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Mimics of ST-segment elevation myocardial infarction (STEMI) are common. We present the case of a STEMI mimic to highlight the importance of a broad differential diagnosis and multidisciplinary care. A 58-year-old woman presented to our hospital with drowsiness, epigastric discomfort and nausea.

Background: TEXTMEDS (Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome) examined the effects of text message–delivered cardiac education and support on medication adherence after an acute coronary syndrome. Methods: TEXTMEDS was a single-blind, multicenter, randomized controlled trial of patients after acute coronary syndrome. The control group received usual care (secondary prevention as determined by the treating clinician); the intervention group also received multiple motivational and supportive weekly text messages on medications and healthy lifestyle with the opportunity for 2-way communication (text or telephone). The primary end point of self-reported medication adherence was the percentage of patients who were adherent, defined as >80% adherence to each of up to 5 indicated cardioprotective medications, at both 6 and 12 months. Results: A total of 1424 patients (mean age, 58 years [SD, 11]; 79% male) were randomized from 18 Australian public teaching hospitals. There was no significant difference in the primary end point of self-reported medication adherence between the intervention and control groups (relative risk, 0.93 [95% CI, 0.84–1.03]; P =0.15). There was no difference between intervention and control groups at 12 months in adherence to individual medications (aspirin, 96% vs 96%; β-blocker, 84% vs 84%; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 77% vs 80%; statin, 95% vs 95%; second antiplatelet, 84% vs 84% [all P >0.05]), systolic blood pressure (130 vs 129 mm Hg; P =0.26), low-density lipoprotein cholesterol (2.0 vs 1.9 mmol/L; P =0.34), smoking ( P =0.59), or exercising regularly (71% vs 68%; P =0.52). There were small differences in lifestyle risk factors in favor of intervention on body mass index 2 (21% vs 18%; P =0.01), eating ≥5 servings per day of vegetables (9% vs 5%; P =0.03), and eating ≥2 servings per day of fruit (44% vs 39%; P =0.01). Conclusions: A text message–based program had no effect on medical adherence but small effects on lifestyle risk factors. Registration: URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364448 ; Unique identifier: ANZCTR ACTRN12613000793718.

Background: Treating known risk factors for coronary artery disease (CAD) has substantially reduced CAD morbidity and mortality. However, a significant burden of CAD remains unexplained. Immunoglobulin E sensitization to mammalian oligosaccharide galactose-α-1,3-galactose (α-Gal) was recently associated with CAD in a small observational study. We sought to confirm that α-Gal sensitization is associated with CAD burden, in particular noncalcified plaque. Additionally, we sort to assess whether that α-Gal sensitization is associated with ST-segment–elevated myocardial infarction (STEMI) Methods: We performed a cross-sectional analysis of participants enrolled in the BioHEART cohort study. We measured α-Gal specific-immunoglobulin E antibodies in serum of 1056 patients referred for CT coronary angiography for suspected CAD and 100 selected patients presenting with STEMI, enriched for patients without standard modifiable risk factors. CT coronary angiograms were assessed using coronary artery calcium scores and segmental plaque scores. Results: α-Gal sensitization was associated with presence of noncalcified plaque (odds ratio, 1.62 [95% CI, 1.04–2.53], P =0.03) and obstructive CAD (odds ratio, 2.05 [95% CI, 1.29-3.25], P =0.002), independent of age, sex, and traditional risk factors. The α-Gal sensitization rate was 12.8-fold higher in patients with STEMI compared with matched healthy controls and 2.2-fold higher in the patients with STEMI compared with matched stable CAD patients (17% versus 1.3%, P =0.01 and 20% versus 9%, P =0.03, respectively). Conclusions: α-Gal sensitization is independently associated with noncalcified plaque burden and obstructive CAD and occurs at higher frequency in patients with STEMI than those with stable or no CAD. These findings may have implications for individuals exposed to ticks, as well as public health policy. Registration: URL: https://www.anzctr.org.au ; Unique identifier: ACTRN12618001322224.

