Cardiovascular diseases

A 42-year-old man presented with acute onset substernal chest pain

Naim Mridha · Eloise Ward · Samual Hayman · Arun Dahiya · Sandhir Prasad

To the Editor: The toll of group A Streptococcus is dramatically unappreciated, despite increasing evidence of its burden.1 In Australia and New Zealand, we recently demonstrated that group A streptococcal throat and skin infections cause a sizable burden at the population level — cellulitis is the main contributor to the total burden of all group A streptococcal diseases and acute rheumatic fever and rheumatic heart disease contribute disproportionately relative to their frequency of occurrence.2,3 At a global level, the burden of group A Streptococcus is not abating. Global Burden of Disease data suggest that incident cases and deaths due to rheumatic heart disease alone have surpassed those of meningitis (Box). In 2019, more than 85% of rheumatic heart disease cases occurred among people aged under 35 years.4 No other group A streptococcal‐specific endpoints are available from the Global Burden of Disease data, yet all‐cause cellulitis was ranked the 24th most frequently occurring condition in high income countries in 2019.4 Group A Streptococcus causes outbreaks of poststreptococcal glomerulonephritis, contributing to the burden of chronic renal disease, and it is estimated to be the fifth most lethal pathogen on the planet, behind the human immunodeficiency virus (HIV), Mycobacterium tuberculosis, Plasmodium falciparum and S. pneumoniae, yet expenditure on vaccine development is only 0.17% of that spent on vaccines for HIV infection, malaria and tuberculosis.5 The divergence in numbers of cases and deaths due to group A Streptococcus compared with meningitis partially demonstrates the value of vaccination. Another major benefit of vaccination is a substantial reduction in antibiotic consumption. Indeed, pharyngitis is a major driver of antibiotic consumption globally, and an estimated 17% of antibiotic prescriptions for pharyngitis among children in the United States could be prevented by a group A Streptococcus vaccine.6 Two major initiatives aim to progress vaccine development. The Australian Strep A Vaccine Initiative (ASAVI) and the Strep A Vaccine Global Consortium (SAVAC) are addressing technical and investment barriers and leading at least one of the current vaccine candidates to an efficacy trial for pharyngitis prevention by 2024.5 An effective vaccine may prevent health and economic burdens due to the full range of group A streptococcal diseases and associated antibiotic consumption. Box – Estimated number of new cases (left) and deaths (right) due to meningitis and rheumatic heart disease globally* * Data obtained from the Global Burden of Disease study 2019.4

Jeffrey W Cannon · Julie Bennett · Michael G Baker · Jonathan R Carapetis

Objective: To compare the frequency and outcomes of cardiac arrests in general practice clinics with those of paramedic‐witnessed cardiac arrests. Design, setting: Retrospective study; analysis of Victorian Ambulance Cardiac Arrest Registry data, 1 January 2000 – 30 December 2019. Participants: Patients with non‐traumatic cardiac arrests whom emergency medical services staff attempted to resuscitate. Main outcome measures: Survival to hospital discharge. Results: 6363 cases of cardiac arrest were identified: 216 in general practice clinics (3.4%) and 6147 witnessed by paramedics (96.6%). The proportion of patients presenting with initial shockable rhythms was larger in clinic (126 patients, 58.3%) than paramedic‐witnessed cases (1929, 31.4%). The proportion of general practice clinic cases in which defibrillation was provided in the clinic increased from 2 of 37 in 2000–2003 (5%) to 19 of 57 patients in 2016–2019 (33%); survival increased from 7 of 37 (19%) to 23 of 57 patients (40%). For patients with initial shockable rhythms, 57 of 126 in clinic cases (45%) and 1221 of 1929 people in paramedic‐witnessed cases (63.3%) survived to hospital discharge; of 47 general practice patients defibrillated by clinic staff, 27 survived (57%). For patients with initial shockable rhythms, the odds of survival were greater following paramedic‐witnessed events (adjusted odds ratio [aOR], 3.39; 95% CI, 2.08–5.54) or general clinic arrests with defibrillation by clinic staff (aOR, 2.23; 95% CI, 1.03–4.83) than for general practice clinic arrests in which arriving paramedics provided defibrillation. Conclusion: Emergency medical services should be alerted as soon as possible after people experience heart attack warning symptoms. Automated external defibrillators should be standard equipment in general practice clinics, enabling prompt defibrillation, which may substantially reduce the risk of death for people in cardiac arrest.

