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Introduction: Cardiac complications of COVID-19 include acute cardiac injury, myopericarditis, cardiomyopathy and arrhythmias. This study aimed to describe the incidence of cardiac complications in patients admitted to hospital with COVID-19 in Australia. Methods: AUS-COVID is a multicentre observational cohort study across 21 Australian hospitals including all index hospitalisations with laboratory-proven COVID-19 in patients aged 18 years or older. All consecutive patients entered in the AUS-COVID Registry by 28 th January 2021 were included in the present study. Results: Six hundred and forty-four hospitalised patients (62.5 ± 20.1 years old, 51.1% male) with COVID-19 were enrolled in the study. Overall in-hospital mortality was 14.3%. Twenty (3.6%) patients developed new atrial fibrillation or flutter during admission and 9 (1.6%) patients were diagnosed with new heart failure or cardiomyopathy. Three (0.5%) patients developed high grade atrioventricular (AV) block. Two (0.3%) patients were clinically diagnosed with pericarditis or myopericarditis. Among the 295 (45.8%) patients with at least one troponin measurement, 99 (33.6%) had a peak troponin above the upper limit of normal (ULN). In-hospital mortality was higher in patients with raised troponin (32.3% vs 6.1%, p Conclusions: Among patients with COVID-19 requiring hospitalisation in Australia, troponin elevation was common but clinical cardiac sequelae were uncommon. The incidence of atrial arrhythmias and troponin elevation was greatest in patients 65 years and older. Trial registration: AUS-COVID. ACTRN12620000486921. http://www.anzctr.org.au/

Introduction: To assess whether hypertension is an independent risk factor for mortality amongst patients hospitalised with COVID-19 and to evaluate the impact of angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) on mortality in patients with a background of hypertension. Methods: This observational cohort study included all consecutive index hospitalisations with laboratory proven COVID-19 aged 18 years or older across 21 Australian hospitals entered in the AUS-COVID Registry by 22nd January 2021. Patients were excluded if their past medical or medication history was not available or if they were transferred to another hospital in which case mortality outcomes were not available. Registry data were analysed for in-hospital mortality in patients with comorbidities including hypertension, and baseline treatment with ACE inhibitors or ARBs. Results: 546 consecutive patients (62.9±19.8 years old, 51.8% male) hospitalised with COVID-19 were enrolled. In the multivariable model, significant predictors of mortality were age (aOR 1.09, 95% CI 1.07-1.12, p Conclusions: In patients hospitalised with COVID-19, pre-existing hypertension was the most prevalent comorbidity but was not independently associated with mortality. Similarly, the baseline use of ACE inhibitors or ARBs had no independent association with in-hospital mortality.

OBJECTIVES: Describe the incidence of cardiac complications in patients admitted to hospital with COVID-19 in Australia. DESIGN: Observational cohort study. SETTING: Twenty-one (21) Australian hospitals. PARTICIPANTS: Consecutive patients aged ≥18 years admitted to hospital with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. MAIN OUTCOME MEASURES: Incidence of cardiac complications. RESULTS: Six-hundred-and-forty-four (644) hospitalised patients (62.5±20.1 yo, 51.1% male) with COVID-19 were enrolled in the study. Overall in-hospital mortality was 14.3%. Twenty (20) (3.6%) patients developed new atrial fibrillation or flutter during admission and 9 (1.6%) patients were diagnosed with new heart failure or cardiomyopathy. Three (3) (0.5%) patients developed high grade atrioventricular (AV) block. Two (2) (0.3%) patients were clinically diagnosed with pericarditis or myopericarditis. Among the 295 (45.8%) patients with at least one troponin measurement, 99 (33.6%) had a peak troponin above the upper limit of normal (ULN). In-hospital mortality was higher in patients with raised troponin (32.3% vs 6.1%, p