BACKGROUND Obstructive sleep apnoea (OSA) occurs frequently in patients with coronary artery disease, with associated intermittent hypoxia a possible stimulus for coronary collateral recruitment through ischaemic preconditioning. We sought to determine whether OSA affects recruitment of coronary collaterals and prognosis of patients presenting with ST elevation myocardial infarction (STEMI). METHODS Patients with a STEMI undergoing percutaneous coronary intervention (PCI) from July 2010 to December 2019 were reviewed. Electronic medical records were accessed to determine documented patient history of OSA. Patients with robust collaterals were defined as Rentrop Grade 2 or 3. RESULTS 1,863 patients were included, of which 143 (7.7%) patients had documented evidence of OSA in their health record. Patients with OSA had a higher body mass index (BMI) (30.2 kg/m2 vs 27 kg/m2, p

Chronic total occlusions (CTO) are found commonly in patients with prior coronary artery bypass grafting (CABG). We sought to determine the effect of CABG on collateral robustness in patients with a CTO. Patients with a CTO diagnosed on coronary angiography between July 2010 and December 2019 were included in this study. Patients were classified as either CTO supplied by a functional graft, CTO supplied by collaterals from a non-grafted donor vessel (non-grafted) or a CTO supplied by collaterals from a grafted donor vessel (grafted). The degree of collateral robustness was determined by the Rentrop classification and collateral connection (CC) grade. Demographic, angiographic and clinical outcomes were recorded. A total of 2088 CTO lesions were identified, of which 878 (42.0%) were supplied by a functional graft, 994 (47.6%) CTOs were supplied by a non-grafted donor vessel and 216 (10.3%) CTOs were supplied by a grafted donor vessel. CTOs supplied by a grafted donor vessel had lower rates of robust collaterals (37.0% vs 83.0%, p

Obstructive sleep apnoea (OSA) which results in hypoxia may affect the ability to recruit coronary collaterals. The aim of this study was to determine whether the severity of OSA affects collateral recruitment in patients with total coronary occlusions. Patients with total coronary artery occlusion were reviewed. Records from the sleep investigation laboratory were reviewed to identify those patients who had undergone diagnostic polysomnography. Robust coronary collaterals were those with Rentrop grade 2 or 3 collaterals. Sixty-four patients with a total coronary occlusion had polysomnography performed, of whom 60 patients had OSA. Thirty-two patients (53.3%) had poor collaterals, whilst 28 (46.7%) had robust collaterals. Twenty-four (40%) patients had mild OSA, 10 (16.7%) had moderate OSA and 26 (43.3%) had severe OSA. Patients with robust collaterals were more likely to be males (96.4% vs 74.3%, p

Invasive coronary physiology has been applied by interventional cardiologists to guide the management of coronary artery disease (CAD), with well-defined thresholds applied to determine whether CAD should be managed with optimal medical therapy (OMT) alone or OMT and percutaneous coronary intervention (PCI). There are multiple modalities in clinical use, including hyperaemic and non-hyperaemic indices. Despite endorsement in the major guidelines, there are various factors which impact and confound the readings of invasive coronary physiology, both within the coronary tree and beyond. This review article aims to summarise the mechanisms by which these factors impact invasive coronary physiology, and distinguish factors that contribute to ischaemia from confounding factors. The potential for mis-classification of ischaemic status is highlighted. Lastly, the authors identify targets for future research to improve the precision of physiology-guided management of CAD.

A chronic total occlusion (CTO) is frequently identified in patients undergoing coronary angiography. The prognostic implications of intermittent hypoxia from obstructive sleep apnea (OSA) on patients with a CTO, and effects on collateral recruitment are unknown. The aim of this study was to determine the prevalence, vascular effects, and prognostic implications of the presence of OSA in patients with a CTO. Patients with a CTO between July 2010 and December 2019 were reviewed. Electronic medical records were accessed to determine documented patient history of OSA, demographics, and clinical course. Patients with robust collateral recruitment were defined as Rentrop grade 2 or 3. A total of 948 patients were included in the study, of which 127 (13.4%) had a documented history of OSA. These patients were younger (67.0 years vs 70.6 years, p0.01), had a higher body mass index (29.6 kg/m