Brian Haskins · Ziad Nehme · Peter A Cameron · Karen Smith

A patent foramen ovale (PFO) is an interatrial shunt, with a prevalence of 20–34% in the general population. While most people do not have secondary manifestations of a PFO, some reported sequelae include ischaemic stroke, migraine, platypnoea–orthodeoxia syndrome and decompression illness. Furthermore, in some cases, PFO closure should be considered for patients before neurosurgery and for patients with concomitant carcinoid syndrome. Recent trials support PFO closure for ischaemic stroke patients with high risk PFOs and absence of other identified stroke mechanisms. While PFOs can be associated with migraine with auras, with some patients reporting symptomatic improvement after closure, the evidence from randomised controlled trials is less clear in supporting the use of PFO closure for migraine treatment. PFO closure for other indications such as platypnoea–orthodeoxia syndrome, decompression illness and paradoxical embolism are based largely on case series with good clinical outcomes. PFO closure can be performed as a day surgical intervention with high procedural success and low risk of complications.

Kenneth K Cho · Shaun Khanna · Phillip Lo · Daniel Cheng · David Roy

Improving systems of care can achieve earlier treatment and increase survival

John K French

Intensive metabolic control reduces the incidence and progression of diabetes‐related micro‐ and macrovascular complications.1,2 Nevertheless, the risk of developing cardiovascular disease is higher for people with diabetes,3 although cardiovascular disease incidence rates are generally declining more rapidly for people with diabetes than for other people.4,5 We analysed hospital discharge data from the Victorian Admitted Episode Dataset6 for 1 January 1999 – 31 December 2016. We identified incident cases of three cardiovascular disease complications (acute myocardial infarction [AMI], stroke, and heart failure) by International Statistical Classification of Diseases, tenth revision, Australian modification (ICD‐10‐AM) codes. Data for 1999‒2003 were examined to ensure that admissions during the observation period (2004‒2016) were index admissions for the specific complication, but were not included in our main analysis. Admission rates were separately calculated for people with type 1 or type 2 diabetes (numbers of people with diagnosed diabetes, by year, were obtained from the National Diabetes Services Scheme, which captures 80–90% of diabetes diagnoses7) and for people without diabetes (derived from Australian Bureau of Statistics census data8). We analysed changes in admission rates by Joinpoint regression (https://surveillance.cancer.gov/joinpoint); points at which changes in the direction or magnitude of linear trends were statistically significant (P < 0.05) were determined with permutation tests. Each trend segment was described by an annual percentage change (APC), and the change for the entire study period as the mean APC (further details: online Supporting Information). The study was approved by the St Vincent’s Hospital Melbourne Human Research Ethics Committee (HREC/18/SVHM/146). A total of 382 107 patients were admitted to Victorian hospitals during 2004–2016 with cardiovascular complications: 278 991 without diabetes (73%), 3645 with type 1 diabetes (1%), and 99 471 with type 2 diabetes (26%). AMI admission rates declined during this period for people with type 1 (mean APC, –7.7%; 95% confidence interval [CI], –13.4% to –1.5%) or type 2 diabetes (mean APC, –11.4%; 95% CI, –13.0% to –9.9%), as well as for people without diabetes (mean APC, –5.0%; 95% CI, –6.7% to –3.4%) (Box 1, Box 2). Stroke admission rates declined significantly during 2004–2016 for people with type 1 diabetes (mean APC, –7.2%; 95% CI, –12.2% to –1.9%); for people with type 2 diabetes, rates declined during 2005–2011 and 2014–2016, but not during 2011–2014 (overall change: –11.9%; 95% CI, –17.0% to –6.5%). For patients without diabetes, the decline during 2005–2014 was significant (mean APC, –4.1%; 95% CI, –5.8% to –2.3%), but not during 2015–2016 (Box 1, Box 2). Admissions for heart failure declined during 2004–2016 for people with type 1 diabetes (mean APC, –10.3%; 95% CI, –14.1% to –6.4%) or type 2 diabetes (mean APC, –9.2%; 95% CI, –11.0% to –7.3%), and also for people without diabetes (mean APC, –2.8%; 95% CI, –4.1% to –1.5%) (Box 1, Box 2). As hospital discharge coding data do not provide information on metabolic control or medication use, we could not assess whether cardiovascular risk factor modification and use of specific medications were associated with changes in admission rates. We also lacked information on disease duration for patients with hospital‐coded diabetes. Further, we have counted admissions of any patients who had presented with complications before 1998 (ie, outside our 5‐year clearance period) as incident admissions; these patients would be at very high risk of further admissions, and their inclusion may have inflated the admission rates we report for the observation period of our study. Few recent studies have assessed outcomes for all three cardiovascular complications in a single investigation. Cardiovascular complication‐related admissions to Victorian hospitals declined during 2004–2016 more rapidly for people with diabetes than for those without diabetes. The relatively greater absolute decline in the numbers of admissions of people with diabetes may be related to the fact that they are considered to be at high risk for cardiovascular disease and are therefore treated more aggressively; the scope for reducing risk with multifactorial target‐driven interventions is greater in these patients. Nevertheless, admission rates for cardiovascular complications of people with diabetes remain relatively high. Box 1 – Age‐ and sex‐adjusted admission rates for cardiovascular complications (with 95% confidence intervals), Victoria, 2004–2016, by diabetes status of patients Box 2 – Annual percentage change (APC) in admissions for cardiovascular complications, Victoria, 2004–2016, by diabetes status Change in event rate, 2004–2016* Change in event rate, by period* Cardiovascular complication and diabetes status Admissions Overall change (95% CI) Mean APC (95% CI%) Mean APC (95% CI) Acute myocardial infarction No diabetes 114 965 –24.8% (–24.9% to –24.7%) –5.0% (–6.7% to –3.4%) — Type 1 diabetes 1272 –7.7% (–8.8% to –6.7%) –7.7% (–13.4% to –1.5%) 1. 2005–2009: +7.0% (–9.7% to +22.8%) 2. 2009–2016: –15.1% (–21.3% to –8.7%) Type 2 diabetes 15 278 –69.0% (–69.0% to –68.8%) –11.4% (–13.0% to –9.9%) — Stroke No diabetes 52 320 –10.9% (–13.6% to –10.6%) –1.7% (–4.9% to +1.5%) 1. 2005–2014: –4.1% (–5.8% to –2.3%) 2. 2014–2016: +9.6% (–10.2% to +33.8%) Type 1 diabetes 504 –44.4% (–50.0% to –41.4%) –7.2% (–12.2% to –1.9%) — Type 2 diabetes 17 440 –68.0% (–68.0% to –67.9%) –11.9% (–17.0% to –6.5%) 1. 2005–2011: –14.7% (–17.6% to –11.7%) 2. 2011–2014: +5.8% (–19.0% to +38.2%) 3. 2014–2016: –26.1% (–39.8% to –9.2%) Heart failure No diabetes 135 524 –22.2% (–22.3% to –22.2%) –2.8% (–4.1% to –1.5%) — Type 1 diabetes 1393 –55.1% (–58.6% to –52.4%) –10.3% (–14.1% to –6.4%) — Type 2 diabetes 52 831 –67.3% (–67.4% to –67.3%) –9.2% (–11.0% to –7.3%) — * Adjusted for age and sex. Event rates for 2004 and 2016 are included in the expanded version of this table in the online Supporting Information.

