Volume 205 Issue 3

An absolute cardiovascular risk approach will better target patients who need pharmacotherapy

Mark R Nelson

An integrated approach incorporating both physical and mental health is critical to “congenital heart health”

Nadine A Kasparian · David S Winlaw · Gary F Sholler

Health technology in the hands of cardiac patients — helpful, hindrance, or hesitate to say?

Robyn Gallagher · Lis Neubeck

A 22-year-old woman presented with a 3-day history of fever, retrosternal chest pain and exertional dyspnoea. Her heart rate was 130 bpm with a blood pressure level of 109/68 mmHg. Physical examination suggested tamponade: distended jugular veins, pulsus paradoxus and muffled heart tones. The chest radiography was notable for the characteristic water-bottle sign (Figure, A).1 Contrast-enhanced chest computed tomography demonstrated a massive pericardial effusion (Figure, B) associated with venous engorgement of the superior and inferior vena cava (SVC, IVC), prevascular space (arrows), and bilateral axillary veins (arrowheads). An emergency thoracoscopic pericardial window was performed and 620 mL of bloody fluid was drained. The presence of anti-nuclear, anti-double-stranded DNA, anti-Smith antibodies and hypocomplementaemia supported the diagnosis of systemic lupus erythematosus.2 The patient recovered after 1 week of intravenous methylprednisolone pulse therapy. At an 8-month follow-up, there have been no recurrences. Figure A B

Tsung-Han Ho · Yi-Tin Tsai

My mother has fallen …

Kate Cole-Adams

Systems, procedures and policies are needed to further reduce the toll of cardiovascular disease

Andrew I MacIsaac

We need to ensure that those who need care most receive it

Ian A Scott

A focus on clinical care standards and better health service distribution is needed to reduce variation in angiography rates

Derek P Chew · Andrew I MacIsaac · Jeffrey Lefkovits · Richard W Harper · Luke Slawomirski · David Braddock · Matthew J Horsfall · Heather A Buchan · Chris John Ellis · David B Brieger · Tom G Briffa

A pre-hospital diagnostic and treatment strategy is appropriate in regions where timely primary percutaneous coronary intervention is not possible

Arshad A Khan · Trent Williams · Lindsay Savage · Paul Stewart · Asma Ashraf · Allan J Davies · Steven Faddy · John Attia · Christopher Oldmeadow · Rohan Bhagwandeen · Peter J Fletcher · Andrew J Boyle

The use of coronary pressure wires (or fractional flow reserve [FFR]) has been shown to reduce the frequency of major adverse cardiac events and of unnecessary stent procedures, and to lower treatment costs in both the public and private sectors in Australia.1-3 FFR is a tool for assessing physiological ischaemia in coronary artery stenosis, measuring pre- and post-stenosis pressures during adenosine-induced hyperaemia. Because it is evidence-based and quantifiable, it may be discussed during the upcoming Medicare reform. Data on its uptake across Australia, however, have not been published. We examined trends in FFR use after its addition to the Medicare Benefits Schedule 10 years ago. We analysed Australian Government Department of Human Services data on Medicare items for coronary flow reserve, coronary angiography and percutaneous coronary angiography. A total of 14 160 FFR services were processed by Medicare during the past 10 years. FFR use grew during this period, with a mean annual increase of 55%, from 131 services in 2007 to 3869 in 2015 (non-parametric analysis, P = 0.004). Time series analysis identified a Gompertz non-linear trend of FFR against time, indicating that national FFR use is continuing to increase, although growth began to slow in 2014. Further, FFR use increased on a population basis by an average of 45% each year, from 1 per 100 000 in 2007 to 16 per 100 000 in 2015, when these figures were highest in New South Wales (23 per 100 000) and Queensland (19 per 100 000) (Box). The national rate of FFR per coronary angiogram increased from 0.02% in 2006 to 4.8% in 2015 (P = 0.004), when the highest rate was in NSW (5.8%). The rate of FFR per percutaneous coronary intervention (PCI) increased from 0.1% in 2006 to 19.2% in 2015 (P = 0.004), when the highest rate was in Queensland (26.6%). In 2015, there were 5.2 PCIs per FFR used; the rate was not related to the population size of the state or territory (Spearman non-parametric correlation, ρS = 0.07; P = 0.87) or to total PCI use (ρS = 0.12, P = 0.78). There was marked variation between states and territories (Box), highlighting heterogeneity across Australia in the use of FFR. The data summarised in the Box allow operators and hospitals to compare their use of FFR with state and national averages, and they facilitate more standardised care across Australia. Barriers to the uptake of FFR include operator and centre experience, availability and cost. It has been suggested that FFR is discouraged by the lower remuneration received if stenting is not performed.4 From a national perspective, however, there is a mean saving of $1200 per patient in the public sector and $5000 per patient in the private sector when FFR makes stenting unnecessary,2 representing a total annual saving of $4 million.4 The use of FFR across Australia is heterogeneous, but it has grown over the past decade, both in absolute numbers and as proportions of coronary angiograms and PCI. Box – Summary of Medicare items for use of a coronary pressure wire (fractional flow reserve [FFR]) processed during 2015 Australia NSW Vic Qld SA WA Tas ACT NT Total FFR services 3869 1764 688 944 146 225 77 11 14 FFR per 100 000 population 16 23 11 19 8 9 15 3 6 FFR per angiogram 1/21 (4.8%) 1/17 (5.8%) 1/28 (3.6%) 1/17 (5.7%) 1/30 (3.4%) 1/29 (3.5%) 1/21 (4.8%) 1/83 (1.2%) 1/38 (2.7%) FFR per percutaneous coronary intervention 1/5.2 (19.2%) 1/4.6 (21.6%) 1/7.0 (14.3%) 1/3.8 (26.6%) 1/6.8 (14.7%) 1/7.7 (13.0%) 1/6.2 (16.2%) 1/34.1 (2.9%) 1/4.3 (23.3%) Source: Australian Government Department of Human Services. Medicare Australia Statistics, medical item reports (http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp) for coronary flow reserve (item number, 38241), coronary angiogram (38215, 38218, 38220, 38222, 38225, 38228, 38231, 38234, 38237, 38240, 38246) and percutaneous coronary angiogram (38243, 38246).

