Rural versus metropolitan ST elevation infarction (STEMI) patients experience delays to care [1]. Existing NSW protocols only divert patients within 90 minutes to percutaneous coronary intervention (PCI) sites. In 2019, Western NSW Local Health District (WNSWLHD) and NSW Ambulance (NSWA) extended this range by implementing a fully centralised management system (CMS), with immediate hot transfer, for all STEMI patients to a PCI centre, covering a vast area of 250,000 km2.

Rural, versus metropolitan, Australians have higher cardiovascular mortality, driven by risk profile differences and reduced timely access to care for ST elevation myocardial infarction (STEMI) [1,2]. In 2019, a centralised management system (CMS), with routine, immediate hot transfer of STEMI patients to a PCI centre, was implemented in Western NSW Local Health District (WNSWLHD).

Acute myocarditis (AM) is uncommon but may be associated with significant acute deterioration, requiring emergency high-level tertiary level care. We therefore sought to examine the contemporary management of myocarditis presenting to a rural referral centre, comparing this to a recently proposed "risk-based approach" [1], providing a framework based on risk of deterioration, to help select those requiring transfer for tertiary level care.

Regional Australians have a higher rate of cardiovascular disease and excess mortality for AMI. This has been driven by diminished timely access to cardiac catheterisation. Orange Health Service (OHS) has developed cardiac catheter services in Western NSW LHD, an area of 276,000 km2. Starting as a diagnostic lab in 2005, the service has developed to an FFR/IVUS capable lab providing 24/7 PCI, supporting a centralised smartphone linked acute ECG reading Cardiology service and prehospital lysis for remote STEMI patients. The development of the service, percentage of patients managed in area and improvements in 30 day AMI mortality are described. Database interrogation was conducted within the OHS cardiac catheter unit database and within NSW Bureau of Health Information (BHI) 30 day AMI mortality reports. Total number of cardiac catheterisation rose (835 in 2007 to 1727 in 2019), PCI from 172 in 2007 to 576 in 2019. PCI for STEMI rose from 29 in 2009 to 208 in 2019 and by 2019 89.4% of all ACS were fully managed within the LHD. NSW BHI data showed a drop in 30 day AMI mortality from 7% in 2009- 12 to 4.8% in 2015-18 which was below the NSW average of 5.9%, with OHS being the 7th busiest catheter lab in NSW for AMI with a risk stratified mortality ratio(RSMR) of 0.91 indicated below expected deathrate for casemix. A rural cardiac catheter service providing a centralised STEMI service and 24/7 rescue PCI in a large geographical area, supported by IT and centralised transport systems, can reduce 30 day AMI mortality in a high risk population. Methodologies are applicable to other rural settings.

Patients from rural areas carry a high burden of cardiovascular (CV) risk factors [1Kotwal S, Ranasinghe I, Brieger D, Clayton P, Cass A, Gallagher M. Long-term outcomes of patients with Acute Myocardial Infarction presenting to regional and remote hospitals. Heart Lung Circ. 2016 Feb;25(2):124-131.Google Scholar, 2AIHW Heart Stroke and vascular diseases July 2018.Google Scholar, 3Bureau of Health InformationMortality following hospitalisation for seven clinical conditions, July 2015–June 2018. BHI, Sydney (NSW)2019Google Scholar]. Rural STEMI patients presenting to non PCI-capable sites have a 21% higher mortality at 18 months [[4]Breiger DB, Chew DP, Redfern J, Ellis C et al MJA Nov 2015 Survival after an acute coronary syndrome:18 month outcomes from the Australian and New Zealand SNAPSHOT ACS Study.Google Scholar]. Orange Health Service (OHS) has provided a centralised cardiology service and rescue PCI to WNSWLHD, spanning an area roughly 250,000km2, since 2015. A retrospective, analysis was conducted of rates of PCI for ACS within WNSWLHD throughout 2015-19. LHD performance in BHI 30 day AMI mortality reports were examined. Cardiac catheterisation increased (1367 in 2015 to 1727 in 2019). Percentage of locally managed ACS cases rose from 84.1% (n=614) in 2015 to 89.4% (n=981) in 2019. STEMIs rose from 163 in 205 to 208 in 2019, with a larger percentage admitted directly to the PCI centre. (65% 2015-18; 45% 2012-15; 26% 2009-12). The BHI 2015-18 report showed OHS managed 1298 AMIs, the 7th highest lab volume in NSW. Mortality remained below state average (OHS 4.8%; NSW wide 5.9%). The risk-standardised mortality ratio (RSMR) of 0.84 (<1.0) indicated lower than expected mortality for casemix. This compares to 894 AMIs 2012-2015 (mortality 4.7% (RSMR 0.84)) and 470 AMIs 2009-2012 (7% mortality (RSMR 0.95)). The 24/7 ECG reading and rescue-PCI service, has led to increased volume and complexity of cardiac catheterisation for AMI at OHS with an increasing percentage of patients managed within WNSWLHD. This has been achieved safely, with decreasing BHI 30 day mortality corrected for casemix, driven by centralisation of STEMI management.