Katerina V Kiburg · Andrew I MacIsaac · Andrew Wilson · Vijaya Sundararajan · Richard J MacIsaac

Objective: To assess long term survival and patient characteristics associated with survival following acute myocardial infarction (AMI) in Australia and New Zealand. Design: Cohort study. Setting, participants: All patients admitted with AMI (ICD‐10‐AM codes I21.0‒I21.4) to all public and most private hospitals in Australia and New Zealand during 2009‒2015. Main outcome measure: All‐cause mortality up to seven years after an AMI. Results: 239 402 initial admissions with AMI were identified; the mean age of the patients was 69.3 years (SD, 14.3 years), 154 287 were men (64.5%), and 64 335 had ST‐elevation myocardial infarction (STEMI; 26.9%). 7‐year survival after AMI was 62.3% (STEMI, 70.8%; non‐ST‐elevation myocardial infarction [NSTEMI], 59.2%); survival exceeded 85% for people under 65 years of age, but was 17.4% for those aged 85 years or more. 120 155 patients (50.2%) underwent revascularisation (STEMI, 72.2%; NSTEMI, 42.1%); 7‐year survival exceeded 80% for patients in each group who underwent revascularisation, and was lower than 45% for those who did not. Being older (85 years or older v 18–54 years: adjusted hazard ratio [aHR], 10.6; 95% CI, 10.1–11.1) or a woman (aHR, 1.15; 95% CI, 1.13–1.17) were each associated with greater long term mortality during the study period, as was prior heart failure (aHR, 1.79; 95% CI, 1.76‒1.83). Several non‐cardiac conditions and geriatric syndromes common in these patients were independently associated with lower long term survival, including major and metastatic cancer, cirrhosis and end‐stage liver disease, and dementia. Conclusion: AMI care in Australia and New Zealand is associated with high rates of long term survival; 7‐year rates exceed 80% for patients under 65 years of age and for those who undergo revascularisation. Efforts to further improve survival should target patients with NSTEMI, who are often older and have several comorbid conditions, for whom revascularisation rates are low and survival after AMI poor.