Austin N May · Anthony Kull · Brendan Gunalingam · J Lynn Francis · George T Lau

An updated guideline providing a synthesis of current evidence-based guidance for health professionals caring for patients with ACS

Derek P Chew · Ian A Scott · Louise Cullen · John K French · Tom G Briffa · Philip A Tideman · Stephen Woodruffe · Alistair Kerr · Maree Branagan · Philip EG Aylward

Cardiac imaging is a rapidly evolving field, with improvements in the diagnostic capabilities of non-invasive cardiac assessment

Christian Hamilton-Craig · Jonathan Chan

To the Editor:The retrospective observational study by Juergens and colleagues1 raises some concerning questions. They chose the variable of English either as first language (EFL) or second language (ESL) and measured significant inferiority of care and outcome for people with ESL. This variable has the advantage of being reasonably easy to collect in a standardised way, but the effect that is being measured is likely to be a proxy for limited English proficiency. We do not need a large trial to know that a patient who is unable to communicate with his or her doctor will have inferior care and outcomes. To be able to provide clinical care, we need to know the language proficiency of the patient. To assess the outcome of the clinical care using an EFL or ESL variable, we need to know whether an interpreter was used and if the interpreter was professional or ad hoc. The authors acknowledge this omission, but they make the contentious statement that “using non-professional interpreters can be expedient”. I would argue that in the setting of an admission for acute coronary syndrome, where vital issues of informed consent and patient understanding of the condition are involved, the use of non-professional interpreters is unethical.2 This is particularly true in Australia where, as Phillips notes, “the Translating and Interpreting Service offers the most extensive telephone interpreting system in the world, providing doctors and pharmacists with rapid, 24-hour access to interpreters”.3 Although, as the authors point out, we cannot know how much of this adverse outcome in correlation with ESL is related to poor communication and how much is related to a higher prevalence of cardiovascular risk factors, it is inconceivable that poor communication is not part of the explanation. A professional interpreter should be used routinely in the setting of an admission for acute coronary syndrome because this will almost certainly improve outcomes4 and is likely to decrease costs,5 and it is a basic right for a patient to be able to communicate fully with clinicians when suffering from a potentially fatal illness.

