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Background Recent data suggest that colchicine may reduce cardiovascular events among patients presenting with acute coronary syndromes. This sub-study of the Australian COPS trial aimed to assess whether colchicine affects health status outcomes. Methods Health status was assessed at baseline and 12-months using the EuroQol-5 Dimension 5-level (EQ-5D-5L) score and the full 19-question Seattle Angina Questionnaire (SAQ). Data were available for 786 patients (388 randomized to colchicine, 398 to placebo). Results Baseline characteristics were well matched between groups; mean age was 60.1 (SD 14.8) years, and 20% were female. Baseline health status scores were impaired, and most parameters demonstrated significant improvement from baseline to 12-months (EQ-5D-5L Visual Analogue Score [VAS] 69.3 to 77.7; SAQ angina frequency score 83.0 to 95.3, both p Conclusions Treatment with colchicine did not appear to affect change in measures of health status following acute coronary syndromes, but it did lead to a greater likelihood of improvement in physical limitation scores. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Peninsula Health, Monash University

Cardiogenic shock is associated with a high risk for morbidity and mortality. The impact of gender on treatment and outcomes is poorly defined. This study aimed to evaluate whether gender influences the clinical management and outcomes of patients with prehospital cardiogenic shock. Consecutive adult patients with cardiogenic shock who were transferred to hospital by emergency medical services (EMS) between January 1, 2015 and June 30, 2019 in Victoria, Australia were included. Data were obtained from individually linked ambulance, hospital, and state death index datasets. The primary outcome assessed was 30-day mortality, stratified by patient gender. Propensity score matching was performed for risk adjustment. Over the study period a total of 3,465 patients were identified and 1,389 patients (40.1%) were women. Propensity score matching yielded 1,330 matched pairs with no differences observed in baseline characteristics, including age, initial vital signs, pre-existing co-morbidities, etiology of shock, and prehospital interventions. In the matched cohort, women had higher rates of 30-day mortality (44.7% vs 39.2%, p = 0.009), underwent less coronary angiography (18.3% vs 27.2%, p0.001), and revascularization with percutaneous coronary intervention (8.9% vs 14.2%, p0.001), compared with men. In conclusion, in this large population-based study, women with cardiogenic shock who were transferred by EMS to hospital had significantly worse survival outcomes and reduced rates of invasive cardiac interventions compared to men. These data underscore the urgent need for targeted public health measures to redress gender differences in outcomes and variation with clinical care for patients with cardiogenic shock.

This study aimed to determine incidences, diagnoses, and outcomes of patients with chest pain attended by paramedics using a large population-based sample.Consecutive emergency medical services (EMS) attendances for non-traumatic chest pain in Victoria, Australia from January 2015 to June 2019 were included. Data were individually linked to emergency, hospital admission and mortality records.During the study period (representing 22,186,930 person-years), chest pain was the reason for contacting EMS in 257,017 of 2,736,570 attendances (9.4%). Overall incidence of chest pain attendances was 1,158 (per 100,000 person-years) with a higher incidence observed with increasing age, among females, among Aboriginal and Torres Strait Islanders, in regional settings, and in socially disadvantaged areas. The most common diagnoses were non-specific pain (46%; 30-day mortality 0.5%), non-ST elevation myocardial infarction (5.3%; mortality 1.3%), pneumonia (3.8%; mortality 3.9%), stable coronary syndromes (3.5%; mortality 0.8%), unstable angina (3.3%; mortality 1.3%), and ST-elevation myocardial infarction (2.8%; mortality 7.0%), while pulmonary embolism (0.7%; mortality 3.2%) and aortic pathologies (0.2%; mortality 22.2%) were rare.Chest pain accounts for one in ten ambulance calls, and underlying causes are diverse. Almost half of patients are discharged from hospital with a diagnosis of non-specific pain and low rates of mortality.

Advances in coronary plaque imaging over the last few decades have led to an increased interest in the identification of novel high-risk plaque features that are associated with cardiovascular events. Existing practices focus on risk stratification and lipid monitoring for primary and secondary prevention of cardiac events, which is limited by a lack of assessment and treatment of vulnerable plaque. In this review, we summarize the multitude of studies that have identified plaque, haemodynamic and patient factors associated with risk of acute coronary syndrome. Future progress in multi-modal imaging strategies and in our understanding of high-risk plaque features could expand treatment options for coronary disease and improve patient outcomes.