Bora Nadlacki · Dennis Horton · Sadia Hossain · Saranya Hariharaputhiran · Linh Ngo · Anna Ali · Bernadette Aliprandi‐Costa · Chris J Ellis · Robert JT Adams · Renuka Visvanathan · Isuru Ranasinghe

We can learn from all clinical trials, whatever their outcomes

Mark R Nelson

The use of coronary artery calcium scoring can assist in defining risk in the primary prevention of cardiovascular disease in Australia.

Garry LR Jennings · Ralph Audehm · Warrick Bishop · Clara K Chow · Siaw-Teng Liaw · Danny Liew · Sara M Linton

To the Editor: Improving our understanding of the place of computed tomography (CT) coronary calcium scoring in the assessment of cardiovascular disease risk is critical. However, we disagree with the conclusions in the article by Venkataraman and colleagues1 that the results of their study support the use of CT coronary calcium scoring in individuals with intermediate risk using the Australian cardiovascular disease risk (ACVDR) calculator. Unfortunately, the study has significant flaws in its outcome measures — CT coronary artery calcium scoring and Multi‐Ethnic Study of Atherosclerosis (MESA) — which result in misleading conclusions. The authors examined the predictive power of the ACVDR to detect individuals having a calcium score greater than zero or greater than 100. However, since CT coronary calcium scoring is not a reference standard for cardiovascular disease, this is an invalid outcome for estimating the comparative accuracy of the various cardiovascular disease risk scores. This study also used the MESA risk score as an outcome measure, although this is a risk calculator that has not been validated in the Australian population. As the MESA score was developed to include CT coronary calcium scoring, any risk calculator that also includes this score is likely to appear to perform better than risk calculators that do not. The authors state that their “findings suggest that Australian patients are undertreated by international standards”. The threshold recommended by the current guidelines for cholesterol‐lowering medication in the United States — used by the authors as the international standard — would more than triple the proportion of the Australian population recommended to take medication.2 Primary prevention of cardiovascular disease involves individuals who have not yet had a cardiovascular event, making it particularly incumbent on medical professionals that recommendations consider benefits and harms. The information gained from CT coronary calcium scoring needs to demonstrate that benefits outweigh risks, such as radiation exposure, costs, and incidental findings. Trials to date have shown no improvements in health outcomes. Overall, patients are more likely to be reclassified in a higher risk category, some correctly, but higher absolute numbers may be incorrectly reclassified as high risk.3 Individuals with a calcium score of zero are still at risk of cardiovascular disease, about 0.5% per year. The notion that images seen on CT coronary calcium scoring demonstrate the presence or absence of disease is appealing, but it is a gross simplification.4 While CT coronary calcium scoring may have a place in risk assessment, the findings from this study do not support its use.

Andrew Hayen · Paul P Glasziou · Jenny A Doust

A 68-year-old man with diabetes presented with progressive dyspnoea of one month duration

Jeet Ram Kashyap · Aayushi Gupta

Objectives: To determine whether a multifaceted primary health care intervention better controlled cardiovascular disease (CVD) risk factors in patients with high risk of CVD than usual care. Design, setting: Parallel arm, cluster randomised trial in 71 Australian general practices, 5 December 2016 – 13 September 2019. Participants: General practices that predominantly used an electronic medical record system compatible with the HealthTracker electronic decision support tool, and willing to implement all components of the INTEGRATE intervention. Intervention: Electronic point‐of‐care decision support for general practices; combination cardiovascular medications (polypills); and a pharmacy‐based medication adherence program. Main outcome measures: Proportion of patients with high CVD risk not on an optimal preventive medication regimen at baseline who had achieved both blood pressure and low‐density lipoprotein (LDL) cholesterol goals at study end. Results: After a median 15 months’ follow‐up, primary outcome data were available for 4477 of 7165 patients in the primary outcome cohort (62%). The proportion of patients who achieved both treatment targets was similar in the intervention (423 of 2156; 19.6%) and control groups (466 of 2321; 20.1%; relative risk, 1.06; 95% CI, 0.85–1.32). Further, no statistically significant differences were found for a number of secondary outcomes, including risk factor screening, preventive medication prescribing, and risk factor levels. Use of intervention components was low; it was highest for HealthTracker, used at least once for 347 of 3236 undertreated patients with high CVD risk (10.7%). Conclusions: Despite evidence for the efficacy of its individual components, the INTEGRATE intervention was not broadly implemented and did not improve CVD risk management in participating Australian general practices. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12616000233426 (prospective).