Takotsubo’s cardiomyopathy and spontaneous coronary artery dissection (SCAD) are important non-atherosclerotic causes for acute coronary syndrome (ACS) to consider in young people presenting with ACS. They share similar epidemiological features (younger age of onset and female preponderance) and are thought to be driven by similar hormonal/ sympathetic pathways. Despite this, there have been few cases where both SCAD and Takotsubo presented together. A 56 year old woman presented to a regional hospital with an inferior ST segment elevation myocardial infarct. She was a distant ex-smoker, and had well controlled hypertension. Cardiac troponins were elevated to 13,557 ng/L. She proceeded to have trans-thoracic echocardiography (TTE) which demonstrated moderate apical hypokinesis and ballooning. Coronary angiography noted severe tubular stenosis to the distal left circumflex artery. The left ventriculogram showed pathognomonic findings of Takotsubo’s cardiomyopathy with apical ballooning and hyperdynamic basal function. Medical management was commenced, with the use of dual antiplatelets, cardioselective beta- blockers, and angiotensin converting enzyme inhibitors. Repeat coronary angiogram 4 weeks following initial presentation demonstrated resolution of her SCAD findings and apical ballooning syndrome. This case describes a rare presentation of concomitant SCAD and Takotsubo cardiomyopathy, describing our management approach to this presentation and its effective outcome. The case highlights similarities in the underlying pathophysiology of these conditions and raises questions to be addressed in future studies.

Background: Limited data exist examining TCM in rural populations. Objective: To examine the current features of TCM in a single, rural, tertiary referral centre. Methods: Retrospective database analysis of all patients undergoing angiography with TCM in 2018 at Orange Health Service, NSW. Results: 35 patients with TCM were identified, from 1580 diagnostic procedures. Incidence was 13/100,000 population/year. Mean age = 71 (±11). N = 32 (91%) were female. Physiological stressors were present in n = 16 (46%), emotional triggers in n = 12 (34%), of which major grievance (family death/illness) occurred in n = 7 (58%). Males (n = 3) had exclusively physiological stressors. Chest pain was present in n = 24 (69%). Mean initial Ejection Fraction was 39% (n = 26). N = 30 (86%) patients had an Inter-TAK score of >40, with those ≤40 (n = 5) all diagnostic of TCM by imaging. “Classical” apical TCM accounted for n = 26 (76%) with midventricular (n = 4, 12%), focal (n = 3, 9%) and basal (n = 1, 3%) variants. Eight (23%) patients had a prior cancer diagnosis, with 1 patient having prior chemotherapy. N = 16 (46%) patients had prior neurological or psychiatric diagnoses. N = 11 (31%) patients experienced significant complications, including systemic embolism (n = 5) and acute pulmonary oedema (n = 4). N = 28 (80%) patients had an admission <10 days. In all cases of >10 day admission (n = 7), this was secondary to the initial physiological stressor. 33/35 patients (94%) returned to premorbid function. Conclusions: TCM in this rural population is common, and associated with significant acute morbidity but high recovery rates, comparable to previous reports. Recently suggested associations with prior cancer - though not chemotherapy - appear reflected in this population.

A case is described in which the short-acting glycoprotein IIb/IIIa receptor antagonist tirofiban was used in combination with heparin, aspirin and prasugrel to successfully treat extensive intracoronary thrombus in a delayed presentation STEMI, illustrating the utility of this approach.