AimsThe relationship between lower socioeconomic status (SES) and poor cardiovascular outcomes is well described; however, there exists a paucity of data exploring this association in cardiogenic shock (CS). This study aimed to investigate whether any disparities exist between SES and the incidence, quality of care or outcomes of CS patients attended by emergency medical services (EMS).Methods and resultsThis population-based cohort study included consecutive patients transported by EMS with CS between 1 January 2015 and 30 June 2019 in Victoria, Australia. Data were collected from individually linked ambulance, hospital, and mortality datasets. Patients were stratified into SES quintiles using national census data produced by the Australian Bureau of Statistics.A total of 2628 patients were attended by EMS for CS. The age-standardized incidence of CS amongst all patients was 11.8 [95% confidence interval (95% CI), 11.4–12.3] per 100 000 person-years, with a stepwise increase from the highest to lowest SES quintile (lowest quintile 17.0 vs. highest quintile 9.7 per 100 000 person-years, P-trend ConclusionThis population-based study demonstrated discrepancies between SES status in the incidence, care metrics, and mortality rates of patients presenting to EMS with CS. These findings outline the challenges in equitable healthcare delivery within this cohort.

Background Patient selection and procedural characteristics continue to evolve in percutaneous coronary intervention (PCI). Australian data on long-term trends and outcomes are limited. This study aimed to identify long-term temporal trends in patient characteristics and outcomes in a large Australian PCI cohort. Methods We analysed data from 41,146 PCI procedures included in the multi-centre Melbourne Interventional Group registry to determine trends in patient characteristics, procedural practices and outcomes from 2005 to 2018. Procedures were divided into 2-yearly periods for trends analysis. Results Temporal trends in patient characteristics showed increases in age, proportion of males, rates of obesity, insulin-requiring diabetes mellitus, current smoking, obstructive sleep apnoea and prior PCI (all Ptrend Conclusions Over the last 14 years, Australian PCI procedural complexity and patient risk profiles have increased. Higher mortality rates appear to relate to increased patient risk profile rather than procedural factors.

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

Aims Risk-standardized mortality rates (RSMR) have been used to monitor hospital performance in procedural and disease-based registries, but limitations include the potential to promote risk-averse clinician decisions and a lack of assessment of the whole patient journey. We aimed to determine whether it is feasible to use RSMR at the symptom-level to monitor hospital performance using routinely collected, linked, clinical and administrative data of chest pain presentations. Methods and results We included 192 978 consecutive adult patients (mean age 62 years; 51% female) with acute chest pain without ST-elevation brought via emergency medical services (EMS) to 53 emergency departments in Victoria, Australia (1/1/2015–30/6/2019). From 32 candidate variables, a risk-adjusted logistic regression model for 30-day mortality (C-statistic 0.899) was developed, with excellent calibration in the full cohort and with optimism-adjusted bootstrap internal validation. Annual 30-day RSMR was calculated by dividing each hospital's observed mortality by the expected mortality rate and multiplying it by the annual mean 30-day mortality rate. Hospital performance according to annual 30-day RSMR was lower for outer regional or remote locations and at hospitals without revascularisation capabilities. Hospital rates of angiography or transfer for patients diagnosed with non-ST elevation myocardial infarction (NSTEMI) correlated with annual 30-day RSMR, but no correlations were observed with other existing key performance indicators. Conclusion Annual hospital 30-day RSMR can be feasibly calculated at the symptom-level using routinely collected, linked clinical, and administrative data. This outcome-based metric appears to provide additional information for monitoring hospital performance in comparison with existing process of care key performance measures.

Background: Regionalized systems of care for the management of cardiogenic shock (CS) are increasingly being utilized. This study aims to assess whether receiving hospital characteristics such as the availability of 24-hour coronary angiography, on-site cardiac surgery, and annual treated CS volume influence outcomes in patients transferred by emergency medical services (EMS) to hospital with CS. Methods: This population-based cohort study included consecutive adult patients with CS who were transferred to hospital by EMS between January 1, 2015 and June 30, 2019 in Victoria, Australia. Data were obtained from individually linked ambulance, hospital, and state death index data sets. The primary outcome assessed was 30-day mortality stratified by the availability of 24-hour coronary angiography (cardiac center) at the receiving hospital. Results: A total of 3,217 patients were transferred to hospital with CS. The population had an average age of 67.9 +/- 16.1 years, and 1,289 (40.1%) were female. EMS transfer to a cardiac center was associated with significantly reduced rates of 30-day mortality (adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.64-0.95), compared with noncardiac centers. Compared with the lowest annual CS volume quartile (18 cases per year), hospitals in the highest volume quartile (55 cases per year) had reduced risk of 30-day mortality (aOR, 0.71; 95% CI, 0.56-0.91). A stepwise reduction in the adjusted probability of 30-day mortality was observed in patients transferred by EMS to trauma level 1 centers (34.6%), compared with cardiothoracic surgical centers (39.0%), noncardiac surgical metropolitan (44.9%), and rural (51.3%) cardiac centers, all P0.05. Conclusion: Receiving hospital characteristics are associated with survival outcomes in patients with CS. These finding have important implications for establishing regionalized systems of care for patients with CS who are transferred to hospital by EMS.

Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Evidence regarding outcomes following PCI is limited. This study aimed to assess differences in outcomes following percutaneous coronary intervention (PCI) between patients with and without RA. The Melbourne Interventional Group PCI registry (2005 to 2018) was used to identify 756 patients with RA. Outcomes were compared with the remaining cohort (n = 38,579). Patients with RA were older, more often female, with higher rates of hypertension, previous stroke, peripheral vascular disease, obstructive sleep apnea, chronic lung disease, myocardial infarction, and renal impairment, whereas rates of dyslipidemia and current smoking were lower, all p

Bioresorbable scaffolds (BRS) are a novel technology in coronary intervention. However, recent trials demonstrate higher rates of device failure compared to contemporary drug-eluting stents. This study sought to utilise a clinical quality registry to assess the medium-term safety of the Abbott Absorb BRS (Abbott Vascular, Santa Clara, CA, USA), in an Australian context.A prospective, observational study of 192 BRS percutaneous coronary interventions (PCI) compared to 31,773 non-BRS PCIs entered in the Victorian Cardiac Outcomes Registry from 2013 to 2017. The main outcome measure was patient-oriented composite endpoint (POCE) events comprising all-cause mortality, any myocardial infarction (MI), and any revascularisation.Bioresorbable scaffolds patients (mean age 61.6±10.5 years, 79% male) were younger, had less comorbidity, less prior PCI, fewer ST elevation myocardial infarction (STEMI) presentations, lower rates of multi-lesion disease and more adjuvant devices compared to non-BRS PCI (all p0.01). All-cause mortality was 2.1%, myocardial infarction (MI) 2.1%, scaffold thrombosis 3.1% and any revascularisation 14.1% (mean follow-up 27.4±8.9 months). POCE events occurred in 11.5% at 1 year and 16.9% at 2 years, comparable to pooled-trial data. Multivariate predictors of POCE were1 scaffold used (odds ratio [OR] 4.6, 95% confidence interval [CI] 1.9-11.4, p0.01) and scaffold diameter ≤2.5 mm (OR 3.3, 95% CI 1.4-7.6, p=0.02). Over 95% guideline adherence was achieved in six of eight patient selection criteria and four of six device deployment criteria.In an Australian setting, BRS were used in non-complex patients. Most guidelines for use were adhered to and outcomes were comparable to pooled trial data. Clinical quality registries are effective in assessing novel treatments and technologies when potential safety concerns develop.

BACKGROUND: His-bundle pacing (HBP) has emerged as a promising technique to avoid pacing complications associated with dyssynchrony from right ventricular pacing, but data are limited to experienced operators and centres. We aimed to evaluate the implementation and outcomes of an HBP program in an Australian setting. METHODS: Data were retrospectively collected on 140 consecutive HBP procedures attempted at three centres from March 2018 to September 2019. The cohort was divided into three groups (early: procedures 1-47, middle: 48-94, late: 95-140) to determine changes in procedural success in relation to operator experience. RESULTS: Median age was 76 years (IQR 68-80 yrs); 69% were male. Atrial fibrillation was present in 59%, left ventricular ejection fraction (LVEF) ≤40% in 25%, and left and right bundle branch blocks present in 23% and 16% respectively, and atrioventricular (AV) block was present in 26%. Overall procedural success was 87%, median implant threshold 0.8V@1 ms, and QRS duration improved in 64% of procedures. Procedural success (early 83%, middle 89%, late 89%, p=0.58) was not different, while median procedural time (early 98 mins, middle 83 mins, late 70 mins, p

