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BMI = body mass indexCV = cardiovascularECMO = extracorporeal membrane oxygenationIABP = intra-aortic balloon pumpLA = left atrialLV = left ventricularMAP = mean arterial pressureMI = myocardial infarctionNSTEMI/STEMI = (non-)ST-segment elevation MIPCI = percutaneous coronary interventionSCAD = spontaneous coronary artery dissection TIMI = Thrombolysis In Myocardial Infarction

Abbreviations used in this review:

In this review: > Risk stratification with simple indices of infarct size post-STEMI similar to cardiac MRI

> Gender differences for STEMI at a large tertiary Australian hospital

> CV risk factors over life and subclinical myocardial disease

> Long-term outcomes for patients aged >85 years with type 2 MI

> Familial clustering of SCAD

> Standard vs. ultrasound-guided radial and femoral access

> Design and novel features of the RAPID-T trial

> Spontaneous coronary dissection

> Impella percutaneous LV assist device

> Transplantation and mechanical circulatory support

8–10 August, 2019; AdelaideMaking Education Easy

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Welcome to this review of the CSANZ (Cardiac Society of Australia and New Zealand) Annual Scientific Meeting 2019, held in August at the Adelaide Conference Centre. This review provides summaries with commentary of ten presentations from the meeting, five were poster finalists, covering a range of topics and including important local data. These begin with research comparing less expensive, readily available modalities for assessing infarct size with cardiac MRI, followed by a comparison from a Melbourne Hospital of STEMI outcomes according to gender. The selections also include several presentations from symposia, concluding with a presentation focussing on the use of the Impella percutaneous LVAD (LV assist device) and data on various mechanical support modalities for patients with cardiogenic shock.We hope you enjoy this Conference Review, and we invite you to send your feedback and comments.

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Professor John Frenchjohn.french@researchreview.com.au

Simple indices of infarct size post ST-elevation myocardial infarction (STEMI) provides similar risk stratification to cardiac MRIAuthors: Sharma L et al.Summary: This prospective study compared readily available, less expensive methods of assessing infarct size assessment (namely Selvester QRS scores from the 12-lead ECG and high-sensitivity troponin-T levels measured at elevation plateau [≥48 hours]) with cardiac MRI in a cohort of 195 patients (86% male) with first-time STEMI (54% anterior) treated with primary (79%) or pharmaco-invasive (21%) PCI. Significant correlations were seen between plateau-phase high-sensitivity troponin-T levels, QRS scores and cardiac MRI-determined infarct sizes post-STEMI for anterior MI (r>0.5 [p<0.01] for all comparisons), but not for nonanterior MI (p>0.10 for all comparisons). Estimates of infarct size were greater with QRS scoring than with cardiac MRI. A binary logistic regression analysis was also undertaken to identify factors contributing to discordant scores and major adverse cardiac events.

Comment: This study aimed to assess whether simple parameters that aid post-STEMI risk stratification, such as QRS scoring on ECGs and the level of high-sensitivity troponin-T at 48–72 hours, can provide similar information to that provided by more expensive and not always accessible cardiac MRI. The results were that these simple parameters were highly correlated with infarct size determined by cardiac MRI. Coronary care unit staff do not always continue to measure cardiac biomarkers, particularly high-sensitivity troponin-T levels at 48–72 hours post-STEMI, although most people are still in hospital at that time, and QRS scoring can be somewhat tedious. Unless cardiac MRI is routinely available, these simple parameters should be routinely measured to assess post-STEMI risk.

Reference: Heart Lung Circ 2019;28(Suppl 4):S321Abstract

Differences in characteristic, performance targets and outcomes for men and women with STEMI in a large tertiary Australian hospitalAuthors: Martin L et al.Summary: This research investigated gender disparities in outcomes for 922 patients who received PCI for STEMI at a tertiary hospital in Melbourne. Compared with male patients, females were older (70 vs. 62 years [p<0.001]), were more likely to present during 8am–6pm Monday–Friday (48% vs. 37% [p<0.01]), via regular ambulance (42% vs. 25% [p<0.001]), with atypical symptoms (23% vs. 11% [p<0.001]) or a TIMI risk score >5 (43% vs. 22% [p<0.001]) and were more likely to fail the 90-minute performance target (36% vs. 20% [p<0.001]). There were no significant differences between genders for time taken to reach specific timepoints of care, namely symptom onset-door, door-ECG, door-cath lab and cath lab-device. Female patients were also more likely than males to have an LV ejection fraction of <40% (40% vs. 30% [p=0.03]) and their 365-day mortality rate was higher (15% vs. 7% [p<0.01]).