The impact of surgical or percutaneous coronary revascularization on prognosis in patients with a chronic total occlusion (CTO) remains uncertain. Particularly, whether revascularization of those with robust coronary collaterals improves prognosis is unknown. The objective of this study was to determine the predictors and prognostic impact of revascularization of a CTO, and to determine the clinical impact of robust coronary collaterals. Patients with a CTO diagnosed on coronary angiography between Jul 2010 and Dec 2019 were included in this study. Management strategy of the CTO was defined as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) or medical management. The degree of collateral robustness was determined by the Rentrop grading classification. Demographic, angiographic and clinical outcomes were recorded. A total of 954 patients were included in the study, of which 186 (19.5%) patients underwent CTO PCI, 296 (31.0%) patients underwent CABG and 472 (49.5%) patients underwent medical management of the CTO. 166 patients (17.4%) had Rentrop grade zero or one collaterals, 577 (60.5%) patients had Rentrop grade two and 211 (22.1%) had Rentrop grade three collaterals. The independent predictors of medical management of the CTO were older age, greater stenosis in the donor vessel, an emergent indication for angiography, a non-LAD CTO and female sex. The degree of collateral robustness was not associated with long-term mortality, while patients who were revascularized either through CABG or PCI had a significantly lower mortality compared to medical management alone (p

Aortic stenosis (AS) once was conceptualized as a mechanical problem with a fixed left ventricular (LV) afterload because of an obstructive valve. With time, there has been growing recognition that AS functions more like a series circuit, with important contributions from the ventricle through to the vasculature. Emerging evidence suggests that higher blood pressure and increased arterial stiffness, synonymous with vascular aging, increases global LV afterload in patients with AS. This in turn, has adverse consequences on quality-of-life measures and survival. Although traditional methods have emphasized measurement of the transvalvular pressure gradient, focusing on valvular hemodynamics alone may be inadequate. By definition, total vascular load of the human circulation includes both steady and pulsatile components. Steady load is best represented by the systemic vascular resistance whereas pulsatile load occurs because of wave reflections and vascular stiffness, and is often referred to as the valvulo-arterial impedance. In the following Review, we evaluate existing and upcoming methods to assess vascular load in patients with AS in order to better understand the effects of vascular aging on this insidious disease process.

Background: It is unclear whether more effective forms of thrombus removal than current aspiration catheters would lead to improved outcomes. We sought to evaluate the prognostic role of residual thrombus burden (rTB), after manual thrombectomy, in patients undergoing primary percutaneous coronary intervention with routine manual thrombectomy in the TOTAL trial (Thrombectomy Versus PCI Alone). Methods: This is a single-arm analysis of patients from the TOTAL trial who underwent routine manual aspiration thrombectomy. The rTB was quantified by an angiographic core laboratory using the Thrombolysis in Myocardial Infarction criteria and validated using existing optical coherent tomography data. Large rTB was defined as grade ≥3. The primary outcome was death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or new or worsening heart failure within 180 days. Results: Of 5033 patients randomized to routine thrombectomy, 2869 patients had quantifiable rTB (1014 [35%] had large rTB). Patients with large rTB were more likely to have hypertension, previous percutaneous coronary intervention, myocardial infarction, or Killip class III on presentation but less likely to have Killip class I. The primary outcome occurred more frequently in patients with large rTB, even after adjustment for known risk predictors (8.6% versus 4.6%; adjusted hazard ratio, 1.83 [95% CI, 1.34–2.48]). These patients also had a higher risk of cardiovascular death (adjusted hazard ratio, 1.83 [95% CI, 1.13–2.95]), cardiogenic shock (adjusted hazard ratio, 2.02 [95% CI, 1.08–3.76]), and heart failure (adjusted hazard ratio, 1.74 [95% CI, 1.02–2.96]) but not myocardial infarction or stroke. Conclusions: Large rTB is a common finding in primary percutaneous coronary intervention and is associated with increased risk of adverse cardiovascular outcomes, including cardiovascular death. Future technologies offering better thrombus removal than current devices may decrease or even eliminate the risk associated with rTB. This, potentially, can turn into a strategic option to be studied in clinical trials. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01149044.