Ruth Webster · Tim Usherwood · Rohina Joshi · Bandana Saini · Carol Armour · Sue Critchley · Gian Luca Di Tanna · Shane Galgey · Charlotte M Hespe · Stephen Jan · Ajay Karia · Baldeep Kaur · Ines Krass · Tracey‐Lea Laba · Qiang Li · Serigne Lo · David P Peiris · Christopher Reid · Anthony Rodgers · Louise Shiel · Jessica Strathdee · Nuria Zamora · Anushka Patel

Patients receive similar treatment and have similar outcomes whether their initial hospital has cardiac catheterisation facilities or not

Peter L Thompson

In Australia, an estimated 12.7% of patients with ST‐elevation myocardial infarction (STEMI) die or have recurrent myocardial infarctions within 30 days of diagnosis.1 Prompt reperfusion reduces morbidity and mortality, and guidelines consequently aim to minimise the time between symptom onset and reperfusion.1,2,3 Patients with chest pain may arrange their own transport to an emergency department or travel by ambulance. The risk period is shorter for patients without access to a defibrillator when they travel by ambulance, and they receive initial management more promptly. In Australia, only one in two patients with STEMI calls an ambulance.4 Characterising patients less likely to call an ambulance would inform targeted public health efforts to improve this situation. We analysed data contributed by 43 hospitals across Australia to the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE)5 for patients with confirmed STEMI who presented to these hospitals during 23 February 2009 – 31 December 2017. We excluded patients who experienced out‐of‐hospital cardiac arrest or cardiogenic shock. We compared the clinical characteristics, time to reperfusion, and hospital outcomes, including death and major adverse cardiovascular events (MACE) — cardiac death, myocardial infarction, heart failure, or shock — for patients who arrived by ambulance or otherwise, after adjusting for Global Registry of Acute Coronary Events (GRACE) risk score6 at baseline. The statistical significance of differences in categorical variables was assessed in Rao–Scott χ2 tests and that of continuous variables in Wilcoxon rank‐sum tests. For adjusted analyses, we used multivariable logistic regression models in a generalised estimating equation (GEE) framework, adjusted for clustering by hospital. Analyses were conducted in SAS 9.4. Ethics approval for the study was granted by the Concord Repatriation General Hospital Human Research Ethics Committee (reference, HREC/08/CRGH/180). Of 2765 patients who presented with STEMI to CONCORDANCE hospitals during 2009–2017, 1616 (58.4%) arrived by ambulance and 1149 (41.6%) by other means. The median age of patients arriving by ambulance (64 years; interquartile range [IQR], 54–74 years) was higher than for the other patients (59 years; IQR, 51–67 years), and the proportions with hypertension, a family history of coronary heart disease, or prior myocardial infarction, atrial fibrillation, or stroke/transient ischaemic attack were larger (Box). Time between arrival at hospital and reperfusion (primary percutaneous intervention or fibrinolysis) was significantly shorter for patients who arrived by ambulance than for other patients (Box). After adjusting for GRACE risk score, the odds of death (adjusted odds ratio [aOR], 1.16; 95% confidence interval [CI], 0.65–2.08) and MACE (aOR, 0.89; 95% CI, 0.72–1.10) were similar for the two patient groups (Supporting Information). Our analysis of data from a large Australian registry indicates that fewer than 60% of patients with STEMI arrive at hospital by ambulance; those who do have a higher median age and larger proportions have histories of cardiovascular disease. Importantly, their median time to reperfusion is shorter than for those not arriving by ambulance, probably because STEMI is diagnosed by electrocardiography during their journey to the hospital, which facilitates priming of emergency departments (for fibrinolysis) and catheterisation laboratories (for percutaneous coronary intervention). Despite the less favourable risk profiles of patients who arrive by ambulance, their hospital outcomes are comparable with those of patients who present directly to hospital, presumably because of their more rapid access to reperfusion. Our finding that patients with STEMI who are older and have more comorbid conditions are more likely to call an ambulance is not novel,7 but does indicate that this has not changed in recent years. This underscores the value of calling an ambulance when chest pain develops, and suggest that this public health message should be more actively promoted. Box – Baseline characteristics and times to reperfusion of 2765 patients who presented with STEMI to CONCORDANCE hospitals, 2009–2017 table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Transport to hospital Characteristic Ambulance Other means P Number of patients 1616 (58.4%) 1149 (41.6%) Age (years), median (IQR) 64 (54‒74) 59 (51‒67) < 0.001 Sex (men) 1140 (71%) 933 (81%) < 0.001 English as first language 1383 (86%) 959 (83%) 0.44 Prior myocardial infarction 252 (16%) 151 (13%) 0.046 Prior heart failure 49 (3%) 27 (2%) 0.27 Prior percutaneous coronary intervention 177 (11%) 116 (10%) 0.46 Prior coronary artery bypass graft 52 (3%) 26 (2%) 0.10 Prior atrial fibrillation 96 (6%) 30 (3%) < 0.001 Prior bleeding 17 (1%) 14 (1%) 0.63 Chronic renal failure 73 (5%) 42 (4%) 0.17 Prior stroke/transient ischaemic attack 94 (6%) 32 (3%) < 0.001 Diabetes 321 (20%) 232 (20%) 0.80 Hypertension 853 (53%) 534 (47%) < 0.001 Dyslipidaemia 696 (43%) 473 (41%) 0.21 Family history of coronary heart disease 514 (32%) 477 (42%) < 0.001 Grace risk score (Fox), median (IQR) 114 (95‒135) 102 (85‒119) < 0.001 Reperfusion modality Primary percutaneous coronary intervention 919 (57%) 486 (42%) < 0.001 Fibrinolysis 434 (27%) 442 (38%) < 0.001 None 320 (20%) 273 (24%) 0.010 Hospital arrival to reperfusion (h), median (IQR) Primary percutaneous coronary intervention 1.2 (0.7‒2.1) 2.1 (1.4‒6.1) < 0.001 Fibrinolysis 0.6 (0.3‒1.3) 0.8 (0.5‒1.3) 0.002 IQR = interquartile range; STEMI = ST‐elevation myocardial infarction.