Exercise capacity is frequently reduced in people with diabetes mellitus (DM), and the contribution of pulmonary microvascular dysfunction remains undefined. We hypothesized that pulmonary microvascular disease, measured by a novel exercise echocardiography technique termed pulmonary transit of agitated contrast (PTAC), would be greater in subjects with DM and that the use of pulmonary vasodilator agent sildenafil would improve exercise performance by reducing right ventricular afterload. Forty subjects with DM and 20 matched controls performed cardiopulmonary exercise testing and semisupine exercise echocardiography 1 h after placebo or sildenafil ingestion in a double-blind randomized crossover design. The primary efficacy end point was exercise capacity (V̇o2peak) while secondary measures included pulmonary vascular resistance, cardiac output, and change in PTAC. DM subjects were aged 44 ± 13 yr, 73% male, with 16 ± 10 yr DM history. Sildenafil caused marginal improvements in echocardiographic measures of biventricular systolic function in DM subjects. Exercise-induced increases in pulmonary artery systolic pressure and pulmonary vascular resistance were attenuated with sildenafil, while heart rate (+2.4 ±1.2 beats/min, P = 0.04) and cardiac output (+322 ± 21 ml, P = 0.03) improved. However, the degree of PTAC did not change ( P = 0.93) and V̇o2peak did not increase following sildenafil as compared with placebo (V̇o2peak: 31.8 ± 9.7 vs. 32.1 ± 9.5 ml·min−1·kg−1, P = 0.42). We conclude that sildenafil administration causes modest acute improvements in central hemodynamics but does not improve exercise capacity. This may be due to the mismatch in action of sildenafil on the pulmonary arteries rather than the distal pulmonary microvasculature and potential adverse effects on peripheral oxygen extraction. NEW & NOTEWORTHY This is one of the largest and most comprehensive studies of cardiopulmonary exercise performance in people with diabetes mellitus and to our knowledge the first to assess the effect of sildenafil using detailed echocardiographic measures during incremental exercise. Sildenafil attenuated the rise in pulmonary vascular resistance while augmenting cardiac output and intriguingly heart rate, without conferring any improvement in exercise capacity. The enhanced central hemodynamic indexes may have been offset by reduced peripheral O2 extraction.

Severe aortic stenosis (AS) is the most common form of valvular heart disease in the developed world, with a rising prevalence due to an ageing Australian population. Transcatheter aortic valve implantation (TAVI) offers a less invasive option for the treatment of severe AS, with evidence supporting TAVI compared with medical therapy in inoperable patients and superior with surgical aortic valve replacement (SAVR) in high-risk patients. Equal outcomes have been observed in all-comer intermediate-risk populations. The Heart Team utilises a shared decision-making approach between physicians and surgeons in risk-stratifying patients and reduces the intrinsic bias that may occur if decisions are made in isolation. Geriatric assessment is useful for identifying preoperative frailty, a major risk factor for death post-aortic valve intervention. In severe AS, a decision can be made collaboratively to pursue TAVI, SAVR, a Ross Procedure or conservative management. The learning curve associated with TAVI has improved markedly, with overall complication rates decreasing around the world. Contemporary changes in practice, such as conscious sedation without general anaesthesia, expedited recovery and early discharge, will likely improve cost-effectiveness. In 2018, TAVI is a well-established procedure in Australia that has revolutionised the management of severe AS. In the future, with an expanding elderly population, the number of patients to benefit from transcatheter therapies for severe AS is hypothesised to increase 4-10-fold. Heart Team assessment is crucial in patients with severe AS to direct appropriate management.

This document establishes the minimum standard for accreditation of institutions and operators as endorsed by the Cardiac Society of Australia and New Zealand (CSANZ) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS). The original Joint Society Position Statement was ratified in August 2014. This 2021 update replaces the original and serves as a consensus within which the Conjoint Committee for Trancatheter Aortic Valve Implantation (TAVI) Accreditation will function, as recommended by Medical Services Advisory Committee (MSAC) Determination for TAVI. This is not a Guideline Statement but takes into consideration regional, legislative, and health system factors important to establishing requirements for TAVI accreditation in Australia.

IntroductionThe coronavirus 2019 disease (COVID-19) pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Pre-existing cardiovascular disease (CVD) increases the morbidity and mortality of COVID-19, and COVID-19 itself causes serious cardiac sequelae. Strategies to minimise the risk of viral transmission to health care workers and uninfected cardiac patients while prioritising high quality cardiac care are urgently needed. We conducted a rapid literature appraisal and review of key documents identified by the Cardiac Society of Australia and New Zealand Board and Council members, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, and key cardiology, surgical and public health opinion leaders.Main recommendationsCommon acute cardiac manifestations of COVID-19 include left ventricular dysfunction, heart failure, arrhythmias and acute coronary syndromes. The presence of underlying CVD confers a five- to tenfold higher case fatality rate with COVID-19 disease. Special precautions are needed to avoid viral transmission to this population at risk. Adaptive health care delivery models and resource allocation are required throughout the health care system to address this need.Changes in management as a result of this statementCardiovascular health services and cardiovascular health care providers need to recognise the increased risk of COVID-19 among CVD patients, upskill in the management of COVID-19 cardiac manifestations, and reorganise and innovate in service delivery models to meet demands. This consensus statement, endorsed by the Cardiac Society of Australia and New Zealand, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, the National Heart Foundation of Australia and the High Blood Pressure Research Council of Australia summarises important issues and proposes practical approaches to cardiovascular health care delivery to patients with and without SARS-CoV-2 infection.