Acute coronary collateralisation of an infarct-related arterial (IRA) territory may be identified during angiography for ST elevation myocardial infarction (STEMI). Whether the presence or absence of these collaterals affects outcomes remains uncertain. A search of EMBASE, MEDLINE and Cochrane Library, using the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines was conducted to identify studies which reported on the association between coronary collaterals and in-hospital and longer term mortality, left ventricular ejection fraction (LVEF), risk of repeat acute myocardial infarction (AMI) and repeat revascularisation. Patients with Rentrop grade 0 or 1 were defined as poor collaterals whilst those with Rentrop grade two or three were defined as those with robust collaterals. Studies were eligible if they included patients ≥ 18 years of age who had immediate coronary angiography for STEMI. Included studies were observational which recorded the degree of collateral blood flow to the IRA. Two investigators reviewed all citations using a predefined protocol with final consensus for all studies, the data from which was then independently entered to ensure fidelity of results. Inverse variance random effects model for the meta-analysis along with risk of bias assessment was performed. 20 studies with a total of 14,608 patients were identified and included in the analysis. Patients with robust collaterals had lower mortality (OR 0.55, 95% CI 0.48–0.64), both in-hospital (OR 0.47, 95% CI 0.35–0.63) and longer term (OR 0.58, 95% CI 0.46–0.75). Patients with robust collaterals also had a higher mean LVEF (SMD 0.23, 95% CI 0.10–0.37). There was no difference in the rates of AMI or repeat revascularisation between patients with robust or poor collaterals. The presence of robust collaterals during STEMI is associated with reduced in-hospital and longer term mortality and improved left ventricular function. These findings have implications for prognostication and identifying patients who require close monitoring following STEMI.

In this study, structural analysis and one-way fluid-structure interaction (FSI) analysis were performed to identify the effect of fluid presence on the mechanical behavior of the stents during stent expansion. An idealized vessel model with stenosis was used for simulation, and stents made of metal and polymer were assumed, respectively. The bilinear model was applied to the stents, and the Mooney-Rivlin model was applied to the arterial wall and plaque. The blood used in the FSI analysis was assumed to be a non-Newtonian fluid. As a result of all numerical simulations, the von Mises stress, the first principal stress and the displacement were calculated as the mechanical behaviors. Through the comparison of the results of the structural analysis with those of the one-way FSI analysis, our results indicated the fluid had no significant influence on the expansion of the metal stent. However, it was found that the expansion of the polymer stent affected by the presence of fluid. These findings meant the one-way FSI technique was suggested to achieve an accurate analysis when targeting a polymer stent for numerical simulation.

Aims: Assess the correlation between diameter stenosis, lesion length, location, diffuse coronary disease and with fractional flow reserve (FFR). Methods/Results: We performed quantitative coronary analysis analysis on 384 lesions with stable coronary artery disease undergoing FFR assessment. Vessels were 59.1% left anterior descending artery (LAD), 16.1% left circumflex artery and 14.8% right coronary artery. Median diameter stenosis was 58% ± 2.5 and median lesion length was 10 mm ± 7.36. 21% of vessels were diffusely diseased. Lesions were 33.6% proximal, 44% mid-vessel and 12% distal. Median FFR was 0.85. Diameter stenosis correlated with lower FFR (p < 0.005, odds ratio [OR]: 2.4 [95% CI: 0.99–5.63]). There was no association between lesion length, location, number of proximal side branches and FFR. Vessels with diffuse disease had a nonsignificant trend for lower FFR (0.84 vs 0.85, p = 0.375, OR: 1.26 [95% CI: 0.76–2.09]). LAD lesions had significantly lower FFR compared with non-LAD (p < 0.001, OR: 2.55 [95% CI: 1.61–4.04]); including left circumflex artery and right coronary artery lesions (p = 0.001, OR: 3.4 [95% CI: 1.7–6.9]) and p = 0.02, OR: 2.55 [95% CI: 1.17–4.34]). Conclusion: FFR is not related to lesion length, location or number of proximal branches.