Background: Transradial cardiac catheterisation is rapidly becoming preferred over the femoral approach. However, some studies have shown that it leads to persistent functional impairment of the artery. We aimed to assess changes in radial artery endothelial function after transradial catheterisation and determine whether intravenous nitroglycerin (IV GTN) infused during angiography might improve arterial dysfunction post-angiography. Methods: Patients undergoing diagnostic coronary angiography were invited to participate. Doppler ultrasound assessment of radial artery function was performed using flow-mediated dilation (FMD) prior to angiography. FMD tests endothelial function by measuring the degree of arterial dilatation following inflation of a pneumatic cuff for 5 min. Patients were then randomised (1:1) to IV GTN (10mcg/min, commenced 10 min prior to radial access) or placebo. Radial artery FMD was reassessed 4 hrs and 1 month post-angiography. Results: 27 patients (intervention n = 14, placebo n = 13) underwent transradial catheterisation. FMD decreased markedly from baseline to 4 hrs in both groups (intervention 12.9 to 7.5%, p = 0.025; placebo 14.7 to 8.1%, p = 0.035). At one month FMD had returned towards baseline with no significant difference in either group. The reduction in FMD was numerically less in the intervention group than the placebo group at both time periods (baseline to 4 hrs and baseline to one month), although these results did not meet statistical significance. Conclusion: Transradial cardiac catheterisation causes transient endothelial dysfunction which is not ameliorated by GTN. This endothelial dysfunction is fully reversible at one month.

Background: With the majority of surgically implanted aortic valves now being bioprosthetic, the number of patients presenting with degenerative bioprostheses is increasing. Re-do surgical aortic valve replacement (SAVR) remains the standard of care, but entails higher operative risk. Transcatheter aortic valve-in-valve (ViV) implantation is emerging as a favourable treatment option, although experience is limited. We report procedural and midterm outcomes of ViV implantation across two centres. Methods: All patients who underwent aortic ViV implantation at Royal Prince Alfred and Macquarie University Hospitals between 2013-2016 were identified. Data was obtained from medical records and transcatheter heart valve databases and recorded according to VARC-2 criteria. All imaging studies were reanalysed. Patient follow-up was conducted via phone interviews. Results: 10 patients underwent aortic ViV implantation (median age 83yrs, 60% male, mean STS 9.9%, NYHA class III-IV). Types of SAVR failure were stenosis(n = 5), mixed(n = 3) and regurgitation(n = 2). All patients had successful deployment of a transcatheter aortic ViV using a self-expanding device (Medtronic CoreValve n = 5, CoreValve Evolut R n = 5). One patient required deployment of a second CoreValve due to malposition of the first. There were no periprocedural deaths, myocardial infarcts, strokes, heart block or device embolisations. One patient had a major bleed from a femoral artery pseudoaneurysm. Valvular/paravalvular aortic regurgitation was absent-mild in nine patients and moderate in one. Average hospital stay was 9days. The 30-day, 6-month and 1-year mortality was 0%. Mean follow-up was 19months. Conclusions: Transcatheter aortic ViV implantation is a safe and effective strategy for treating degenerative aortic bioprostheses in high risk patients.

Introduction: Giant cell myocarditis (GCM) is an exceedingly rare cause of fulminant myocarditis with a very poor prognosis. We report a case of GCM in which mechanical circulatory support was used as a bridge to transplantation. Case Presentation: A previously well 40yo Caucasian woman presented to ED with three weeks of breathlessness and pleuritic chest pains. She was afebrile, tachycardic and normotensive. Her JVP was elevated and she had mild pedal oedema and muffled heart sounds. ECG showed sinus tachycardia with inferolateral T-wave inversion and low-voltages. CXR was congested and showed cardiomegaly. Blood tests revealed elevated troponins and deranged LFTs. TTE showed LVH, moderately impaired systolic function and a large pericardial effusion. Several investigations into the aetiology of her cardiomyopathy were performed. Coronary angiography and autoimmune serology were normal. Cardiac MRI demonstrated diffuse abnormal myocardial signal on T2 with late gadolinium enhancement. Transcatheter myocardial biopsy demonstrated a florid inflammatory infiltrate of lymphocytes, eosinophils and multinucleated giant cells with associated myocyte necrosis, consistent with GCM. The patient deteriorated and was commenced on IV methylprednisone and a VA ECMO circuit was established prior to transfer to the NSW transplant centre. The patient underwent implantation of a biventricular assist device as a bridge-to-transplant, however, whilst awaiting transplant she died from multi-organ failure. Conclusion: This case highlights many key features of GCM: it occurs in young adults, presents with heart failure, is diagnosed on myocardial biopsy and has a terrible prognosis. Mechanical circulatory support has an emerging role as a bridge-to-transplantation for these patients.