Background Stroke rates and risk factors may change as percutaneous coronary intervention practice evolves and no data are available comparing stroke incidence after percutaneous coronary intervention to the general population. Aims This study aimed to identify the incidence and risk factors for inpatient and subsequent stroke following percutaneous coronary intervention with comparison to age-matched controls. Methods Data were prospectively collected from 22,618 patients undergoing percutaneous coronary intervention in the Melbourne Interventional Group registry (2005–2015). The cohort was compared to the North-East Melbourne Stroke Incidence Study population-based cohort (1997–1999) and predefined variables assessed for association with inpatient or outpatient stroke. Results Inpatient stroke occurred in 0.33% (65.3% ischemic, 28.0% haemorrhagic, and 6.7% cause unknown), while outpatient stroke occurred in 0.55%. Inpatient and outpatient stroke were associated with higher rates of in-hospital major adverse cardiovascular outcomes ( p Conclusions Risk of inpatient stroke following percutaneous coronary intervention appears to be largely associated with clinical status at presentation, while outpatient stroke relates more to age and chronic disease. Compared to the general population, outpatient stroke rates following percutaneous coronary intervention are higher for younger, but not older, patients.

ImportancePrehospital point-of-care troponin testing and paramedic risk stratification might improve the efficiency of chest pain care pathways compared with existing processes with equivalent health outcomes, but the association with health care costs is unclear.ObjectiveTo analyze whether prehospital point-of-care troponin testing and paramedic risk stratification could result in cost savings compared with existing chest pain care pathways.Design, Setting, and ParticipantsIn this economic evaluation of adults with acute chest pain without ST-segment elevation, cost-minimization analysis was used to assess linked ambulance, emergency, and hospital attendance in the state of Victoria, Australia, between January 1, 2015, and June 30, 2019.InterventionsParamedic risk stratification and point-of-care troponin testing.Main Outcomes and MeasuresThe outcome was estimated mean annualized statewide costs for acute chest pain. Between May 17 and June 25, 2022, decision tree models were developed to estimate costs under 3 pathways: (1) existing care, (2) paramedic risk stratification and point-of-care troponin testing without prehospital discharge, or (3) prehospital discharge and referral to a virtual emergency department (ED) for low-risk patients. Probabilities for the prehospital pathways were derived from a review of the literature. Multivariable probabilistic sensitivity analysis with 50 000 Monte Carlo iterations was used to estimate mean costs and cost differences among pathways.ResultsA total of 188 551 patients attended by ambulance for chest pain (mean [SD] age, 61.9 [18.3] years; 50.5% female; 49.5% male; Indigenous Australian, 2.0%) were included in the model. Estimated annualized infrastructure and staffing costs for the point-of-care troponin pathways, assuming a 5-year device life span, was $2.27 million for the pathway without prehospital discharge and $4.60 million for the pathway with prehospital discharge (incorporating virtual ED costs). In the decision tree model, total annual cost using prehospital point-of-care troponin and paramedic risk stratification was lower compared with existing care both without prehospital discharge (cost savings, $6.45 million; 95% uncertainty interval [UI], $0.59-$16.52 million; lower in 94.1% of iterations) and with prehospital discharge (cost savings, $42.84 million; 95% UI, $19.35-$72.26 million; lower in 100% of iterations).Conclusions and RelevancePrehospital point-of-care troponin and paramedic risk stratification for patients with acute chest pain could result in substantial cost savings. These findings should be considered by policy makers in decisions surrounding the potential utility of prehospital chest pain risk stratification and point-of-care troponin models provided that safety is confirmed in prospective studies.

Purpose During the COVID-19 pandemic, widespread public health measures were implemented to control community transmission. The association between these measures and health-related quality of life (HRQOL) among patients following percutaneous coronary intervention has not been studied. Methods We included consecutive patients undergoing percutaneous coronary intervention (PCI) in the state-wide Victorian Cardiac Outcomes Registry between 1/3/2020 and 30/9/2020 (COVID-19 period; n = 5024), with a historical control group from the identical period one year prior (control period; n = 5041). HRQOL assessment was performed via telephone follow-up 30 days following PCI using the 3-level EQ-5D questionnaire and Australian-specific index values. Results Baseline characteristics were similar between groups, but during the COVID-19 period indication for PCI was more common for acute coronary syndromes. No patients undergoing PCI were infected with COVID-19 at the time of their procedure. EQ-5D visual analogue score (VAS), index score, and individual components were higher at 30 days following PCI during the COVID-19 period (all P

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.

