in Australia that provide acute cardiac care service. Eligible participants were adults (18-85 years) who presented with ACS and had evidence of coronary artery disease on coronary angiography managed with either percutaneous coronary intervention or medical therapy. Patients were assigned to receive either colchicine (0.5 mg twice daily for the first month, then 0.5 mg daily for 11 months) or placebo, in addition to standard secondary prevention pharmacotherapy, and were followed up for a minimum of 12 months. The primary outcome was a composite of all-cause mortality, ACS, ischemia-driven (unplanned) urgent revascularization, and noncardioembolic ischemic stroke in a time to event analysis., Results: A total of 795 patients were recruited between December 2015 and September 2018 (mean age, 59.8±10.3 years; 21% female), with 396 assigned to the colchicine group and 399 to the placebo group. Over the 12-month follow-up, there were 24 events in the colchicine group compared with 38 events in the placebo group ( P =0.09, log-rank). There was a higher rate of total death (8 versus 1; P =0.017, log-rank) and, in particular, noncardiovascular death in the colchicine group (5 versus 0; P =0.024, log-rank). The rates of reported adverse effects were not different (colchicine 23.0% versus placebo 24.3%), and they were predominantly gastrointestinal symptoms (colchicine, 23.0% versus placebo, 20.8%)., Conclusions: The addition of colchicine to standard medical therapy did not significantly affect cardiovascular outcomes at 12 months in patients with ACS and was associated with a higher rate of mortality. Registration: URL: https://www.anzctr.org.au; Unique identifier: ACTRN12615000861550.

Background: The 12-lead electrocardiogram (ECG) remains the primary test for diagnosis of acute myocardial infarction (MI) secondary to acute coronary occlusion or near occlusion, with insufficient collateral circulation. Decisions regarding urgent reperfusion are based on whether or not there's new ST-segment elevation. The de Winter ECG pattern is a distinct ECG pattern without any ST-segment elevation, it may be missed by anyone unfamiliar with it., Case Summary: We present a case whose chief complaint was severe central chest pain, the patient was diagnosed with acute MI secondary to a culprit lesion in the left anterior descending artery, despite the ECG not meeting standard STEMI criteria. After the ECG's significance was recognized by paramedics, the patient received immediate percutaneous coronary intervention with stenting and was discharged home after a brief hospital admission., Discussion: In some cases, acute MI presents with ECG features that do not meet the standard criteria for STEMI diagnosis. The de Winter ECG pattern is one such example. This pattern should be immediately recognizable to those responsible for the activation of the catheterization laboratory, physicians, and paramedics included., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aim: Out-of-hospital cardiac arrest (OHCA) during COVID-19 has been reported by countries with high case numbers and overwhelmed healthcare services. Imposed restrictions and treatment precautions may have also influenced OHCA processes-of-care. We investigated the impact of the COVID-19 pandemic period on incidence, characteristics, and survival from OHCA in Victoria, Australia., Methods: Using data from the Victorian Ambulance Cardiac Arrest Registry, we compared 380 adult OHCA patients who received resuscitation between 16th March 2020 and 12th May 2020, with 1218 cases occurring during the same dates in 2017-2019. No OHCA patients were COVID-19 positive. Arrest incidence, characteristics and survival rates were compared. Regression analysis was performed to understand the independent effect of the pandemic period on survival., Results: Incidence of OHCA did not differ during the pandemic period. However, initiation of resuscitation by Emergency Medical Services (EMS) significantly decreased (46.9% versus 40.6%, p = 0.001). Arrests in public locations decreased in the pandemic period (20.8% versus 10.0%; p < 0.001), as did initial shocks by public access defibrillation/first-responders (p = 0.037). EMS caseload decreased during the pandemic period, however, delays to key interventions (time-to-first defibrillation, time-to-first epinephrine) significantly increased. Survival-to-discharge decreased by 50% during the pandemic period (11.7% versus 6.1%; p = 0.002). Survivors per million person-years dropped in 2020, resulting in 35 excess deaths per million person-years. On adjusted analysis, the pandemic period remained associated with a 50% reduction in survival-to-discharge., Conclusion: The COVID-19 pandemic period did not influence OHCA incidence but appears to have disrupted the system-of-care in Australia. However, this could not completely explain reductions in survival., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction : This review explores the Starling-like physiological control method (SLC) for rotary ventricular assist devices (VADs) for severe heart failure. The SLC, based on mathematical models of the circulation, has two functions modeling each ventricle. The first function controls the output of the VAD to the arterial pool according to Starling's law, while the second function accounts for how the blood returns to the heart from the veins. The article aims to expose clinicians to SLC in an accessible and clinically relevant discussion. Areas Covered : The article explores the physiology underlying the controller, its development and how that physiology can be adapted to SLC. Examples of controller performance are demonstrated and discussed using a benchtop model of the cardiovascular system. A discussion of the limitations and criticisms of SLC is presented, followed by a future outlook on the clinical adoption of SLC. Expert Opinion : Due to its simplicity and emulation of the natural cardiac autoregulation, SLC is the superior physiological control method for rotary VADs. However, current technical and regulatory challenges prevent the clinical translation of SLC of VADs. Further technical and regulatory development will enable the clinical translation of SLCs of VADs in the coming years.