Objective: To assess whether improvements in preventative care for people with diabetes have resulted in a relative decrease in the burden of coronary artery disease (CAD) compared to people without diabetes. Methods: All patient-level linked coronary angiography and hospital separation data at a large Australian tertiary referral hospital between 2013 and 2019 were obtained. Indication for angiography and extent of CAD were based on original classification by treating cardiologists, classified as no disease, mild, moderate or severe. Propensity scores were estimated to match people with and without diabetes on a 1:1 ratio. Ordinal logistic regression models were fitted to assess trends in CAD severity in people with and without diabetes over time with adjusted odds ratios (adjOR) reported. Results: For 3,016 people identified in the coronary angiography database and matched using propensity scores, 1508(50%) were diagnosed with diabetes. Angiographic evidence of CAD was detected in 1155(77%) and 1257(83%) people without and with diabetes. For people with diabetes there was an increased risk of more extensive CAD in 2018 compared to 2013 (adjOR: 2.02 95% C.I. 1.36, 2.99). This risk appears to have been attenuated in 2019 with no significant change in CAD burden between 2013 and 2019 (adjOR: 1.33 95% C.I. 0.90, 1.98). In contrast, there was no effect of time on CAD burden in people without diabetes. Conclusions: The initial increase in severity of disease burden seen in our study for people with diabetes compared to those without diabetes may represent improved CAD screening rather than suboptimal application of preventative therapies. Possibly, greater recent use of newer glucose lowering medications with cardiovascular protective effects accounts for the attenuation of CAD burden in 2019 for people with diabetes. These findings highlight the importance of aggressive risk factor modification for people with diabetes to minimize the development and progression of CAD. Disclosure K.V. Kiburg: None. A.I. MacIsaac: None. V. Sundararajan: None. R. MacIsaac: None.

Objective: To assess the impact of preventative therapies on the extent of coronary artery disease (CAD) in people with and without diabetes in a real-world setting. Research Design and Methods: Patient-level linked coronary angiography and hospital separation data at a large Australian tertiary referral hospital between 2013 and 2019 were obtained and a random sample of patient charts reviewed for medication use (renin-angiotensin system (RAS) inhibitors, statins and antiplatelets). Indication for angiography and extent of CAD were based on the original classification by treating cardiologists, classified as no disease, mild, moderate or severe. Propensity scores were estimated and used to weight in the ordinal logistic regression models. Models were fitted to assess trends in CAD severity in people with and without diabetes with adjusted odds ratios (adjOR) reported. Results: For 805 people identified in the coronary angiography database with medication use information available, 386(48%) were diagnosed with diabetes. Angiographic evidence of CAD was found in 297(71%) and 301(78%) of people without and with diabetes, respectively. People with diabetes were at an increased risk of more extensive CAD disease compared to people without diabetes (adjOR: 1.37 95% C.I. 1.00, 1.88). However, when adjusted for the use of RAS inhibitors, statins and antiplatelets there was no difference in the extent of CAD between people with and without diabetes (adjOR: 1.22 95% C.I. 0.87, 1.69). Conclusions: These findings highlight the increased risk that people with diabetes have for more extensive CAD than people without diabetes. Our results also suggest that with the aggressive and appropriate use of traditional cardiovascular disease preventative therapies it may be possible to significantly reduce the excess CAD burden observed in people with diabetes. Disclosure K.V. Kiburg: None. A.I. MacIsaac: None. G.E. McCluskey: None. V. Sundararajan: None. R. MacIsaac: None.

The risks of percutaneous coronary intervention (PCI) in obese and particularly morbidly obese patients remain uncertain.1082 consecutive patients were categorised as non-obese (NO, body mass index (BMI)30kg/mObese and morbidly obese patients were younger (p=0.016), more frequently female (p=0.036), more frequently diabetic (p0.0001), with better renal function (p0.0001), and prior PCI (p=0.01). There was no difference in major adverse cardiovascular or cerebrovascular events (MACCE) (NO=1.2%, O=0.8%, MO=2.5%, p=NS), acute kidney injury, bleeding, length of stay, 30-day readmission or 30-day mortality. Obese and morbidly obese patients received increased contrast (NO=180 [150-230]mL, O=190 [160-250]mL, MO=200 [165-225]mL, p=0.016), dose area product (NO=75.56 [50.61-113.69]GycmPercutaneous coronary intervention can be performed in obese and morbidly obese patients without elevated risk for most clinical outcomes. However, radiation increases above levels that could cause both transient and late effects. Strategies should be pursued to minimise radiation dose.