Over the last 3 decades there have been substantial improvements in treatments aimed at reducing cardiovascular (CV) events. As these treatments have been developed, there have been parallel improvements in coronary imaging modalities that can assess plaque volumes and composition, using both invasive and noninvasive techniques. Plaque progression can be seen to precede CV events, and therefore, many studies have longitudinally assessed changes in plaque characteristics in response to various treatments, aiming to demonstrate plaque regression and improvements in high-risk features, with the rationale being that this will reduce CV events. In the past, decisions surrounding treatments for atherosclerosis have been informed by population-based risk scores for initiation in primary prevention and low-density lipoprotein cholesterol levels for titration in secondary prevention. If outcome data linking plaque regression to reduced CV events emerge, it may become possible to directly image plaque treatment response to guide management decisions.

Background Over the last thirty years, there has been exponential growth in the number and scale of national cardiovascular disease registries. We aimed to provide a comprehensive outline of contemporary national cardiac registries across all subspecialties. Methods We performed a systematic literature review by searching OvidMedline in August 2019 to identify registries relating to six pre-specified domains (Table). For inclusion, registries had to be national in nature, actively collecting data, and publishing either peer-reviewed publications or online reports. Results A total of 24,076 records were identified from six domain-specific Medline searches; 24,057 abstracts were screened with 19,435 non-relevant records excluded; 4,624 full texts were screened with 4,473 non-relevant texts excluded; and 151 registries met inclusion criteria representing 51 countries. Of these, 15 related to cardiac surgery, 27 to arrhythmia (17 device, 5 ablation, 7 atrial fibrillation), 21 to congenital heart disease (14 general, 2 interventional, 4 surgical, and 1 disease specific), 43 to coronary disease or percutaneous coronary intervention (22 PCI, 21 CAD), 27 to heart failure (13 heart failure, 5 transplant, 2 mechanical support, 7 disease specific), and 18 related to structural intervention (3 any, 13 transcatheter aortic valve replacement, 2 mitral intervention). Nine national registries (USA, Sweden, Finland, Denmark, UK, Portugal, Norway, Taiwan, and Singapore) covered multiple domains. Quality scoring using the Monash University Clinical Quality Registry Grading System (a composite score of recruitment, and data completeness, definitions, reliability and validation), demonstrated marked heterogeneity in quality between registries. Conclusions Cardiac registries have seen rapid growth, however the use and quality among various subspecialties differs markedly across world regions. Given the multiple benefits, clinicians, funders and health bureaucrats should be encouraged to focus on the range, quality and uptake of national registries. Figure 1 Funding Acknowledgement Type of funding source: None

Background Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Despite this, data regarding long-term outcomes following percutaneous coronary intervention (PCI) are limited. Methods We identified 756 patients with RA from the Melbourne Interventional Group PCI registry (2005–2018) and compared outcomes to the remaining cohort (N=38,579). Cox regression analysis was performed to assess risk of adverse cardiac events including long-term mortality (derived from linkage with the National Death Index [NDI]). Results Patients with RA were older (68.9±10.0 vs. 64.6±12.0 years) and more often female (40% vs. 23%), with higher rates of hypertension (70% vs 67%), previous stroke (9% vs 6%), peripheral vascular disease (9% vs 6%), obstructive sleep apnoea (10% vs 5%), chronic lung disease (22% vs 12%), prior myocardial infarction (32% vs 27%), and impaired renal function (eGFR20mm in 39% vs 35%), and rates of no reflow were higher (5% vs 3%), all p Conclusions Patients with RA undergoing PCI have more comorbidities and longer, more complex coronary lesions. After adjustment, risk of short-term adverse outcomes are similar, while risk of long-term mortality is higher, particularly among patients with acute coronary syndromes. Funding Acknowledgement Type of funding source: None