Comment: As women are in general older than men, when their coronary event occurs, prognosis has been thought to be worse than in men post-MI. It has been debated, however, whether their prognosis has been due primarily to more (age-related) comorbidities or is gender-related. This study examined differences between men and women regarding outcomes after primary PCI, particularly mortality, from a large primary PCI centre in Melbourne. As with other studies, while women with MI tend to have this event several years older than men (in this study 8 years older), the authors found on multivariable analysis that age and a TIMI risk score >5, but not gender, were predictors of mortality at 1 year. However, the study was not powered to assess whether young women may be at higher risk than young men post-STEMI.

Reference: Heart Lung Circ 2019;28(Suppl 4):S343Abstract

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Cardiovascular risk factors over the life course as determinants of subclinical myocardial diseaseAuthors: Huynh Q et al.Summary: This research followed 562 schoolchildren into adulthood to explore associations between markers of subclinical myocardial disease and cardiorespiratory fitness, BMI and MAP (mean arterial pressure); at latest follow-up, abnormal global longitudinal strain was present in 102 of the participants, LV hypertrophy in 55, LA enlargement in 268 and increased LV filling pressure in 32. Current physical measurements were generally better predictors of myocardial function and structure than prior measurements. Significant associations were detected between both abnormal global longitudinal strain and LA enlargement and childhood cardiorespiratory fitness (respective odds ratios 0.77 [CI 0.62–0.96] and 1.32 [1.08–1.60]) irrespective of adult cardiorespiratory fitness; LA enlargement was not associated with BMI or MAP in childhood or adulthood. The relationship between abnormal global longitudinal strain and BMI was influenced primarily by the current BMI, but the association between BMI and MAP appeared to be consistent over the life-course. Associations between LV hypertrophy and cardiorespiratory fitness, BMI and MAP depended mainly on current versus earlier cardiorespiratory fitness, BMI and MAP. No association was detected between LV filling pressure and any childhood measurement, but it was associated with current BMI and MAP.

Comment: This study examined CV risk factors over ~30 years of life as determinants of subclinical myocardial disease. In 1985, 562 school children were selected and were followed up in both 2004–2006 and 2017–2019. Cardiorespiratory fitness, BMI and MAP were determined at baseline and at each follow-up. Cardiac function assessed with echocardiography, looking at LA size, LV hypertrophy and global longitudinal strain, was determined at follow-up. Interestingly, these parameters changed at different timepoints, and LA enlargement, cardiorespiratory fitness and BMI were associated at the final follow-up in subjects who were aged 39–49 years. MAP at late follow-up was associated with LV hypertrophy. This very interesting study of longitudinal changes in myocardial parameters and health implies simple assessments such as BMI, MAP and cardiorespiratory fitness should be undertaken at school and early adulthood to target interventions.

Reference: Heart Lung Circ 2019;28(Suppl 4):S164Abstract

Long term outcomes in patients aged >85 years presenting with type II myocardial infarction (type II MI)Authors: Kunniardy P et al.Summary: Presentation, management and long-term outcomes were reported for 956 consecutive patients aged >85 years (43.8% male) presenting to a single centre with NSTEMI, stratified as type 1 or 2 (according to the 4th Universal Definition of MI); 50% of the patients had a type 2 MI. For the patients with type 2 MI, the predominant presentations were delirium (34.3%), sepsis (18.4%), noncardiac surgery (8.5%) and bleeding/anaemia (6.7%), and they were less likely to undergo invasive coronary angiography (2.5% vs. 17.0% [p<0.001]) or be prescribed aspirin (77% vs. 84%), although their statin use was higher (78% vs. 69% [p<0.001]), as was their in-hospital mortality rate (21.1% vs. 13.5% [p=0.002]). Over a mean 1.3 years’ follow-up, 46.6% of patients died. Despite greater in-hospital mortality, no significant association was detected between type 2 MI and increased long-term mortality (adjusted hazard ratio 1.1 [95% CI 0.8–1.2]).