ObjectiveTo assess whether hypertension is an independent risk factor for mortality among patients hospitalised with COVID-19, and to evaluate the impact of ACE inhibitor and angiotensin receptor blocker (ARB) use on mortality in patients with a background of hypertension.MethodThis observational cohort study included all index hospitalisations with laboratory-proven COVID-19 aged ≥18 years across 21 Australian hospitals. Patients with suspected, but not laboratory-proven COVID-19, were excluded. Registry data were analysed for in-hospital mortality in patients with comorbidities including hypertension, and baseline treatment with ACE inhibitors or ARBs.Results546 consecutive patients (62.9±19.8 years old, 51.8% male) hospitalised with COVID-19 were enrolled. In the multivariable model, significant predictors of mortality were age (adjusted OR (aOR) 1.09, 95% CI 1.07 to 1.12, pConclusionsIn patients hospitalised with COVID-19, pre-existing hypertension was the most prevalent comorbidity but was not independently associated with mortality. Similarly, the baseline use of ACE inhibitors or ARBs had no independent association with in-hospital mortality.

Background: Guidelines recommend that all non–ST-segment elevation acute coronary syndrome (NSTEACS) patients with high-risk features receive a coronary angiogram. We hypothesised that the widely reported gender disparity in the use of angiography might be the result of women more frequently being stratified into the lower-risk category. Objectives: The aim of the study was to review studies reporting risk stratification of NSTEACS patients by gender, compare risk profiles, and assess impact on use of coronary angiography. Methods: PubMed, Scopus, and EMBASE databases were searched on June 17, 2014, using MeSH terms/subheadings and/or key words with no further limits. The search revealed 1230 articles, of which 25 met our objective. Results: Among the 28 risk-stratified populations described in the 25 articles, women were more likely to be stratified as high-risk in 13 studies; men were more likely to be stratified as high-risk in 3 studies. After meta-analyses, women had a 23% higher odds of being stratified as high-risk than did men (P = .001). Lower-risk patients were more likely to receive an angiogram in 15 study populations. Conclusions: Contrary to our hypothesis, this review showed that women with NSTEACS are more likely than men to be considered high-risk when stratified using a range of risk assessment methods. Lower rates of angiography in women form part of a broader treatment-risk paradox, which may involve gender bias in the selection of patients for invasive therapy.

BACKGROUND: Literature suggests an ongoing gender disparity in the use of coronary angiography and subsequent interventions among patients with acute coronary syndrome (ACS). OBJECTIVES: The study aimed to examine gender differences in the use of coronary interventions amongst patients with acute coronary syndrome (ACS) admitted to a major metropolitan hospital in Melbourne during the period 2009-2012. METHODS: We undertook a retrospective analysis of a hospital database of 2096 ACS patients. ACS included unstable angina (UA), ST-segment-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). RESULTS: The mean age of the patients was 64.3 years and 624 (30%) were women. Half of them were diagnosed as NSTEMI, 23% as STEMI and 25% as UA. Compared to men, women were older at admission, less likely to be diagnosed with STEMI and less likely to smoke. No gender difference was observed for severe co-morbidities or use of coronary angiography. Women diagnosed with STEMI were 39% less likely to receive an angioplasty stent (adjusted odds ratio 0.61, 95% confidence intervals 0.39-0.96) and 66% less likely to receive grafts (adjusted OR 0.34, 95% CIs 0.13-0.93). Women diagnosed with NSTEMI were 44% less likely to receive grafts (adjusted OR 0.56, 95% CIs 0.37-0.83). Younger women aged 35-49 years were less likely to receive an angioplasty stent, and older women >50 years were less likely to receive grafts. CONCLUSIONS: Adherence to guideline based treatment will help to ensure knowledge translation from guideline to practice. Further research investigating symptom presentation, use of non-invasive tests and medical management of ACS by gender may further explain gender difference for coronary interventions.

Variations in the delivery of evidence based care to high risk patients with Acute Coronary Syndromes (ACS) exist between hospitals. We hypothesised that the relative proportion of admitted high risk patients contributes to variation in care and outcomes.Receipt of evidence based therapies (EBT) according to patient risk was documented in the Australian Co-operative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE). Hospitals were stratified into quartiles (Q) by fraction of high risk patients according to: GRACE Risk Score (GRS), chronic kidney disease (CKD), age, Killip class, and myocardial infarction (MI). For each category, EBT and mortality were compared between hospital groups.This study included 8390 ACS patients from 39 hospitals. Patients with GRS130, CKD, and80years, were less likely to receive EBT at high proportion hospitals (p0.0001 for all). After adjustment, proportion of patients with CKD negatively predicted coronary angiography (CA) (Q4 vs Q1: OR 0.21, 95%CI 0.10-0.45). Adjusted 6month mortality was greater in CKD and trended greater in80years in hospitals treating the highest proportions of these patients (Q4 vs Q1 OR 3.80, 95%CI 1.85-7.83, and OR 3.10, 95%CI 0.99-9.70 respectively).Elderly ACS patients and those with CKD are less likely to receive EBT at hospitals seeing high proportions of these patients. Failure to provide EBT to these high risk populations may contribute to avoidable mortality in these institutions.