Eleanor Redwood · Karice Hyun · John K French · Leonard Kritharides · Mark Ryan · Derek P Chew · Mario D'Souza · David B Brieger

Managing patients with acute chest pain should include opportunistic discussion of strategies for preventing coronary artery disease

Johannes T Neumann · Andrew M Tonkin

Objective: To determine whether the availability of invasive coronary angiography at the hospital of presentation influences catheterisation rates for patients with acute coronary syndrome (ACS), and whether presenting to a catheterisation‐capable hospital is associated with better outcomes for patients with ACS. Design, setting: Retrospective cohort study; analysis of Cooperative National Registry of Acute Coronary Events (CONCORDANCE) data. Setting, participants: Adults admitted with ACS to 43 Australian hospitals (including 31 catheterisation‐capable hospitals), February 2009 – October 2018. Main outcome measures: Major adverse cardiovascular events (myocardial infarction, stroke, congestive heart failure, cardiogenic shock, cardiovascular death) and all‐cause deaths in hospital and by six and 12‐ or 24‐month follow‐up. Results: The proportion of women among the 5637 patients who presented to catheterisation‐capable hospitals was smaller than for the 2608 patients who presented to hospitals without catheterisation facilities (28% v 33%); the proportion of patients diagnosed with ST elevation myocardial infarction was larger (32% v 20%). The proportions of patients who underwent catheterisation (81% v 70%) or percutaneous coronary intervention (49% v 35%) were larger for those who presented to catheterisation‐capable hospitals. The baseline characteristics of patients who underwent catheterisation were similar for both presentation hospital categories, as were rates of major adverse cardiovascular events and all‐cause death in hospital and by 6‐ and 12‐ or 24‐month follow‐up. Conclusions: Although a larger proportion of patients who presented to catheterisation‐capable hospitals underwent catheterisation, patients with similar characteristics were selected for the procedure, independent of the hospital of presentation. Major outcomes for patients were also similar, suggesting equitable management of patients with ACS across Australia.

Michael Ayad · Karice Hyun · Mario D’Souza · Julie Redfern · Janice Gullick · Mark Ryan · David B Brieger

Objectives: To assess the efficacy of a pro‐active, absolute cardiovascular risk‐guided approach to opportunistically modifying cardiovascular risk factors in patients without coronary ischaemia attending a chest pain clinic. Design: Prospective, randomised, open label, blinded endpoint study. Setting: The rapid access chest pain clinic of Royal Hobart Hospital, a tertiary hospital. Participants: Patients who presented to the chest pain clinic between 1 July 2014 and 31 December 2017 who had intermediate to high absolute cardiovascular risk scores (5‐year risk ≥ 8%). Patients with known cardiac disease or from groups with clinically determined high risk of cardiovascular disease were excluded. Main outcome measures: The primary endpoint was change in 5‐year absolute risk score (Australian absolute risk calculator) at follow‐up (at least 12 months after baseline assessment). Secondary endpoints were changes in lipid profile, blood pressure, smoking status, and body mass index, and major adverse cardiovascular events. Results: The mean change in risk at follow‐up was +0.4 percentage points (95% CI, –0.8 to 1.5 percentage points) for the 98 control group patients and –2.4 percentage points (95% CI, –1.5 to –3.4 percentage points) for the 91 intervention group patients; the between‐group difference in change was 2.7 percentage points (95% CI, 1.2–4.1 percentage points). Mean changes in lipid profile, systolic blood pressure, and smoking status were larger for the intervention group, but not statistically different from those for the control group. Conclusions: An absolute cardiovascular risk‐guided, pro‐active risk factor management strategy employed opportunistically in a chest pain clinic significantly improved 5‐year absolute cardiovascular risk scores. Trial registration: Australia New Zealand Clinical Trial Registry, ACTRN12617000615381 (retrospective).