Background and aim Combining therapy with a thiopurine is favored when commencing infliximab in Crohn's disease; however, the optimal 6-thioguanine nucleotide (TGN) level and how long to continue thiopurines after induction are uncertain. We aimed to compare outcomes after induction and during maintenance in combination therapy versus infliximab monotherapy in Crohn's and to examine whether TGN levels were associated with outcomes. Methods Crohn's patients induced with infliximab with or without concomitant thiopurines were retrospectively identified. Response to induction and clinical outcomes in subsequent 6-month maintenance semesters were analyzed. A TGN level ≥235 pmol/8 × 108 red blood cells was considered therapeutic. Results In 89 patients, response to induction was higher in combination therapy than monotherapy (74 vs 47%, P = 0.04). This benefit was only seen in patients with a therapeutic TGN (odds ratio 3.72, confidence interval 1.07-13.0, P = 0.04). Combination therapy during induction yielded a three times longer time to subsequent need for treatment escalation or treatment failure compared with monotherapy (29 vs 9 months, P = 0.01), with both therapeutic and subtherapeutic TGNs independent predictors on multivariate analysis. Among 370 semesters, there was no difference in outcomes between combination therapy and monotherapy (P = 0.42), nor when combination semesters were stratified by therapeutic versus subtherapeutic TGN (P = 0.56). In semester 1 only, a significantly higher remission rate was observed with therapeutic compared with subtherapeutic TGN (76% vs 33%, P = 0.02). Conclusions Combination therapy dosed with an optimized thiopurine was superior to infliximab monotherapy for induction of response, durability of response, and clinical outcomes in the first 6 months following induction. Thereafter, combination therapy yielded no clinical advantage, supporting consideration of thiopurine withdrawal on a case-by-case basis.

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/m2, n = 214), overweight (25 to 29.9 kg/m2, n = 234), and obese (>30 kg/m2, 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

BackgroundBalloon aortic valvuloplasty (BAV) has seen renewed interest since the advent of transcatheter aortic valve implantation (TAVI). The study aimed to characterise a contemporary BAV cohort and determinants of clinical outcomes.MethodsPatients undergoing BAV at a single tertiary centre were retrospectively reviewed over a 10-year period, and functional and mortality outcomes were reported with up to a 2-year follow-up.Results224 patients (aged 82.5±8.3 years; 48% female) underwent BAV over the study period. Indications were either destination treatment (39%) or bridge-to-valve replacement (61%)—including bridge-to-decision (29%), symptom relief while on the waitlist (27%), and temporary contraindications to TAVI/aortic valve replacement (AVR) (5%). The mean reduction of aortic mean pressure gradient was 38%. Procedural mortality occurred in 0.5%, stroke in 1.3%, and major bleeding in 0.9%. Twelve-month mortality was 36% overall, and 26% and 50% in the bridging and destination groups, respectively. New York HeartAssociation (NYHA) class improved by ≥1 at 30 days in 50%. Among the bridge-to-TAVI/AVR group, 40% proceeded to TAVI/AVR within 12 months following BAV. In multivariate analysis, active malignancy at baseline (OR: 4.4, 95% CI: 1.3 to 15.1, p=0.02), smoking history (OR: 3.3, 95% CI: 1.3 to 7.9, pConclusionsBAV remains a useful procedure with relatively low rates of complications, however, 1-year mortality rates are high. Contemporary indications for BAV include a bridge to definitive valve replacement or destination treatment.

Cardiac involvement can occur following bacteremia secondary to Neisseria meningitidis (Garcia et al. Rev Soc Bras Med Trop. 1999;32(5):517–5122) and is likely underrecognized. However, meningococcal disease presenting as primary myopericarditis in immunocompetent adults is a relatively rare phenomenon. We discuss an unusual presentation of meningococcal disease and the investigation and treatment strategies implemented.

Primary percutaneous coronary intervention (PPCI) is the preferred therapy for patients presenting with ST-elevation myocardial infarction (STEMI). We reviewed patients undergoing PCI for STEMI over a 6-year period to evaluate changes in procedural characteristics and clinical outcomes given recent changes to STEMI guidelines.All patients presenting to the Alfred Hospital, a tertiary referral hospital, between 1 January 2010 and 31 December 2015 undergoing PCI for STEMI were identified. Detailed review of their procedure reports was performed and 30-day and 12-month clinical outcomes were recorded including major adverse cardiac events (MACE).There was a total of 445 patients aged 60.6±12.4 years with 369 (82.9%) male. There was a significant increase in radial access use over the 6-year period 0/49 (0%) in 2010 vs 56/113 (49.6%) in 2015 (p0.01). There was a significant reduction in the use of IIb/IIIa receptor antagonists during the period 29/49 (59%) in 2010 vs 24/113 (21%) in 2015 (p0.01) and use of aspiration thrombectomy 15/49 (31%) in 2010 vs 19/113 (17%) in 2015 (p0.01). There was no significant reduction in major bleeding over this period with 2/49 (4%) in 2010 vs 5/108 (5%) in 2015 (p=0.32). Thirty-day and 12-month mortality was also unchanged.Between 2010 and 2015 there has been a significant increase in the use of radial access and a reduction in the use of glycoprotein IIb/IIIa antagonists and aspiration thrombectomy in patients undergoing PPCI. This was not associated with changes in major bleeding or 30-day or 12-month mortality.