IntroductionAortic stenosis is the most common cardiac valve pathology worldwide and has a mortality rate of over 50% at 5 years if left untreated. Transcatheter aortic valve implantation (TAVI) is a minimally invasive and highly effective alternative treatment option to open-heart surgery. High-grade atrioventricular conduction block (HGAVB) is one of the most common complications after TAVI and requires a permanent pacemaker. Due to this, patients are typically monitored for 48 hours post TAVI, however up to 40% of HGAVB may delayed, and occur after discharge. Delayed HGAVB can cause syncope or sudden unexplained cardiac death in a vulnerable population, and no accurate methods currently exist to identify patients at risk.Methods and analysisThe prospective observational study on the accuracy of predictors of high-grade atrioventricular conduction block after transcatheter aortic valve implantation (CONDUCT-TAVI) trial is an Australian-led, multicentre, prospective observational study, aiming to improve the prediction of HGAVB, after TAVI. The primary objective of the trial is to assess whether published and novel invasive electrophysiology predictors performed immediately before and after TAVI can help predict HGAVB after TAVI. The secondary objective aims to further evaluate the accuracy of previously published predictors of HGAVB after TAVI, including CT measurements, 12-lead ECG, valve characteristics, percentage oversizing and implantation depth. Follow-up will be for 2 years, and detailed continuous heart rhythm monitoring will be obtained by inserting an implantable loop recorder in all participants.Ethics and disseminationEthics approval has been obtained for the two participating centres. Results of the study will be submitted for publication in a peer-reviewed journal.Trial registration numberACTRN12621001700820.

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.

AimsDormant coronary collaterals are highly prevalent and clinically beneficial in cases of coronary occlusion. However, the magnitude of myocardial perfusion provided by immediate coronary collateral recruitment during acute occlusion is unknown. The aim of this study was to quantify collateral myocardial perfusion during balloon occlusion in patients with coronary artery disease (CAD).Methods and resultsPatients without angiographically visible collaterals undergoing elective percutaneous transluminal coronary angioplasty (PTCA) to a single epicardial vessel underwent two scans with 99mTc-sestamibi myocardial perfusion single-photon emission computed tomography (SPECT). All subjects underwent at least three minutes of angiographically verified complete balloon occlusion, at which time an intravenous injection of the radiotracer was administered, followed by SPECT imaging. A second radiotracer injection followed by SPECT imaging was performed 24 hours after PTCA.The study included 22 patients (median [interquartile range] age 68 [54-72] years, 10 (45%) female). The perfusion defect extent was 19 [11–38] % of the LV, and the collateral perfusion at rest was 64 [58-67]% of normal.ConclusionThis is the first study to describe the magnitude of short-term changes in coronary microvascular collateral perfusion in patients with CAD. On average, despite coronary occlusion and an absence of angiographically visible collateral vessels, collaterals provided more than half of the normal perfusion.Graphical abstractDormant collaterals are highly prevalent but the magnitude of myocardial perfusion provided by immediate coronary collateral recruitment during acute occlusion in humans is unknown. Patients without angiographically visible collaterals underwent intravenous injection with 99mTc-sestamibi during coronary balloon inflation followed by SPECT imaging. A control scan was performed 24 hours later..Median collateral perfusion during coronary occlusion was 64% of normal.