J Andrew Black · Julie A Campbell · Serena Parker · James E Sharman · Mark R Nelson · Petr Otahal · Garry Hamilton · Thomas H Marwick

Guidelines for reporting results from randomised trials have long underscored the importance of confidence intervals

Karla Hemming · Monica Taljaard

Objectives: To investigate causes of death of people with cancer alive five years after diagnosis, and to compare mortality rates for this group with those of the general population. Design, setting, participants: Retrospective cohort study; analysis of South Australian Cancer Registry data for all people diagnosed with cancer during 1990–1999 and alive five years after diagnosis, with follow‐up to 31 December 2016. Main outcome measures: All‐cause and cancer cause‐specific mortality, by cancer diagnosis; standardised mortality ratios (study group v SA general population) by sex, age at diagnosis, follow‐up period, and index cancer. Results: Of 32 646 people with cancer alive five years after diagnosis, 30 309 were of European background (93%) and 16 400 were males (50%); the mean age at diagnosis was 60.3 years (SD, 15.7 years). The median follow‐up time was 17 years (IQR, 11–21 years); 17 268 deaths were recorded (53% of patients; mean age, 80.6 years; SD, 11.4 years): 7845 attributed to cancer (45% of deaths) and 9423 attributed to non‐cancer causes (55%). Ischaemic heart disease was the leading cause of death (2393 deaths), followed by prostate cancer (1424), cerebrovascular disease (1175), and breast cancer (1118). The overall standardised mortality ratio (adjusted for age, sex, and year of diagnosis) was 1.24 (95% CI, 1.22–1.25). The cumulative number of cardiovascular deaths exceeded that of cancer cause‐specific deaths from 13 years after cancer diagnosis. Conclusions: Mortality among people with cancer who are alive at least five years after diagnosis was higher than for the general population, particularly cardiovascular disease‐related mortality. Survivorship care should include early recognition and management of risk factors for cardiovascular disease.

Bogda Koczwara · Rosie Meng · Michelle D Miller · Robyn A Clark · Billingsley Kaambwa · Tania Marin · Raechel A Damarell · David M Roder

Recent proposals to adopt tenecteplase as the recommended thrombolytic agent for stroke reperfusion will reduce its availability for patients with acute myocardial infarction

Mark Parsons · Leonid Churilov · Aletta E Schutte · Christopher Levi

Introduction: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) cause significant morbidity and premature mortality among Australian Aboriginal and Torres Strait Islander peoples. RHDAustralia has produced a fully updated clinical guideline in response to new knowledge gained since the 2012 edition. The guideline aligns with major international ARF and RHD practice guidelines from the American Heart Association and World Heart Federation to ensure best practice. The GRADE system was used to assess the quality and strength of evidence where appropriate.Main recommendations: The 2020 Australian guideline details best practice care for people with or at risk of ARF and RHD. It provides up‐to‐date guidance on primordial, primary and secondary prevention, diagnosis and management, preconception and perinatal management of women with RHD, culturally safe practice, provision of a trained and supported Aboriginal and Torres Strait Islander workforce, disease burden, RHD screening, control programs and new technologies.Changes in management as a result of the guideline: Key changes include updating of ARF and RHD diagnostic criteria; change in secondary prophylaxis duration; improved pain management for intramuscular injections; and changes to antibiotic regimens for primary prevention. Other changes include an emphasis on provision of culturally appropriate care; updated burden of disease data using linked register and hospitalisations data; primordial prevention strategies to reduce streptococcal infection addressing household overcrowding and personal hygiene; recommendations for population‐based echocardiographic screening for RHD in select populations; expanded management guidance for women with RHD or ARF to cover contraception, antenatal, delivery and postnatal care, and to stratify pregnancy risks according to RHD severity; and a priority classification system for presence and severity of RHD to align with appropriate timing of follow‐up.

