Cardiovascular diseases

Long term outcomes primarily depend on left ventricular function

Hugh D Wolfenden · Greg Cranney

Current performance standards are high and promising new technologies are finding it difficult to compete

Ahmad Farshid · Simon O'Connor

New pharmacological treatment options have improved the prognosis for those with this rare disease

David L Prior · Heath Adams · Trevor J Williams

The ongoing quest for optimal efficacy without compromising long term patient safety

Daniel Chen · Nigel Jepson

We need to fill evidence gaps and make clinical advances to reduce these diseases of disadvantage

Philippa J May · Asha C Bowen · Jonathan R Carapetis

Inspection of the jugular veins provides a simple means of determining whether pressures in the right side of the heart are normal or elevated

Andrew Elder · Balakrishnan (Kichu) R Nair

The lower rate of coronary angiography is the key disparity in the care of Aboriginal patients with acute coronary syndromes

Rosanna Tavella · Katharine McBride · Wendy Keech · Janet Kelly · Amanda Rischbieth · Christopher Zeitz · John F Beltrame · Philip A Tideman · Alex Brown

Significant advances have been made, but optimising models of care remains a major challenge

Damon A Bell · Gerald F Watts

The distinction is essential to determine aetiology and treatment

Elizabeth Whiting · Madeline E McCready

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

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

Most cases can be diagnosed by good clinical assessment at the bedside

Martin Veysey

The National Heart Foundation guideline has been updated to reflect recent evidence and Australian conditions

Garry LR Jennings

Updated recommendations from the National Heart Foundation take into account the findings of recent meta-analyses, systematic reviews and randomised controlled trials

Genevieve M Gabb · Arduino A Mangoni · Craig S Anderson · Diane Cowley · John S Dowden · Jonathan Golledge · Graeme J Hankey · Faline S Howes · Les Leckie · Vlado Perkovic · Markus Schlaich · Nicholas A Zwar · Tanya L Medley · Leonard Arnolda