During the COVID-19 pandemic there has been a reduction in hospital admissions for acute myocardial infarction. This manuscript presents the analysis of Google Trends meta-data and shows a marked spike in search volume for chest pain that is strongly correlated with COVID-19 case numbers in the United States. This raises a concern that fear of contracting COVID-19 may be leading patients to self-triage using internet searches. Research Letter. During the COVID-19 pandemic, physicians worldwide have noted reductions in hospital admissions for emergencies including acute myocardial infarction and ischemic stroke.1,2 Several explanations have been proposed including reduced air pollution, changes in diet and lifestyle, or, most worryingly, avoidance of hospitals to reduce the risk of COVID-19 infection.3 There is significant concern that instead of presenting to hospital, fear of COVID-19 has led patients to self-triage using internet searches. Google Trends™ is a free publicly available tool that monitors how often search items are queried over time and provides insights into public health behavior. Recommendations for the documentation of Google Trends™ analyses have previously been published4 and were consulted to facilitate reproducibility of the present study. We quantified searches in the United States (US) for the symptom of interest, chest pain, and the control terms toothache, abdominal pain, knee pain, heart attack and stroke (time period 1st Jan 2017 to 24th May 2020, accessed 28th May 2020, no quotation marks, no combination symbols, all query categories). Data on the number of COVID-19 cases per day in the US was retrieved from USAFacts.org, which collates data from government agencies and is used by the Centers for Disease Control and Prevention. Time-lag correlation analysis was performed using R. To assess the relationship between chest pain searches and COVID-19 caseload, data on search volume was also collected for the states with the highest and lowest numbers of COVID-19 cases. No extramural funding was used to support this work. The number of cases of COVID-19 in the US rose rapidly throughout March 2020 and during the same month the relative search frequency of the symptom chest pain, but not the control terms, nearly doubled compared to the previous three years (Figure 1A). There was a strong correlation between the number of new COVID-19 cases and Google search queries for chest pain (Pearson correlation coefficient 0.79 with 18-day time-lag) (Figure 1B). The search volume for chest pain also spiked in the states with the three highest (New York, New Jersey, Illinois), but not the three lowest (Hawaii, Montana, Alaska), COVID-19 caseloads (Figure 2). In this analysis we describe a strong correlation between the increase in COVID-19 cases and the utilization of Google for medical information. Chest pain is a common presenting symptom of life-threatening medical conditions including coronary artery disease, aortic dissection and pulmonary embolus, but is not a common symptom of COVID-19.5 The analysis presented here suggests that the rise in COVID-19 cases has led patients to seek medical information about their symptoms from the internet at substantially higher rates compared to the previous three years. This does not appear to be due to generally increased search volumes nor seasonal variation (Figure 1). Within the US this was observed in states with a high prevalence of COVID-19 but not states with a low prevalence (Figure 2). This was despite all analyzed states instituting stay-at-home orders, which suggests this phenomenon is not related to lockdown restrictions. This raises a significant concern that in regions where caseloads are high, fear of contracting COVID-19 may be leading patients to self-triage, potentially in lieu of presenting to hospital. The rise in search volume for ‘chest pain’ but not ‘heart attack’ or ‘stroke’ may be explained by several hypotheses, including patients being more likely to search for symptoms rather than diagnoses, or it may reflect the reduced hospitalisations for these conditions during the COVID-19 pandemic and hence fewer patients receiving the diagnostic labels ‘heart attack’ and ‘stroke’. Indeed it was recently reported that the rate of catheter laboratory activation for ST-segment elevation myocardial infarction has decreased by 38% in the US compared to the pre-COVID-19 period,1 and there have been similar reductions in hospital presentations for other life-threatening conditions such as acute aortic dissection.6 This has been accompanied by a concurrent increase in out-of-hospital cardiac arrests7 and, amongst patients that did present to hospital with acute myocardial infarction, increased rates of delayed presentation and complications.8 While COVID-19 has a mortality of approximately 1%,9 acute myocardial infarction in the absence of contemporary treatment has a one-month mortality of up to 50%.10 As lockdown regulations begin to relax worldwide there is a significant risk of a second-wave of COVID-19, and so it is critical to re-emphasize to patients that internet searches are not an alternative to professional medical attention.

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

We aimed to evaluate the safety and feasibility of rotational atherectomy (RA) in patients with severe aortic stenosis (AS).Heavily calcified coronary lesions are commonly encountered in elderly patients with severe AS who are being considered for transcatheter aortic valve implantation. The use of RA in these patients is controversial as they may be at a higher risk of complications.We retrospectively enrolled patients with severe AS who underwent RA across two hospitals from March 2010 to September 2019. Patients with severe AS prior to or within 8 weeks of RA were included.Twenty-seven (27) consecutive patients (83±5.2 yrs 63% male) with severe AS (peak velocity 4.1±0.5 m/s, mean gradient 40.0±10.2 mmHg) were enrolled and 31 lesions were treated with RA across 30 separate procedures. Three (3) (11.1%) patients had left ventricular ejection fraction ≤30%. Nine (9) (30%) procedures involved percutaneous coronary intervention of multiple arteries, with most lesions in the right coronary artery (51.6%) and left anterior descending artery (32.3%). Three (3) (9.7%) lesions were in the left main stem. RA-facilitated stenting was successful in all lesions. There were no episodes of coronary perforation or slow-flow/no-reflow. There was one episode of coronary dissection in an artery that did not undergo RA, which was successfully treated with a drug-eluting stent. There were no deaths within 30 days and three deaths (11.1%) within 1 year.Rotational atherectomy in patients with severe AS is feasible and has a low rate of procedural complications.