Comment: The study examined nearly 1000 patients aged over 85 years (mean age 89 years) with NSTEMIs. The proportions of type 1 and type 2 MIs were equal. Delirium was the most common presentation of type 2 MI (34% of patients) followed by sepsis in 18%, 7% bleeding and 8.5% noncardiac surgery. Patients with type 2 MI were slightly more likely to be prescribed aspirin and undergo invasive angiography. However, despite higher in hospital mortality, patients with type 2 MI had similar late mortality. The absence of guidelines for management and an evidence base is evident. The management of type 2 MI is currently being studied in the ACT-2 trial (ACTRN12618000378224).

Reference: Heart Lung Circ 2019;28(Suppl 4):S308Abstract

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Familial clustering of spontaneous coronary artery dissectionAuthors: McGrath-Cadell L et al.

Summary: These researchers recruited participants via social media to determine the clinical characteristics and initial genetic data for families in which at least one family member had experienced an episode of SCAD (spontaneous coronary artery dissection). At the time of reporting, 235 participants had been recruited, and among these there were 23 cases with familial clustering involving sister-sister pairs in six families, three first-degree cousins in one family, two first-degree cousins in two families, a mother-son pair and a family with monozygotic twins both having experienced SCAD. The presentation included a comparison of symptoms, age at SCAD, clinical syndromes, CV risk factors, SCAD risk factors, environmental triggers, SCAD locations, acute management, LV function and recurrent SCAD events in these families compared against isolated cases. Also at the time of reporting, a segregation analysis was being conducted on whole-genome sequencing data from three sister-sister pairs in order to identify rare variants that exist exclusively in affected family members.

Comment: With routine early invasive angiography being performed in the last decade on patients with both STEMI and NSTEMI, SCAD has been increasingly recognised as a cause of MI. This is an impressive cohort put together by the group led by Prof Bob Graham in Sydney, with over 1000 cases and 7000 matching controls. Replication was not seen of rare alleles in genes previously reported to be associated with SCAD, making this disorder polygenic. Furthermore, no increased risks were found for SCAD cases compared with controls for many common variants associated with (atherosclerotic) MI. An impressive familial cohort of SCAD is described; this disorder is likely to be polygenic. Further studies in more families are needed to clarify possible genetic associations.

Reference: Heart Lung Circ 2019;28(Suppl 4):S330Abstract

Procedural success rates from the Standard versus Ultrasound-guided Radial and Femoral access (SURF) trialAuthors: Nguyen P et al.

Summary: Patients undergoing coronary angiography or PCI were randomised to cardiac catheterisation via transradial (n=700) or transfemoral (n=688) access. Both groups were also randomised to ultrasound-guided (n=357 transradial; n=331 transfemoral) or standard (n=343 transradial; n=357 transfemoral) access. Compared with the transradial approach, the transfemoral approach was associated with a significantly shorter mean access time (85.51 vs. 118.39 sec [p<0.0001]), fewer access attempts (mean, 1.6 vs. 1.8 [p=0.02]) and difficult accesses (28 vs. 67 [p<0.0001]), but a higher venepuncture rate (9.3% vs. 4% [p<0.0001]). Compared with standard access, ultrasound-guided access was associated with a significantly shorter mean access time (93.1 vs. 111 sec [p=0.01]), fewer access attempts, (mean 1.5 vs. 1.9 [p<0.0001]) and difficult accesses (31 vs. 64 [p=0.0007]), a higher first-pass success rate (73.1% vs. 59.6% [p<0.0001]) and a lower venepuncture rate (4.1% vs. 9.1% [p<0.0001]).