Key Points Question What are the incidence and clinical outcomes of adults with shock that is not related to trauma who accessed the emergency medical service (EMS) system in Victoria, Australia? Findings In this cohort study, the incidence of prehospital shock treated by EMS was 76 per 100 000 person-years, and the 30-day mortality rate was 32.8%. Meaning These findings suggest that nontraumatic shock of varying etiologies among adults initially receiving care from EMS is associated with a high risk of morbidity and mortality., This population-based cohort study assesses the incidence, etiology, and clinical outcomes of patients with nontraumatic shock treated by emergency medical services (EMS) in Victoria, Australia., Importance Nontraumatic shock is a challenging clinical condition, presenting urgent and unique demands in the prehospital setting. There is a paucity of data assessing its incidence, etiology, and clinical outcomes. Objective To assess the incidence, etiology, and clinical outcomes of patients treated by emergency medical services (EMS) with nontraumatic shock using a large population-based sample. Design, Setting, and Participants This population-based cohort study included consecutive adult patients with shock not related to trauma who received care by EMS between January 1, 2015, and June 30, 2019, in Victoria, Australia. Data were obtained from individually linked ambulance, hospital, and state death index data sets. During the study period there were 2 485 311 cases attended by EMS, of which 16 827 met the study’s inclusion criteria for shock. Main Outcomes and Measures The primary outcome was 30-day mortality. Secondary outcomes included length of hospital stay, emergency department discharge disposition, rates of coronary angiography and revascularization procedures, and the use of mechanical circulatory support. Results A total of 12 695 patients were successfully linked, with a mean (SD) age of 65.7 (19.1) years; 6411 (50.5%) were men. The overall population-wide incidence of EMS-treated prehospital shock was 76 (95% CI, 75-77) per 100 000 person-years. An increased incidence was observed in men (79 [77-81] per 100 000 person-years), older patients (eg, aged 70-79 years: 177 [171-183] per 100 000 person-years), regional locations (outer regional or remote: 100 [94-107] per 100 000 person-years), and in areas with increased socioeconomic disadvantage (lowest socioeconomic status quintile: 92 [89-95] per 100 000 person-years). Patients with hospital outcome data were stratified into shock etiologies; 3615 (28.5%) had cardiogenic shock: 3998 (31.5%), septic shock; 1457 (11.5%), hypovolemic shock; and 3625 (28.6%), other causes of shock. Nearly one-third of patients (4158 [32.8%]) were deceased at 30 days. In multivariable analyses, increased age (all etiologies: hazard ratio [HR], 1.04; 95% CI, 1.03-1.04), female sex (cardiogenic shock: HR, 1.26; 95% CI, 1.12-1.42), increased initial heart rate (all etiologies: 1.01; 95% CI, 1.00-1.01), prehospital intubation (all etiologies: HR, 3.93; 95% CI, 3.48-4.44), and preexisting comorbidities (eg, chronic kidney disease, all etiologies: HR, 1.25; 95% CI, 1.10-1.42) were independently associated with 30-day mortality, while higher socioeconomic status (all etiologies: HR, 0.96; 95% CI, 0.94-0.98) and increased initial systolic blood pressure (all etiologies: HR, 0.99; 95% CI, 0.99-0.99) were associated with lower risk. Conclusions and Relevance This population-level cohort study found that EMS-treated nontraumatic shock was a common condition, with a high risk of morbidity and mortality regardless of etiology. It disproportionately affected men, older patients, patients in regional areas, and those with social disadvantage. Further studies are required to assess how current systems of care can be optimized to improve outcomes.