Previous studies indicate that women who underwentwho underwent transcatheter aortic valve implantation (TAVI) have poorer 30-day outcomes compared with men. However, the effect of gender as a prognostic factor for long-term outcomes following TAVI remains unclear. Between 2008 and 2018, all patients (n = 683) who underwent TAVI in 2 centres in Melbourne, Australia were prospectively included in a registry. The primary end-point was long-term mortality. The secondary end points were Valve Academic Research Consortium-2 (VARC-2) in-hospital complications and mortality at 30-days and 1-year. Of 683 patients, 328 (48%) were women. Women had a higher mean STS-PROM score (5.2 ± 3.1 vs 4.6 ± 3.5, p < 0.001) but less co-morbidities than men. Women had a significantly higher in-hospital bleeding rates (3.3% vs 1.0%, Odds Ratio 4.21, 95% confidence interval [CI] 1.16 to15.25, p = 0.027) and higher 30-day mortality (2.4% vs 0.3%, hazard ratio [HR] 8.75, 95% CI 1.09 to 69.6, p = 0.040) than men. Other VARC-2 outcomes were similar between genders. Overall mortality rate was 36% (246) over a median follow up of 2.7 (interquartile rang [IQR] 1.7 to 4.2) years. Median time to death was 5.3 (95% CI 4.7 to 5.7) years. One-year mortality was similar between genders (8.3% vs 7.8%), as was long-term mortality (HR = 0.91, 95% CI 0.71 to 1.17, p = 0.38). On multivariable analysis, female gender was an independent predictor for 1-year mortality (HR = 2.33, 95% CI 1.11 to 4.92, p = 0.026), but not long-term mortality (HR = 0.78, 95% CI 0.54 to 1.14, p = 0.20). In the women only cohort, STS-PROM was the only independent predictor of long-term mortality (HR 1.88, 95% CI 1.42 to 2.48, p < 0.001). In conclusion, women had higher rates of peri-procedural major bleeding and 30-day mortality following TAVI. However, long-term outcomes were similar between genders., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Unplanned readmissions to hospital after percutaneous coronary intervention (PCI) pose a significant burden to the healthcare system and are potentially preventable. In this study, we sought to determine the incidence of, and risk factors for, unplanned hospital readmissions within 30 days following PCI. We prospectively collected data on 28,488 patients undergoing PCI between 2013 and 2019, who were enrolled in the state-wide multi-centre Victorian Cardiac Outcomes Registry. Patients' data were then linked to data from the Victorian Department of Health administrative database that records statewide hospital admissions. Disease diagnosis codes were used to identify cause of readmission. Patients who had an unplanned readmission were further divided into those who had a cardiac vs. non-cardiac cause for readmission. Overall, 3059 patients (10.7%) had an unplanned hospital readmission within 30 days of PCI, of which 1848 patients (60.4%) were readmitted for primarily cardiac diagnoses. Independent predictors of both 30-day unplanned cardiac and non-cardiac readmissions post-PCI were female sex, having ≥1 admission in the 12 months prior to PCI, acute coronary syndrome presentation, having any in-hospital complication and being discharged on an oral anticoagulant (all p < 0.05). A stepwise increase in readmission risk was observed with increasing number of admissions from 1 to ≥4 admissions in the 12 months prior to PCI. In conclusion, a substantial proportion of patients undergoing PCI have unexpected readmissions to hospital in the 30 days following PCI. Targeted strategies for patients with risk factors for readmission may be useful to reduce this significant burden to the healthcare system.