Background Exercise capacity is frequently reduced in people with diabetes mellitus (DM) and may be due to subclinical cardiac dysfunction. Speckle-tracking echocardiography is now widely available; however, the clinical utility and significance of left ventricular (LV) strain and twist parameters remain uncertain. We hypothesized that LV strain and twist would be reduced in DM subjects during exercise. Methods Adults with type 1 or type 2 DM and age- and sex-matched controls performed cardiopulmonary exercise testing (VO2 peak) and supine bicycle exercise echocardiography. Detailed echocardiographic assessment of biventricular function was performed at baseline and repeated during incremental exercise to maximal intensity. Results Of the 60 participants completing the study protocol, 51 (34 DM, 17 controls; mean age, 42 ± 13 years; 69% male; DM duration, 16 ± 10 years) had sufficient image quality to assess LV deformation and twist mechanics at rest. Of these, 38 (25 DM, 13 controls) were able to be assessed immediately after exercise. Baseline LV systolic and diastolic function using standard echocardiography measurements were similar between groups. Resting LV global longitudinal strain, twist, twist rate and untwist rate, and the corresponding peak exercise and reserve measures did not differ significantly. As compared with the control subjects, exercise capacity was reduced in the DM cohort (VO2 peak 33 ± 10 vs 41 ± 12 mL/minute/kg; P = .02); however, no correlation was observed between VO2 peak and LV twist reserve (R = 0.28, P = .09), LV twist rate reserve (R = 0.14, P = .39), or LV untwist rate reserve (R = 0.24, P = .14). Conclusions Despite reduced VO2 peak, LV twist mechanics at rest and after maximal intensity exercise did not differ significantly in a cohort of asymptomatic DM subjects with normal resting LV systolic and diastolic function compared with age- and sex-matched controls. This would suggest that exercise capacity can be reduced in the absence of subclinical cardiac dysfunction and that noncardiac factors should be considered as alternative explanations.

There is limited data from Australia and New Zealand comparing transcatheter aortic valve implantation (TAVI) with conventional surgical aortic valve replacement (sAVR).Between 2009 and 2015, 64 patients underwent TAVI and 669 underwent sAVR at a single centre. Patients' peri-operative details were analysed and compared between groups. Propensity-score matching was performed for risk adjustment.Patients receiving TAVI were older (mean age in years TAVI: 83.9±4.6 vs. sAVR: 71±9.9, P0.001), and were more likely to be female (TAVI: 67%, 43/64, vs. sAVR: 32%, 217/669, P0.001). Unadjusted 30-day mortality was comparable between groups (2/64, 3% vs. 22/669, 3%, P0.99). The matched analysis revealed comparable 30-day mortality (TAVI: 2/44, 5% vs. sAVR: 2/44, 5%, P0.99). New atrial arrhythmia occurred more frequently within the sAVR cohort (TAVI: 1/44, 2% vs. sAVR 18/44, 41%, P0.001). Complete heart block requiring permanent pacemaker was more frequent amongst the TAVI cohort (TAVI: 10/44, 23% vs. sAVR 2/44, 5%, P=0.039). At two years, survival was comparable between groups (TAVI: 74±1.7 vs. sAVR: 80±0.1%, P=0.65).This single centre experience suggests that TAVI is a valuable treatment option for high-risk surgical patients with comparable survival.

The index of microcirculatory resistance (IMR), an invasive measure of microvascular function, has been shown to correlate with clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study is to evaluate the predictive value of IMR on left ventricular recovery in patients undergoing a pharmacoinvasive strategy for STEMI.The index of microcirculatory resistance was assessed following percutaneous coronary intervention (PCI) in 31 patients with STEMI who were initially managed with thrombolysis. Other markers of microvascular function such as coronary flow reserve (CFR), TIMI flow grade, corrected TIMI frame count (cTFC), and ST-segment resolution were also recorded. All indices were evaluated against measures of left ventricular function and recovery 3 months postindex event.The IMR correlated with left ventricular function, as assessed by wall motion score and ejection fraction at 3-month follow-up (rA¢Â€Â‰=A¢Â€Â‰0.652, PA¢Â€Â‰=A¢Â€Â‰0.005; rA¢Â€Â‰=A¢Â€Â‰-0.452, PA¢Â€Â‰=A¢Â€Â‰0.011, respectively). The traditional methods of assessing microvascular function, such as CFR, TIMI flow grade, cTFC, and ST-segment resolution did not correlate with wall motion score and ejection fraction at 3 months. Post-PCI IMR was significantly lower in those patients with left ventricular recovery at 3 months (18A¢Â€Â‰U vs 39A¢Â€Â‰U, PA¢Â€Â‰