Item does not contain fulltext OBJECTIVES: This study sought to evaluate sex differences in procedural characteristics and clinical outcomes of instantaneous wave-free ratio (iFR)- and fractional flow reserve (FFR)-guided revascularization strategies. BACKGROUND: An iFR-guided strategy has shown a lower revascularization rate than an FFR-guided strategy, without differences in clinical outcomes. METHODS: This is a post hoc analysis of the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate stenosis to guide Revascularization) study, in which 601 women and 1,891 men were randomized to iFR- or FFR-guided strategy. The primary endpoint was 1-year major adverse cardiac events (MACE), a composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization. RESULTS: Among the entire population, women had a lower number of functionally significant lesions per patient (0.31 +/- 0.51 vs. 0.43 +/- 0.59; p < 0.001) and less frequently underwent revascularization than men (42.1% vs. 53.1%; p < 0.001). There was no difference in mean iFR value according to sex (0.91 +/- 0.09 vs. 0.91 +/- 0.10; p = 0.442). However, the mean FFR value was lower in men than in women (0.83 +/- 0.09 vs. 0.85 +/- 0.10; p = 0.001). In men, an FFR-guided strategy was associated with a higher rate of revascularization than an iFR-guided strategy (57.1% vs. 49.3%; p = 0.001), but this difference was not observed in women (41.4% vs. 42.6%; p = 0.757). There was no difference in MACE rates between iFR- and FFR-guided strategies in both women (5.4% vs. 5.6%, adjusted hazard ratio: 1.10; 95% confidence interval: 0.50 to 2.43; p = 0.805) and men (6.6% vs. 7.0%, adjusted hazard ratio: 0.98; 95% confidence interval: 0.66 to 1.46; p = 0.919). CONCLUSIONS: An FFR-guided strategy was associated with a higher rate of revascularization than iFR-guided strategy in men, but not in women. However, iFR- and FFR-guided strategies showed comparable clinical outcomes, regardless of sex. (Functional Lesion Assessment of Intermediate Stenosis to guide Revascularization [DEFINE-FLAIR]; NCT02053038).

Although the safety of valve-in-valve transcatheter aortic valve replacement has improved, coronary ostium obstruction remains a significant complication, with chimney stenting a possible solution to circumvent this complication. In this case, we discuss the failure of a chimney stent in a case of valve-in-valve transcatheter aortic valve replacement resulting in cardiogenic shock. (Level of Difficulty: Advanced.), Graphical abstract, Although the safety of valve-in-valve transcatheter aortic valve replacement has improved, coronary ostium obstruction remains a significant complication…

Objective This study aimed to assess the pathophysiological differences between saphenous vein grafts (SVG) and native coronary arteries (NCA) following presentation with non-ST elevated myocardial infarction (NSTEMI). Background There is accelerated pathogenesis of de novo coronary disease in harvested SVG following coronary artery bypass (CABG) surgery, which contributes to both early and late graft failure , and is also causal in adverse outcomes following vein graft PCI. However in vivo assessment, with OCT imaging, comparing the differences between vein grafts and NCAs has not previously been performed. Methods We performed a retrospective, observational, analysis in patients who underwent PCI with adjunctive OCT imaging following presentation with NSTEMI , where the infarct-related artery (IRA) was either in an SVG or NCA. Results A total of 1550 OCT segments was analysed from thirty patients with a mean age of 66.3 (±9.0) years were included. The mean graft age of 13.9 (±5.6) years in the SVG group. OCT imaging showed that the SVG group had evidence of increased lipid pool burden (lipid pool quadrants, 2.1 vs 2.7; p = 0.021), with a reduced fibro-atheroma cap-thickness in the SVG group (45.0 μm vs 38.5 μm; p = 0.05) and increased burden of calcification (calcified lesion length = 0.4 mm vs 1.8 mm; p = 0.007; calcified quadrants = 0.2 vs 0.9; p = 0.001; arc of superficial calcium deposits = 11.6° vs 50.9°; p = 0.007) when compared to NCA. Conclusion This OCT study has demonstrated that vein grafts have a uniquely atherogenic environment which leads to the development of calcified, lipogenic, thin-capped fibro-atheroma's, which may be pivotal in the increased, acute and chronic graft failure rate, and may underpin the increased adverse outcomes following vein graft PCI.