There have been numerous and intriguing advancements in antithrombotic therapy for myocardial infarction since it was described in the earliest issues of Thrombosis and Haemostasis . In this article, we revisit historical breakthroughs and describe the four most challenging contemporary themes relating to antithrombotic therapy in myocardial infarction. In all four, the challenge is to find the best balance of reducing specific levels of ischaemic risks without increasing bleeding risk. The first is the question of the optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). This includes discussion of monotherapy after a period of DAPT. The second relates to the role of genotype and phenotype-guided individualisation of antiplatelet therapy. There is emerging evidence for a role of pheno/genotyping in identifying individuals at high risk for recurrent ischaemic events or in guiding the timing of cardiac surgery for patients on DAPT. The third addresses the increasing evidence for dual pathway inhibition, for example, with rivaroxaban in addition to aspirin in patients where high ischaemic and low bleeding risk is demonstrated. Finally the fourth highlights the challenge of the most appropriate combination of antiplatelet and anticoagulation therapy for patients with known atrial fibrillation after PCI. In most individuals, oral P 2 Y 12 inhibitor therapy combined with a direct acting oral anticoagulant appears to be the best strategy based on the available evidence. Overall, the progress in antithrombotic therapy achieved over the last seven decades is remarkable, however, there are important issues to address and progress still to be made., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Stent thrombosis (ST) is an uncommon but serious complication of percutaneous coronary intervention (PCI). The reported rate of definite ST with new generation drug-eluting stents ranges from 0.5 to 1% at 30 days. We aimed to examine the incidence and outcomes of ST in a real-world setting., Methods: The Victorian Cardiac Outcomes Registry was established in 2012 as a state-wide clinical quality registry, with all PCI capable centres contributing in 2017. Data were collected on 41,137 consecutive PCI procedures from 2013 to 2017. We describe the patient characteristics and clinical outcomes in definite and probable ST at 30 days., Results: Stent thrombosis occurred in 225 patients (0.55%). Compared to patients without ST, these patients were more likely to be female (32.0% vs 23.4%, p≤0.01) and have a history of diabetes (28.6% vs 21.9%, p=0.02). ST was more common in patients with severely reduced left ventricular ejection fraction (14.9% vs 4.6%, p<0.001) and in patients presenting with ST-elevation myocardial infarction, cardiogenic shock and cardiac arrest for their index PCI (all p<0.001). Dual antiplatelet therapy at 30 days was less frequent in patients with ST (84.8% vs 92.0%, p<0.001), while 30-day mortality was more common: 23.6% versus 2.0% (p<0.001)., Conclusions: Even with contemporary stents and adjunctive medications, ST still occurs following 1 in 200 PCIs, and is associated with increased mortality at 30 days., (Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Aims: To evaluate the association of limited English proficiency (LEP) with reperfusion times and outcomes in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI)., Methods and Results: This cohort study included 5385 patients who underwent PPCI in 2013-2017 and were prospectively enrolled in the Victorian Cardiac Outcomes Registry. Data linkage to government administrative datasets was performed to identify patients' preferred spoken language, socioeconomic status, and ambulance utilization data. Patients who had a preferred spoken language other than English were defined as having LEP. Of the study cohort, 430 patients (8.0%) had LEP. They had longer mean symptom-to-door time (STDT) [164 (95% confidence interval, CI 149-181) vs. 136 (95% CI 132-140) min, P < 0.001] but similar mean door-to-balloon time [79 (95% CI 72-87) vs. 76 (95% CI 74-78) min, P = 0.41]. They also had higher major adverse cardiovascular and cerebrovascular events (MACCE; 13.5% vs. 9.9%; P = 0.02), severe left ventricular dysfunction (11.0% vs. 8.4%, P = 0.02), and heart failure (HF) hospitalizations within 30 days of PPCI (5.1% vs. 2.0%, P < 0.001). On multivariable analysis, LEP did not independently predict 30-day MACCE [odds ratio (OR) 1.16, 95% CI 0.79-1.69; P = 0.45] but was an independent predictor of both prolonged STDT ≥ 120 min (OR 1.25, 95% CI 1.02-1.52; P = 0.03) and 30-day HF hospitalizations (OR 2.01, 95% CI 1.21-3.36; P = 0.008)., Conclusion: Patients with LEP undergoing PPCI present later and are more likely to have HF readmissions within 30 days of percutaneous coronary intervention, but with similar short-term MACCE. More effort to provide education in varied languages on early presentation in STEMI is required., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)