Background: Orange is a regional base hospital servicing a rural population of 270,775 people across 250,000km2. It offers 24/7 rescue PCI to support pre-hospital and in-hospital thrombolysis across the LHD. Additionally, PPCI is offered for patients presenting directly or by ambulance diversion to Orange within business hours and for lytic ineligible patients presenting anytime within the LHD. Methods: A retrospective audit of patients who underwent PPCI and rescue PCI at Orange Hospital from 1/1/15-31/12/15 was performed. Patients were identified using audits and medical records. Results: PPCI was performed for 22 patients: 17 presented in-hours and 5 presented out-of-hours but had a contraindication to lysis. The median door-to-balloon (DTB) time was 52min (see table). DTB times were shorter for patients who had their diagnostic ECG performed by paramedics using the LIFENET system compared to by ED (median DTB time 35min versus 74min). Rescue PCI was required in 32 of the 104 patients who were thrombolysed in 2015 (31%). The majority (68%) of rescue PCI cases were performed outside business hours (0800-1700 weekdays). Mean transport time to Orange hospital was 75+/-48min and mean transport distance was 131km. Median DTB time was 70min (see table).Tabled 1DTB time0-30min30-60min60-90min>90minPPCI (%)11442817Rescue PCI (%)19192537 Open table in a new tab Conclusion: Orange Hospital has demonstrated the feasibility of a 24/7 primary and rescue PCI service operating within a rural setting. Better systems of transport and ambulance diversion to the PPCI centre will expand the benefits of this service.

Background: Rural STEMI patients have lower rates of reperfusion and higher mortality compared to their metropolitan counterparts, in part due to the large distances and resource limitations of rural NSW. We aimed to review the contribution of patient delays in accessing timely reperfusion. Methods: A retrospective audit of STEMI patients within Western NSW LHD in 2015 was undertaken. Comparisons were made with NSW ambulance data on metropolitan STEMI patients from a single month in 2012. Results: 150 patients were diagnosed with STEMI in 2015. Of these, 49% called an ambulance and 51% presented directly to ED. For patients calling an ambulance, the median symptom-onset-to-call time was 34 min, compared to 66 min for metropolitan patients. Symptom onset to first clinical contact (FCC) was significantly longer for rural patients presenting direct to ED (median 110min) compared to those presenting via ambulance (median 72min)(p=0.037). Mean FCC time to lysis for rural ambulance was 44+/-26 min versus 60+/-33 min for ED (p=0.02). FCC was outside the thrombolysis window (12hrs) in 9% of rural patients, compared to 4% in metro patients.Tabled 1Table: Symptom onset to FCC according to mode of presentation and locationSymptom onset to FCC0-30min30-60min60-90min>90minMetro Ambulance(%)25161346Rural Ambulance(%)31171735Rural ED(%)2113956 Open table in a new tab Conclusion: The majority of rural STEMI patients do not call an ambulance, delaying care and preventing access to pre-hospital thrombolysis. Strategies to reduce these delays are vital to address disparities in clinical outcomes for rural patients.

Background: Rural compared to metropolitan STEMI patients have a higher mortality. Western NSW LHD implemented the State-wide Cardiac Reperfusion Strategy for pre-hospital thrombolysis (PHT) in 2014. Cardiologists confirm ECGs meet STEMI-criteria and paramedics then administer thrombolysis. LIFENET ECG transmission is also available within all non-base hospitals throughout the LHD. We hypothesised that PHT and use of LIFENET would achieve shorter first-contact-to-needle (FCTN) times than in-hospital thrombolysis (IHT). Methods: We retrospectively analysed data on all STEMI patients who underwent thrombolysis within the Western NSW LHD in 2015. Results: 104 patients were thrombolysed for STEMI, with 65 successfully reperfusing. First medical contact was with paramedics in 46% of cases and with ED in 54%. Paramedics administered thrombolysis in 28% of cases and ED in 72%. Overall, mean FCTN time was 55+/-32 min (Table 1). The mean FCTN time for PHT was significantly less than for IHT (44+/-26 min versus 60+/-33 min; p=0.02). There was a non-significant trend towards shorter FCTN times for patients presenting to small rural hospitals whose diagnostic ECG was sent via LIFENET involving early cardiologist input as compared to routine care (55+/-30 min versus 58+/-38; p>0.05).Tabled 1FCTN time0-30min30-60min60-90min>90minPHT(%)275977IHT(%)19411921 Open table in a new tab Conclusion: PHT has achieved shorter FCTN times than IHT within the LHD. Expansion of the LIFENET system with early cardiologist input has scope to further improve FCTN and reduce mortality for rural STEMI patients.