Background Hospital procedures have been associated with cognitive change in older patients. This study aimed to document the prevalence of mild cognitive impairment in individuals undergoing left heart catheterization ( LHC ) before the procedure and the incidence of cognitive decline to 3 months afterwards. Methods and Results We conducted a prospective, observational, clinical investigation of elderly participants undergoing elective LHC . Cognition was assessed using a battery of written tests and a computerized cognitive battery before the LHC and then at 3 months afterwards. The computerized tests were also administered at 24 hours (or discharge) and 7 days after LHC . A control group of 51 community participants was recruited to calculate cognitive decline using the Reliable Change Index. Of 437 participants, mild cognitive impairment was identified in 226 (51.7%) before the procedure. Computerized tests detected an incidence of cognitive decline of 10.0% at 24 hours and 7.5% at 7 days. At 3 months, written tests detected an incidence of cognitive decline of 13.1% and computerized tests detected an incidence of 8.5%. Cognitive decline at 3 months using written tests was associated with increasing age, whereas computerized tests showed cognitive decline was associated with baseline amnestic mild cognitive impairment, diabetes mellitus, and prior coronary stenting. Conclusions More than half the patients aged >60 years presenting for LHC have mild cognitive impairment. LHC is followed by cognitive decline in 8% to 13% of individuals at 3 months after the procedure. Subtle cognitive decline both before and after LHC is common and may have important clinical implications. Clinical Trial Registration Information URL : www.anzctr.org.au . Unique identifier: ACTRN 12607000051448.

Background The reasons for reduced exercise capacity in diabetes mellitus (DM) remains incompletely understood, although diastolic dysfunction and diabetic cardiomyopathy are often favored explanations. However, there is a paucity of literature detailing cardiac function and reserve during incremental exercise to evaluate its significance and contribution. We sought to determine associations between comprehensive measures of cardiac function during exercise and maximal oxygen consumption (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot{V}O_{2}$$\end{document}V˙O2peak), with the hypothesis that the reduction in exercise capacity and cardiac function would be associated with co-morbidities and sedentary behavior rather than diabetes itself. Methods This case–control study involved 60 subjects [20 with type 1 DM (T1DM), 20 T2DM, and 10 healthy controls age/sex-matched to each diabetes subtype] performing cardiopulmonary exercise testing and bicycle ergometer echocardiography studies. Measures of biventricular function were assessed during incremental exercise to maximal intensity. Results T2DM subjects were middle-aged (52 ± 11 years) with a mean T2DM diagnosis of 12 ± 7 years and modest glycemic control (HbA1c 57 ± 12 mmol/mol). T1DM participants were younger (35 ± 8 years), with a 19 ± 10 year history of T1DM and suboptimal glycemic control (HbA1c 65 ± 16 mmol/mol). Participants with T2DM were heavier than their controls (body mass index 29.3 ± 3.4 kg/m2 vs. 24.7 ± 2.9, P = 0.001), performed less exercise (10 ± 12 vs. 28 ± 30 MET hours/week, P = 0.031) and had lower exercise capacity (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot{V}O_{2}$$\end{document}V˙O2peak = 26 ± 6 vs. 38 ± 8 ml/min/kg, P

Background In this prospective study, we compared the invasive measures of microvascular function in two subsets: patients with pharmacoinvasive thrombolysis for STEMI, and patients undergoing percutaneous coronary intervention (PCI) for NSTEMI. Methods The study consisted of 17 patients with STEMI referred for cardiac catheterisation post thrombolysis, and 20 patients with NSTEMI. Coronary physiological indexes were measured in each patient before and after PCI. Results The median pre-PCI index of microcirculatory function (IMR) at baseline was significantly higher in the STEMI group than the NSTEMI group (26 units vs. 15 units, p = 0.02). Following PCI, IMR decreased in both groups (STEMI 20 units vs. NSTEMI 14 units, p = 0.10). There was an inverse correlation between post PCI IMR and left ventricular ejection fraction (LVEF) (r = −0.52, p = 0.001). Furthermore, post PCI IMR was an independent predictor of index admission LVEF in the total population (β = −0.388, p = 0.02). Conclusion Invasive measures of microvascular function are inferior in a pharmacoinvasive STEMI group compared to a clinically stable NSTEMI group. In the STEMI population, the IMR following coronary intervention appears to predict LVEF.

