Evolving management and improving outcomes of pregnancy-associated spontaneous coronary artery dissection (P-SCAD): a systematic review.

Background: Pregnancy-associated spontaneous coronary artery dissection (P-SCAD) is defined as SCAD occurring during pregnancy or within 3 months post-partum. Earlier systematic reviews have suggested a high maternal and foetal mortality rate. We undertook a structured systematic review of P-SCAD demographics, management and maternal and foetal outcomes. Methods: Case study identification was conducted according to PRISMA guidelines, with screening of all published P-SCAD cases not meeting pre-defined exclusion criteria. Of two hundred and seventy-three publications screened, one hundred and thirty-eight cases met inclusion criteria. Cases were allocated to one of three time periods; 1960-85 (twenty cases) reflecting early management of P-SCAD, 1986-2005 (forty-two cases) reflecting recent management, and 2006-16 (seventy-six cases), reflecting contemporary management. Results: The only significant demographic change in women experiencing P-SCAD over the last 50 years was an increasing proportion of primigravidas (p = 0.02). Management and outcomes, however, have altered significantly. Emergent angiography (p < 0.0001), reduced thrombolysis (p = 0.006) and increasingly conservative or percutaneous management (p < 0.0001) are associated with dramatic reductions in maternal mortality (85% in earliest reports to 4% in the last decade, p < 0.0001) and foetal mortality (50% in earliest reports to 0.0% in the last decade, p = 0.023). Conclusion: This systematic review of temporal changes in presentation, management and outcomes of P-SCAD represents the widest range of variables analysed in the largest cohort of P-SCAD patients to date. In the setting of earlier coronary angiography and increasingly conservative management, maternal and foetal survival rates continue to improve

Telehealth in Australian cardiology: insight into factors predicting the use of telephone versus video during the COVID-19 pandemic

BACKGROUND: The use of telehealth has increased dramatically in Australia in 2020 as a pragmatic response to the COVID-19 pandemic; however, differences between telehealth modalities have not been established. AIM: To identify characteristics contributing to choosing telephone (TP) versus video consultation (VC) and assess patient outcomes between telehealth modalities. METHODS: We conducted an observational study of cardiology outpatients at a tertiary hospital with appointments from 17 March 2020 to 12 August 2020. Demographic variables and appointment modality were compared between each group. Outcomes assessed were mortality, emergency department (ED) presentations and cross over between appointment modalities. RESULTS: There were 1754 telemedicine encounters with 1188 patients seen by TP and 327 patients by VC. Consulting volume increased from previous years. Cardiac mortality was low (0.3%). There were no differences in mortality or ED presentations between telehealth modalities. Patients choosing TP over VC were older (P < 0.001), more likely to be female (P = 0.005), non-English-speaking (P = 0.041), living in metropolitan Melbourne (P < 0.0001), undertaking a first appointment (P = 0.002) and seeing particular cardiologists (P < 0.001). VC patients were more likely to have early review (P = 0.015), and this was likely to be TP (P < 0.0001). TP patients were more likely to follow up in person (P < 0.0001). CONCLUSION: During COVID-19, we increased consultation volumes without adverse patient outcomes. We identified factors influencing the choice of telemedicine modality which did not translate into differences in mortality or ED presentations. Telemedicine is a growing platform with an important role of facilitating access to healthcare for diverse patient groups

Intracoronary IgG4-related disease as an unusual cause of sudden cardiac arrest: a case series

BACKGROUND: IgG4-related disease (IgG4-RD) is a fibro-inflammatory condition classically causing retroperitoneal fibrosis, aortitis, thyroiditis, or pancreatitis. Diagnosis includes the presence of lymphoplasmacytic infiltrate (with >40% ratio IgG4+:IgG plasma cells) and fibrosis. Cardiac involvement may include aortic, pericardial, or coronary disease. Coronary manifestations encompass obstructive intra-luminal lesions, external encasing pseudo-tumour on imaging, or lymphoplasmacytic arteritis. CASE SUMMARY: Case 1: A fit and healthy 50-year-old man was found deceased. His only known medical condition was treated Hashimoto's thyroiditis. Post-mortem examination demonstrated an isolated severe stenosis of the left anterior descending (LAD) coronary artery without histopathological evidence of acute myocardial infarction. Coronary plaque histopathology showed florid IgG4-positive plasma cell infiltrate throughout all layers of the artery with dense fibrous tissue connective tissue stroma, all features consistent with coronary artery IgG4-RD. Case 2: A 48-year-old man collapsed at work. Computed tomography scan 1 week prior reported an ill-defined para-aortic retroperitoneal soft tissue density. No cardiac symptoms were reported in life. Post-mortem examination showed coronary arteritis and peri-arteritis with sclerosing peri-aortitis in the LAD. There was myocardial fibrosis of the anterior left ventricle and focal myocarditis of the right ventricle. DISCUSSION: IgG4-related disease presenting as sudden cardiac death without any preceding symptoms is very rare (six prior cases identified on literature review). Reported targeted successful interventions for intracoronary IgG4-RD diagnosed in life have included steroid therapy and B cell depleting therapy (i.e. rituximab). If cardiac symptoms are present in a patient with known IgG4-RD, cardiac investigations should be promptly arranged