Anna P Ralph · Sara Noonan · Vicki Wade · Bart J Currie

To the Editor: Cardiac injury has been reported in about 20% of patients with coronavirus disease 2019 (COVID‐19) admitted to hospital.1 Elevated troponin is associated with higher complications and death rates.2,3 We report our experience in managing the cardiovascular care of all patients with COVID‐19 admitted to our 783‐bed quarternary hospital in Perth between 1 February and 1 May 2020. The hospital approved the data collection for a clinical quality improvement audit and provided an exemption from ethics review and approval to publish the results. Patients with COVID‐19 with an abnormal electrocardiogram (ECG) showed markers of increased disease severity, had a longer hospital stay and intensive care unit (ICU) admission. Eighteen patients (11 males), with a mean age 59 years (standard deviation [SD], 18), were admitted for a mean 14 days (SD, 15) with symptoms of cough (78%), fever (72%), dyspnoea (61%), fatigue (44%), chest pain (22%), and presyncope (5%). The mean presentation was 6 days (SD, 4) from onset of symptoms. Eight patients required admission to the ICU, and we recorded no deaths. The comorbidities included obesity (four patients), ischaemic heart disease (two patients), diabetes mellitus (four patients), and hypertension (six patients). Cardiac investigations included ECGs (72%), high sensitivity troponin (67%), brain natriuretic peptide (7%), and echocardiogram (6%). Upon admission, eight patients (63%) had an abnormal ECG, which included PR depression, biphasic T waves, PR prolongation, Q waves, ST elevation, atrial flutter, right bundle branch block, and atrial trigeminy. Two patients had elevated troponin. All brain natriuretic peptide and echocardiogram results were normal. Patients who did not have an ECG had low risk markers for disease severity. Patients with a normal ECG had a mean heart rate 84 beats/min (SD, 11), mean QRS duration 92 milliseconds (SD, 9), and mean QTc interval 414 milliseconds (SD, 59) compared with patients with abnormal ECGs, who had a mean heart rate 93 beats/min (SD, 11), mean QRS 96 milliseconds (SD, 18), and mean QTc 400 milliseconds (SD, 110). Seven patients had repeat ECG during their admission. Five patients developed new abnormalities on follow‐up ECGs, including transient ST elevation, sinus bradycardia, junctional rhythm, atrial fibrillation, and complete heart block. Our data show a consistent trend of increased disease severity in patients with abnormal admission ECG (Box). Patients with abnormal ECG required longer hospital admission (61% longer), double the incidence of documented arrhythmias, and double the requirement for oxygen, ventilation and inotropic support. Measures of significant inflammatory response (ferritin, C‐reactive protein, D‐dimer) were markedly higher in patients with abnormal ECG. Half of the patients developed an abnormal rhythm during admission: complete heart block (one patient), supraventricular tachycardia (one patient), atrial fibrillation (three patients), sinus tachycardia (three patients), and sinus bradycardia (one patient). Cardiac procedures performed were transesophageal echocardiogram/cardioversion (one patient), and pacemaker implantation (one patient). Our limited experience suggests an ECG may be helpful in prognostication and triaging of all patients with COVID‐19. An abnormal rhythm may arise from cardiac stress due to cytokine response, direct myocardial viral injury, or physiological strain from multi‐organ injury. Pulmonary injury from pneumonia, acute respiratory distress syndrome and pulmonary emboli can lead to significant right ventricular strain that predisposes to arrhythmia. Sepsis, and related cytokine response, is associated with atrial fibrillation. Myocardial inflammation and subsequent scarring can lead to ventricular arrhythmia and conduction disorders. ECG is a low cost test that can be performed easily and rapidly with minimal risk of viral exposure to staff. ECG should be an essential test in the COVID‐19 pandemic. Box – Characteristics of patients with coronavirus disease 2019 (COVID‐19) admitted to hospital Total Abnormal ECG Normal ECG No ECG Total number of patients 18 8 5 5 Age (years), mean (SD) 59 ± 19 67 ± 14 52 ± 15 53 ± 24 Admission (days), mean (SD) 14 ± 15 21 ± 19 13 ± 11 3 ± 2 Ferritin (μg/L), mean (SD) 1594 ± 1658 2328 ± 2141 1089 ± 620 970 ± 1206 Creatinine (μmol/L), mean (SD) 103 ± 64 110 ± 71 86 ± 33 110 ± 82 CRP (mg/L), mean (SD) 166 ± 165 255 ± 198 124 ± 108 39 ± 42 D‐dimer (mg/L), mean (SD) 4.17 ± 6.23 7.03 ± 8.29 1.99 ± 1.39 0.64 ± 0.42 Arrhythmias 9 7 < 5 na Number of patients requiring oxygen 10 6 < 5 < 5 Oxygen use (days), mean (SD) 19 ± 14 23 ± 15 15 ± 11 4 ICU admission (days), mean (SD) 19 ± 11 23 ± 11 12 ± 9 Nil Ventilation (days), mean (SD) 14 ± 10 18 ± 10 7 ± 5 Nil Inotropic support (days) mean (SD) 13 ± 12 18 ± 12 5 ± 6 Nil CRP = C‐reactive protein; ECG = electrogardiogram; ICU = intensive care unit; na = not applicable; SD = standard deviation.

Kaitlyn Lam · Sarah McClelland · Michael J Dallo