Comment: Ultrasound is commonly used by vascular surgeons and interventional radiologists for gaining arterial access in patients undergoing endovascular procedures, but it is not routinely used in cardiac catheterisation laboratories. This trial randomised the use of ultrasound in gaining arterial access via the radial or femoral routes in patients undergoing coronary angiography or PCI. Ultrasound guidance reduced access time and difficult accesses, suggesting this modality should be used in both radial and femoral arterial access. The study was undertaken predominantly among operators who were trained in largely femoral access, although the majority had switched to predominantly radial access. Whether the findings would be similar in the future when the majority of interventional cardiologists are trained to largely use radial access is a matter of conjecture.

Reference: Heart Lung Circ 2019;28(Suppl 4):S422Abstract

Embedding clinical trials in registries – progress to dataPresenter: Chew D

Summary/comment: The design and novel features of the RAPID-T trial were presented in the clinical trial symposium. This trial is to be presented at an ESC hotline session, and thus the results were embargoed. It randomised patients presenting with chest pain suspected to be due to an acute coronary syndrome syndrome, without STEMI, to emergency departments in South Australia to an accelerated high-sensitivity troponin-T testing regimen with 0- to 1-hour measurements compared with standard care with measurements of troponin-T over 3 hours, with results reported to 29 ng/L, which was the upper reference limit of the fourth-generation troponin-T assay. This is the reference limit that clinicians in South Australia have been used to receiving on laboratory reports. The significant methodological aspect of this trial was patient recruitment using a large group of trained medical student personnel as a novel recruitment strategy.

Clinical Trials Council Meeting

Independent commentary by Professor John French, Director of Coronary Care and Cardiovascular Research at Liverpool Hospital, Sydney, and conjoint Professor at the University of New South Wales and University of Western Sydney. After basic physician training he undertook a PhD at the University of Adelaide, further cardiology training at Greenlane Hospital, Auckland, New Zealand, and a Wellcome Trust Postdoctoral Fellowship at University College London, UK. Prior to his current position Professor French was appointed to Greenlane Hospital and the University of Auckland from 1992-2003. Professor French has been an investigator and co-investigator in numerous randomised controlled trials, and was on the steering committees of the SHOCK, OAT, HERO-2 and CRISP-AMI trials. Professor French has served on the clinical endpoints committees of several major trials. Professor French’s current major research interests include the acute coronary syndromes especially ST elevation MI, and cardiac biomarkers, especially high-sensitivity troponins.

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CSANZ 2019 Conference ReviewTM

Spontaneous artery coronary dissectionPresenter: Saw J

Summary/comment: Dr Saw, an interventional cardiologist from Vancouver British Columbia, gave two presentations on SCAD, at ANZET and in a session on heart disease and women. She indicated that the usual approach to management of this problem is conservative rather than interventional, although PCI should be considered in a subgroup of patients who have haemodynamic instability. However, what ancillary medical therapies, such as antiplatelet agents and statins, should be used is also uncertain. Unfortunately, there is a rate of recurrent SCAD, and this disorder needs trial-based evidence for clinical management.

ANZET Lecture 2 & CSANZ Women in Cardiology

Impella percutaneous LVAD: global best practice and cost-effectiveness in an Australian settingPresenter: Lombardi B

Summary/comment: Dr Lombardi gave an informative presentation on the use of the Impella mechanical support device in cardiogenic shock. Cardiogenic shock remains a high-mortality syndrome with mortality between 30 and 50%. This device has various physiological advantages over other forms of haemodynamic support such as ECMO or IABP, and in ‘shock centres’ in the US it is being increasingly used. However randomised trial evidence for its use is currently lacking, and is urgently needed.

ANZET

Transplantation and mechanical circulatory support – from complementary to competitive?Presenter: McGiffin D

Summary/comment: David McGiffin, a cardiac surgeon from Melbourne, presented data about various mechanical modalities for support for patients with cardiogenic shock, including IABP, ECMO and the Impella device. Unfortunately, ECMO does cause some adverse haemodynamic features, including increases in LV end-diastolic pressure and wall stress, although as Dr McGiffin indicated these can be treated by the use of an Impella device. In patients with cardiogenic shock, the role of a dedicated ‘shock team’ involving interventionalists, noninvasive cardiologists, cardiac surgeons, anaesthetists and intensivists is evolving, and hopefully will lead to lower mortality rates of 40–50% in unselected patient series.

ANZET

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