Mortality associated with moderate and severe mitral regurgitation in 608 570 men and women undergoing echocardiography

Background Although the prognostic implications of severe mitral regurgitation (MR) are well recognised, they are less clear in moderate MR. We therefore explored the prognostic impact of both moderate and severe MR within the large National Echocardiography Database Australia cohort. Methods Echocardiography reports from 608 570 individuals were examined using natural language processing to identify MR severity and leaflet pathology. Atrial (aFMR) or ventricular (vFMR) functional MR was assessed in those without reported leaflet pathology. Using individual data linkage over median 1541 (IQR 820 to 2629) days, we examined the association between MR severity and all-cause (153 612/25.2% events) and cardiovascular-related mortality (47 840/7.9% events). Results There were 319 808 men and 288 762 women aged 62.1±18.5 years, of whom 456 989 (75.1%), 102 950 (16.9%), 38 504 (6.3%) and 10 127 (1.7%) individuals had no/trivial, mild, moderate and severe MR, respectively, reported on their last echo. Compared with those with no/trivial MR (26.5% had leaflet pathology, 19.2% died), leaflet pathology (51.8% and 78.9%, respectively) and actual 5-year all-cause mortality (54.6% and 67.5%, respectively) increased with MR severity. On an adjusted basis (age, sex and leaflet pathology), long-term mortality was 1.67-fold (95% CI 1.65 to 1.70) and 2.36-fold (95% CI 2.30 to 2.42) higher in moderate and severe MR cases (p<0.001) compared with no/trivial MR. The prognostic pattern for moderate and severe MR persisted for cardiovascular-related mortality and within prespecified subgroups (leaflet pathology, vFMR or aFMR, and age<65 years). Conclusions Within a large real-world clinical cohort, we confirm that conservatively managed severe MR is associated with a poor prognosis. We further reveal that moderate MR is associated with increased mortality, irrespective of underlying aetiology.No Full Tex

Mortality associated with moderate and severe mitral regurgitation in 608 570 men and women undergoing echocardiography

BACKGROUND: Although the prognostic implications of severe mitral regurgitation (MR) are well recognised, they are less clear in moderate MR. We therefore explored the prognostic impact of both moderate and severe MR within the large National Echocardiography Database Australia cohort. METHODS: Echocardiography reports from 608 570 individuals were examined using natural language processing to identify MR severity and leaflet pathology. Atrial (aFMR) or ventricular (vFMR) functional MR was assessed in those without reported leaflet pathology. Using individual data linkage over median 1541 (IQR 820 to 2629) days, we examined the association between MR severity and all-cause (153 612/25.2% events) and cardiovascular-related mortality (47 840/7.9% events). RESULTS: There were 319 808 men and 288 762 women aged 62.1±18.5 years, of whom 456 989 (75.1%), 102 950 (16.9%), 38 504 (6.3%) and 10 127 (1.7%) individuals had no/trivial, mild, moderate and severe MR, respectively, reported on their last echo. Compared with those with no/trivial MR (26.5% had leaflet pathology, 19.2% died), leaflet pathology (51.8% and 78.9%, respectively) and actual 5-year all-cause mortality (54.6% and 67.5%, respectively) increased with MR severity. On an adjusted basis (age, sex and leaflet pathology), long-term mortality was 1.67-fold (95% CI 1.65 to 1.70) and 2.36-fold (95% CI 2.30 to 2.42) higher in moderate and severe MR cases (p<0.001) compared with no/trivial MR. The prognostic pattern for moderate and severe MR persisted for cardiovascular-related mortality and within prespecified subgroups (leaflet pathology, vFMR or aFMR, and age<65 years). CONCLUSIONS: Within a large real-world clinical cohort, we confirm that conservatively managed severe MR is associated with a poor prognosis. We further reveal that moderate MR is associated with increased mortality, irrespective of underlying aetiology. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12617001387314)