The Cardiac Society of Australia and New Zealand (CSANZ) and the Australia and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) have joined together to provide recommendations for institutions and individual operators to assess their ability to initiate and maintain a transcatheter valve program. Transcatheter aortic valve replacement has been developed as an alternative to traditional surgical replacement of the aortic valve in high risk patients, particularly the frail elderly. The position paper has endorsed the important role of a multi-disciplinary "Heart Team" in selecting patients for TAVI as fundamental to the establishment of a successful program. The paper outlines recommendations for the cardiologist to have a background in structural intervention and the surgeon to have experience in high-risk aortic valve replacement. It is further recommended that TAVI programs be established in high volume cardiac surgical centres where on site valve surgery is performed. The paper is intended to provide guidance to individual operators and prospective institutions considering the establishment of a successful TAVI program.

The health burden of type 2 diabetes mellitus (T2DM) is increasing worldwide, with a substantial portion of this burden being due to the development of cardiovascular (CV) disease. Multiple individual randomised clinical trials of intensive versus conventional glucose control, based on the use of traditional oral hypoglycaemic agents, have failed to convincingly show that intensive glucose control significantly reduces CV disease outcomes. In recent times, two new approaches to lowering glucose levels have become available. One targets the "incretin effect" which involves the modulation of peptide hormones that normally regulate glucose levels when nutrients are given orally. The other approach is based on inhibiting the sodium-glucose co-transporter 2 (SGLT-2) in the tubules of the kidney to promote glycosuria. Incretin-based therapies, especially glucagon-like peptide-1 receptor analogues, reduce glucose levels, with a low risk of hypoglycaemia, by increasing insulin secretion, inhibiting glucagon release and increasing satiety. Clinical and experimental studies have also shown favourable effects on CV disease risk factors such as dyslipidaemia, blood pressure, and improvements in endothelial function and cardiac contractility. Similarly, SGLT-2 inhibitors reduce glucose levels with a low risk for hypoglycaemia and have positive effects on multiple CV disease risk factors. Whether the beneficial effects of these new glucose lowering approaches on surrogate markers of CV disease risk translates to an improvement in CV events remains unknown. Several CV outcome trials are currently being performed to show that at a minimum, these novel glucose lowering agents are safe, but also have positive CV benefits.

OBJECTIVE To determine whether pulmonary microvascular disease is detectable in subjects with diabetes and associated with diminished exercise capacity using a novel echocardiographic marker quantifying the pulmonary transit of agitated contrast bubbles (PTAC). RESEARCH DESIGN AND METHODS Sixty participants (40 with diabetes and 20 control subjects) performed cardiopulmonary (maximal oxygen consumption [VO2peak]) and semisupine bicycle echocardiography exercise tests within a 1-week period. Pulmonary microvascular disease was assessed using PTAC (the number of bubbles traversing the pulmonary circulation to reach the left ventricle, categorized as low PTAC or high PTAC). Echocardiographic measures of cardiac output, pulmonary artery pressures, and biventricular function were obtained during exercise. RESULTS Subjects with diabetes and control subjects were of similar age (44 ± 13 vs. 43 ± 13 years, P = 0.87) and sex composition (70% vs. 65% male, P = 0.7). At peak exercise, low PTAC was present in more participants with diabetes than control subjects (41% vs. 12.5%, χ2 P = 0.041) and, in particular, in more subjects with diabetes with microvascular complications compared with both those without complications and control subjects (55% vs. 26% vs. 13%, χ2 P = 0.02). When compared with high PTAC, low PTAC was associated with a 24% lower VO2peak (P = 0.006), reduced right ventricular function (P = 0.015), and greater pulmonary artery pressures during exercise (P = 0.02). CONCLUSIONS PTAC is reduced in diabetes, particularly in the presence of microvascular pathology in other vascular beds, suggesting that it may be a meaningful indicator of pulmonary microvascular disease with important consequences for cardiovascular function and exercise capacity.

Background Left heart catheterisation with coronary angiography (CA) may lead to cognitive dysfunction, as a result of neurological injury. The aim was to assess the incidence of cognitive dysfunction in elderly patients three months after CA and investigate any association between cognitive dysfunction and microembolic count during CA. Methods This was a prospective observational study with a control cohort. Cognitive testing was undertaken at baseline and at 3months using a battery of 8 neuropsychological tests. Subjects comprised 51 CA patients, aged≥50years, with normal baseline cognition, and 31 community control participants. Microemboli were measured by Transcranial Doppler throughout the procedure. All patients underwent trans-femoral CA with aortography and ventriculography. Cognitive dysfunction was defined in an individual when their reliable change index score was less than −1.96 on 2 or more tests and/or their combined z score was less than −1.96. Microembolic count was assessed by off-line manual counting and automatic software was also used to count and differentiate gaseous from solid microemboli. Results Cognitive dysfunction was identified in 15.7% of patients at 3months. Microemboli were detected in all patients, predominantly during aortography and ventriculography. The median total embolic count was 365 (IQR 192, 574), the majority being gaseous (84%). There was no multivariable association between cognitive dysfunction at 3months and microembolic count. Conclusions This study demonstrated that cognitive dysfunction following CA is not associated with microembolic load. Cognitive dysfunction occurs in 15.7% of patients at 3months. This is reassuring for the proceduralist and suggests that other perioperative elements are involved.