Ben Gray

In reply

Craig P Juergens · John K French · David B Brieger

Passion, hard work and patience … that’s what it takes to be a dermatologist

Cate Swannell

Flinders University health academic Associate Professor Wendy Edmondson is the recipient of this year’s South Australian Premier’s NAIDOC Award. Associate Professor Edmondson, a Badimaya Aboriginal woman born in Western Australia, has been recognised for her significant and ongoing commitment to Aboriginal health and education in South Australia. The Premier’s NAIDOC Award recognises the outstanding achievements and service of an extraordinary South Australian who has made a significant contribution to the lives of Aboriginal people. Associate Professor Edmondson, who has worked and volunteered for 37 years in the fields of Aboriginal health and education, lectures in health sciences at Flinders. She is based at the University’s Poche Centre for Indigenous Health and Wellbeing at Flinders and is commencing a PhD later this year to record her father’s life. In 2014, Ms Edmondson established the Purple Starfish Foundation to address racism experienced by Aboriginal people in health services, and at Flinders University she has volunteered her time to support Aboriginal students, especially those travelling far from their homes. In 2001, she was appointed inaugural CEO of the newly reformed Aboriginal Health Council of South Australia, and in 2010 she was awarded a Churchill fellowship to research the gap in Aboriginal and Torres Strait Islander life expectancy in Australia, in comparison to New Zealand, Canada, and the United States. http://blogs.flinders.edu.au/flinders-news/2016/07/08/premiers-award-for-poche-stalwart/ University of New South Wales Scientia Professor Henry Brodaty has won The Ryman Prize for his tireless work over 30 years to combat dementia – a disease that affects around 342 000 Australians. The $250,000 international prize rewards the best work in the world that has enhanced quality of life for older people. It is the world’s richest prize of its type and was established to create the equivalent of a Nobel Prize for people working in the field of the health of older people. Professor Brodaty, who is Co-Director of UNSW’s Centre for Healthy Brain Ageing (CHeBA), received the award from New Zealand’s Deputy Prime Minister, Bill English, in Wellington. As well as treating thousands of patients at his clinic, Professor Brodaty has been a pre-eminent researcher into ways to improve diagnosis and treatment of dementia. He has published extensively and is also is a highly respected teacher and presenter who has inspired generations of dementia researchers to follow in his footsteps. One of the initiatives led by CHeBA at UNSW is the Dementia Momentum, which brings together researchers and the community to change the future of dementia incidence. The goal is to drive momentum in awareness, research and societal change for a brighter future. http://med.unsw.edu.au/news/unsw-professor-wins-nobel-prize-ageing Classically-trained opera singer Myora Kruger has been named the inaugural recipient of Bond University’s Indigenous Medical Scholarship, introduced this year as part of the University’s commitment to help close the gap on education and healthcare for Aboriginal and Torres Strait Islander people. The 19-year-old plans on becoming an ear, nose and throat (ENT) specialist upon graduation, living out her dreams of helping singers with vocal damage and working with remote Indigenous communities to improve child health. The prestigious scholarship will cover Ms Kruger’s tuition fees through Bond University’s medical program, the fastest pathway available to graduate as an intern eligible to practice medicine in Australia and New Zealand. Professor Helen Chenery, Executive Dean of Bond University’s Faculty of Health Sciences & Medicine, said Bond University was committed to growing its Indigenous medical cohort in order to see more Indigenous doctors enter the workforce. https://bond.edu.au/news/48043/indigenous-students-medical-ambition-song Dr Stephanie Simonds, a researcher at the Monash Biomedicine Discovery Institute, has been awarded the prestigious 2016 Victorian Premier’s Award for Health and Medical Research. Dr Simonds’ award recognizes her research into how the brain regulates blood pressure and cardiovascular diseases in obesity. Her research - published in two separate issues of one of the world’s most prestigious science journals, Cell, including a first author paper – revealed the role of the hormone, leptin, in the development of elevated blood pressure in obesity. Dr Simonds’ research is aimed at unraveling the role that leptin has in causing cardiovascular diseases. In people of normal weight, when they have had enough food – their fat cells produce leptin, triggering the brain to stop eating. However, in people with obesity, this message is ignored, and large levels of leptin build up. Working with Professor Michael Cowley, also from the Monash Biomedicine Discovery Institute, Dr Simonds and her colleagues are working in animal models to isolate the area of the brain that increases blood pressure when it is exposed to high leptin levels. It is hoped that developing therapies that could actively block high leptin levels in this brain region could lower the cardiovascular disease risk associated with obesity. http://www.med.monash.edu.au/news/2016/researcher-wins-premiers-award-for-medical-research.html A new national centre to research cognitive health has been launched to help Australian researchers work to prevent cognitive decline. The National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Cognitive Health is the first of its kind in Australia and will be based at the Australian National University Research School of Population Health, with the second major site at the Academic Unit for Psychiatry of Old Age, Department of Psychiatry, University of Melbourne. The new centre was awarded $2.5 million from the NHMRC. It will be both a national and international collaboration of leading researchers, clinicians, policy makers and consumers which will focus on cognitive health promotion and prevention of cognitive decline. Professor Kaarin Anstey, who will lead the Centre, said it will identify risk factors, conduct intervention studies to improve cognitive function, and develop guidelines and modelling for new policies. http://medicine.unimelb.edu.au/today/new-national-centre-to-study-cognitive-health

Cate Swannell

This calendar will be updated each month. If you have an event you would like to add, please include relevant details in an email to cswannell@mja.com.au

Cate Swannell