Understanding Exercise Capacity: From Elite Athlete to HFpEF

Exercise capacity is a spectrum that reflects an individual's functional capacity and the dynamic nature of cardiac remodelling along with respiratory and skeletal muscle systems. The relationship of increasing physical activity, increased cardiac mass and volumes, and improved cardiorespiratory fitness (CRF) is well established in the endurance athlete. However, less emphasis has been placed on the other end of the spectrum, which includes individuals with a more sedentary lifestyle and small hearts who are at increased risk of functional disability and poor clinical outcomes. Reduced CRF is an independent predictor of all-cause mortality and cardiovascular events determined by multiple inter-related exogenous and endogenous factors. In this review, we explore the relationship of physical activity, cardiac remodelling, and CRF across the exercise spectrum, emphasising the critical role of cardiac size in determining exercise capacity. In contrast to the large compliant left ventricle of the endurance athlete, an individual with a lifetime of physical inactivity is likely to have a small, stiff heart with reduced cardiac reserve. We propose that this might contribute to the development of heart failure with preserved ejection fraction in certain individuals, and is key to understanding the link between low CRF and increased risk of heart failure

Small Heart Size and Premature Death in 366,484 Individuals With Normal Ejection Fraction

BACKGROUND: In patients with preserved left ventricular ejection fraction (LVEF), small ventricular size has been associated with reduced functional capacity, but its impact on clinical outcomes is unclear. OBJECTIVES: The goal of this study was to determine the relationship between small heart size and premature mortality within a large multicenter adult patient cohort with transthoracic echocardiographic examinations. METHODS: We divided 366,484 individuals with LVEF ≥50% (including a subset of 279,442 individuals with high-normal LVEF ≥60%) by sex and increasing quartiles for LV end-diastolic volume (LVEDV), LVEDV indexed to body surface area (LVEDVi), and LV end-diastolic diameter to assess associations with 5-year mortality through linkage with the National Death Index. RESULTS: During approximately 2 million person-years of follow-up, 65,241 deaths occurred. Increasing LV chamber size was associated with reduced odds of 5-year all-cause mortality, particularly for higher LVEF. As compared with the larger quartiles, the smallest cardiac size quartiles were associated with higher 5-year all-cause mortality, even after adjusting for age. The smallest LVEDVi quartile was associated with a 14% to 18% higher odds of 5-year all-cause mortality, with a greater effect with high-normal LVEF. There was a U-shaped relationship between LV chamber size and all-cause mortality. For cardiovascular-related mortality, females in the smallest LVEDVi quartile had a 17% increased odds of mortality, which increased to 30% in those with LVEF ≥60%. In men, there was no significant association between smallest cardiac size and cardiovascular-related mortality. CONCLUSIONS: In individuals with normal LVEF, small ventricular size is associated with increased mortality, particularly among females and those with higher LVEF

Taking the pulse of Timor-Leste's cardiac needs: a 10-year descriptive time-trend analysis

BACKGROUND: Timor-Leste is one of the poorest countries in the world. The East Timor Hearts Fund is a charitable organisation involving Australian cardiologists providing outreach screening and access to cardiac interventions. AIMS: To assess ten years of clinical volume, demographics and patient outcomes. Our intention was to identify existing limitations to facilitate planning for further capacity building over the next decade. METHODS: The East Timor Hearts Fund database was sectioned into 2-year intervals (2009/2010, 2011/2012, 2013/2014, 2015/2016 and 2017/2018). Demographics and clinical outcomes of patients were compared, with subgroup analysis of adult (>18 years old), paediatric and interventional patients. RESULTS: Over 10 years, 2050 patient encounters have occurred; 1119 (54.6%) encounters occurred in 2017/2018; 73.6% of patients were assessed in the capital Dili. Rheumatic and congenital cardiac diseases remain very common (39.1% of adult new patients and 74.2% of paediatric new patients), with 1.4% of new patients exhibiting both pathologies. The number of new patients with rheumatic or congenital heart disease tripled in 2017/2018 compared to 2009/2010 (99 vs 34 patients, P < 0.0001). Paediatric case volume increased over 10-fold over 10 years (288 new patients in 2017/2018 vs 24 in 2009/2010, P < 0.0001), with corresponding increase in proportion of paediatric interventions (59.4% in 2017/2018 vs 25.0% in 2009/2010, P = 0.027). For patients undergoing intervention (n = 87), post-procedural complications and mortality are extremely low (3.4% and 1.1%, respectively), with all eligible patients attending at least one post-procedure appointment. CONCLUSION: Demand for cardiac services in Timor-Leste is rising exponentially, with inequitable geographic coverage. Rheumatic and congenital cardiac diseases remain priorities for assessment, and paediatric case volume is increasing. Patients undergoing intervention experience good medical outcomes