Most data assessing the accuracy of electrocardiographic (ECG) screening in identifying cardiac pathology in athletes are derived from relatively unselected cohorts of subjects involved in competitive sports. We hypothesized that the prevalence of ECG abnormalities may be greater in athletes performing the greatest combination of exercise intensity and duration, namely professional endurance athletes. A total of 1,007 male and 254 female elite adult athletes underwent cardiovascular screening inclusive of an electrocardiogram, interpreted using the 2010 European Society of Cardiology guidelines. Training-related ECG changes (group 1) were more common in endurance athletes (EAs) than nonendurance athletes (NEAs; 90.8% vs 86.0%, p = 0.04), as were multiple (≥2) training-related changes (78.9% vs 53.5%, p

Background/objectives We performed a prospective study to investigate markers of percutaneous coronary intervention (PCI) related microvascular injury. Methods Consecutive patients undergoing PCI for stable angina were studied. The index of microvascular resistance (IMR) was measured using a temperature and pressure sensing guidewire (TPSG) before and after single vessel PCI. Basal transit-time (TmnBase), that reflected non-hyperemic blood flow was also measured. Fasting bloods were taken to measure blood sugar, HbA1c and lipids. Asymmetric dimethylarginine (ADMA) was also measured as a marker of systemic endothelial function. Results 55 patients were included in the study. Mean age was 59.9 ± 11.2, 74.1% male. There was no significant difference in IMR post PCI compared with pre PCI values (IMR pre PCI = 16.96 [11.5,25.38] vs. IMR post PCI 14.2 [10.37,26.25] p = 0.96). IMR post PCI was higher in diabetic (DM) patients compared with non-diabetics [IMR post DM = 22.72 (13.35,42.91) vs. no DM = 13.9 (10.18,21.45), p = 0.02]. Fasting blood sugar, HbA1c and IMR pre PCI were correlated with post PCI IMR. IMR pre PCI, HbA1C and fasting glucose were higher in patients who developed PCI related microvascular dysfunction. The strongest independent predictor of post PCI IMR was the pre PCI IMR. Conclusion The baseline status of the microcirculation is an important determinant of post PCI microvascular function. Diabetics appear to have higher post PCI IMR.

significant coronary artery disease. The right coronary artery (RCA) was a large, dominant vessel with normal angiographic appearance. Given the concurrent finding of the right upper lobe PE, it was initially postulated that the patient's presentation resulted from embolic obstruction of her LMCA and LAD through a patent foramen ovale (PFO). The patient was managed medically with intravenous tirofiban and heparin infusions for 48 h, and ongoing aspirin, atorvastatin and carvedilol. Warfarin was subsequently commenced for PE. The patient became pain free and remained stable after day 1 of hospital admission. Transthoracic and transoesophageal echocardiography (TTE and TOE) confirmed moderate segmental left ventricular dysfunction in the LAD territory, but failed to show any evidence of PFO to support the initial postulate of coronary artery embolus. Screening for other systemic thrombotic disease demonstrated a right below knee deep vein thrombosis (DVT), but the patient's thrombophilic and vasculitic screens were negative. A repeat coronary angiogram was performed 6 days later. In the LMCA, there was stainingof vessel consistent with a dissection flap, extending into the LAD. The LCX and RCAwere normal. At this stage, the patient was transferred to our institution for consideration of coronary artery bypass graft (CABG) surgery in a haemodynamically stable, pain free state. Her coronary angiograms were reviewed. The initial coronary angiogram demonstrated a dissection of the left main trunk which extended down the proximal and mid-LAD. RCA was dominant and normal (Fig. 1). Review of the subsequent coronary angiogram demonstrated staining in the mid-distal LMCA, with a clear cap in the mid-LAD consistent with dissection (Fig. 2). TOE excluded dissection of theaorticroot.Therefore,thepatienthadspontaneousdissectionsofthe LMCA and LAD, with an incidental finding of PE. Given the patient has remained stable and pain free, the decision was made to manage her conservatively. Medical therapy was up-titrated with the addition of perindopril. The patient was discharged after a 2-week period of intensive monitoring in hospital, with regular follow up arranged.