Out-of-hospital cardiac arrest (OHCA) is frequently associated with ST-elevation myocardial infarction (STEMI) and has a high mortality. We aimed to identify differences in characteristics and very long-term outcomes for STEMI patients with and without OHCA managed with percutaneous coronary intervention (PCI).We analysed data from 12,637 PCI patient procedures for STEMI in the multi-centre Melbourne Interventional Group registry between January 2005 and December 2018. Multivariable models examined associations with OHCA presentation and 30-day mortality. Long-term outcomes were assessed through linkage with the Australian National Death Index.Compared with patients without OHCA (N = 11,580), patients with OHCA (N = 1057) were younger, more often male, had less cardiovascular risk factors, and more often presented with cardiogenic shock. OHCA preceded an increasing proportion of STEMI PCI cases from 2005 to 2018 (2.4% vs. 9.2%). Factors independently associated with OHCA presentation were younger age, male gender, prior valve surgery, multi-vessel disease, LAD culprit, small vessel diameter, and renal impairment on presentation. Patients with OHCA had lower procedural success, higher rates of bleeding and stroke, larger infarct size (measured by peak CK), and higher 30-day mortality (37% vs. 5%; all p 0.05). Cardiogenic shock, renal impairment and lower ejection fraction were independently associated with 30-day mortality. Long-term mortality was 44% vs. 20% (median follow-up 4.6 years), with Cox regression analysis demonstrating no difference in survival if patients survived beyond 30 days (HR 1.18, 95% CI 0.95-1.47).OHCA has a high short-term mortality and precedes an increasing proportion of STEMI PCI cases. Thirty-day survivors have an excellent long-term prognosis.

Transcatheter aortic valve implantation (TAVI) is increasingly used for intermediate- and high-risk patients with severe symptomatic aortic stenosis (AS). However, safe undertaking of the procedure may be precluded by various anatomic factors. This study sought to identify prevalence of factors that prevent progression to TAVI.TAVI candidates with severe AS undergoing workup coronary angiography and iliac vessel angiography (±cardiac-gated CT) were identified and factors precluding TAVI were reviewed retrospectively from a single-centre cardiac database over a 10-year period.197 patients were included; mean age was 81.5±6.5years (±SD); 46.2% were male. 26.9% of TAVI candidates could not proceed to femoral access TAVI due to various factors including unsuitable peripheral vasculature (13.2%), untreated coronary artery disease (CAD) deemed high risk for TAVI (8.1%), unfavourable aortic characteristics (4.1%), and low-lying coronary ostia (1.5%). Factors associated with unsuitable femoral vasculature included female gender (p0.01) and any CAD (p=0.03). Factors associated with the presence of unrevascularised CAD included male gender (p0.01), estimated glomerular filtration rate (eGFR)30mL/min/1.73mNon-progression to TAVI among higher risk patients with severe AS has become less common over the last 10 years with improvements in operator experience, lower profile devices, and wider ranges of valve sizes.

Objective Diabetes (DM) and osteoarthritis (OA) are two common co-existing chronic conditions. However, whether this is due to shared risk factors or may differ between joints is unclear. We performed a systematic review to determine whether abnormal glucose metabolism is a risk factor for knee, hip and hand OA, separately, independent of age and obesity. Methods A systematic search of Ovid Medline and EMBASE was performed from inception until October 2016 to identify studies relating glucose metabolism to osteoarthritis-related outcomes. Studies were included if they related DM and OA and the knee, hip, or hand were examined separately. In the structured synthesis, objective measures of DM and adjustment for age and obesity were also required. Results Of the 40 included studies, 28 examined the knee, nine the hip and 14 the hand. Five studies with a longitudinal component used objective measures of DM (blood glucose) and knee OA (radiography or joint replacement) and adjusted for age and obesity (21,299 participants). Of these, three found no association, one found a reduction in risk and one, which adjusted for the presence but not magnitude of obesity, found an increase in risk. Of the longitudinal studies examining the relationship between DM and OA that accounted for obesity, none provided evidence of an independent relationship between DM and hip (2 studies) or hand OA (1 study). Conclusion There is little evidence to suggest that impaired glucose metabolism is a risk factor, independent of obesity, for knee OA and no evidence that impaired glucose metabolism is an independent risk factor for hip or hand OA.

Over the last decade, systems of care for ST-elevation myocardial infarction (STEMI) have evolved to try to improve outcomes and timely access to percutaneous coronary intervention (PCI). There have also been advances in PCI techniques and adjunctive pharmacotherapies. In this study, we sought to determine temporal changes in practices and clinical outcomes of PCI in patients with STEMI. We prospectively collected data on 8,412 consecutive patients undergoing PCI for STEMI between 2005 and 2016 in the multicenter Melbourne Interventional Group registry. Data were divided by procedure year for trends analysis. The primary end point was 30-day mortality. Patient demographics and comorbidities including smoking and diabetes have remained stable. The volume of primary PCI performed within 12 hours of symptom onset has significantly risen (65.7% to 80.1%, p