Cardiovascular diseases

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

Cardiac troponin testing in general practice should be limited to patients presenting with ischaemic symptoms that occurred more than 24 hours previously

Constantine N Aroney · Louise Cullen

Your heart's just fine

Leslie M Taylor

An estimated 970 000 Australians may not be receiving recommended combination blood pressure- and lipid-lowering therapy

Emily Banks MB BS, PhD, FAFPHM · Simon R Crouch MB BS, PhD, FAFPHM · Rosemary J Korda PhD · Bill Stavreski BEcon, MPPM · Karen Page RN, MNursStud, BEd · Katherine A Thurber MPhil · Robert Grenfell MB BS, MPH, FAFPHM

Cardiovascular health for all in Australia requires language-sensitive health systems

Christine B Phillips MB BS, MPH, FRACGP

Hospitals should offer multilingual opportunities for patients of different backgrounds

Craig P Juergens MB BS, DMedSc, FRACP · Bilyana Dabin PhD · John K French BMedSc, MB ChB, PhD · Leonard Kritharides MB BS, PhD, FRACP · Karice Hyun BSc, MAppStat · Jens Kilian MB BS, PhD, FRACP · Derek PB Chew MB BS, MPH, FRACP · David Brieger MB BS, PhD, FRACP

Australia has lost one of its leading clinical and medical researchers

Christopher M Reid PhD

Concerns regarding efficacy and safety in real-world populations

Nicole L Pratt PhD · Emmae N Ramsay BSc, GradDipAppStats, MClinEpi · Gillian E Caughey PhD · Sepehr Shakib MB BS, FRACP, PhD · Elizabeth E Roughead BPharm, MAppSc, PhD

The snapshot will inform the development of strategies that improve the outcomes for heart failure patients

Phillip J Newton RN, PhD · Patricia M Davidson RN, PhD · Christopher M Reid PhD · Henry Krum* MB BS, PhD, FRACP · Christopher Hayward MD · David W Sibbritt PhD · Emily Banks MB BS, PhD, FAFPHM · Peter S MacDonald MB BS, FRACP, PhD

Assessing acute coronary syndrome patients for diabetes is practicable and useful

John Oldroyd PhD · Adrienne O'Neil PhD · David L Hare MB BS, DPM, FRACP

Encouraging evidence about expanding access to medications and reducing cardiovascular risk among Indigenous Australians

Amal N Trivedi MD, MPH · Allan J Pollack MB BS(Hons), FRACS(Orth), MPH(PP) · Helena C Britt BA, PhD · Graeme C Miller MB BS, PhD, FRACGP · Christopher Harrison BPsych(Hons), MSocHlth · Margaret A Kelaher PhD, BSc(Psych)

The availability of a catheterisation laboratory appears to have a significant impact on long-term mortality in acute coronary syndrome patients

David B Brieger MB BS, PhD, FRACP · Derek PB Chew MB BS, MPH, FRACP · Julie Redfern PhD, BAppSc(Hons), BSc · Chris Ellis BM, FRACP · Tom G Briffa PhD · Tegwen E Howell BEcon, MEcSt · Bernadette Aliprandi-Costa RN, BHSc · Carolyn M Astley RN, BN, DrPH · Greg Gamble MSc · Bridie Carr BA, SRN, OND · Christopher JK Hammett BHB, MB ChB, MD · Neville Board BA, RN, MPH · John K French MB ChB, PhD, FRACP

Cardiac troponin is a useful biomarker for acute coronary syndromes, but caution in primary care contexts is needed

Helen M Wilcox MB BS (Hons), FRACGP, DCH · Alistair W Vickery MB BS, FRACGP · Jon D Emery MB BCh, FRACGP, DPhil

This case report provides evidence that the mechanism of pulmonary oedema resulting from funnel-web spider envenoming is cardiogenic

Geoffrey K Isbister MB BS, FACEM, MD · Kate V Sellors BMed, FACEM, GradCertClinToxicol · Ursula Beckmann MD, FRACP, FJFICM · Angela L Chiew BSc(Med), MB BS · Michael A Downes FACEM · Ingrid Berling BMed, FACEM