BACKGROUND:Rural vs metropolitan ST-elevation myocardial infarction (STEMI) patients experience delayed access to percutaneous coronary intervention (PCI). Existing New South Wales (NSW) Statewide Cardiac Reperfusion Strategy protocols provide thrombolysis and ambulance diversion for patients within 90 minutes of a PCI centre in regional and rural NSW. Rural patients presenting to non-PCI hospitals and those more than 90 minutes from PCI are not routinely, urgently, diverted under existing protocols. METHOD:Western NSW Local Health District, covering 250,000 km2 and a population of 278,759, implemented a centralised management system (CMS) in 2019, in partnership with NSW Ambulance, utilising existing STEMI thrombolysis protocols and extending "drip and ship" protocols for "hot transfer" of all patients to the 24/7 PCI centre, by direct ambulance diversion up to 120 minutes by road, or via multi-stage transfer by road or air, or via interhospital transfer. Data for 2 years post-CMS was compared to historical controls. Time from first clinical contact (FCC) to reperfusion, FCC to PCI centre, major adverse clinical events and percentage of patients undergoing angiography within 24 hours were compared in "medium" (90-120 minutes) and "long" (>120 minutes) transfer zones, not covered by existing protocols. RESULTS:Outcomes were recorded for 274 patients before and 348 after CMS implementation (17% medium and 31% long transfer zones). Medium and long transfer zones had greater proportions of smokers and Indigenous patients than short transfer zones. There was significantly lower ambulance utilisation in the long (38%) compared with the short transfer zone (55%, p<0.001). In the long transfer zone, there were significant improvements in FCC to reperfusion (40 vs 48 minutes, p<0.05), FCC to PCI centre (296 vs 344 minutes, p<0.01), and angiography in 24 hours (77% vs 58%, p<0.01), with no significant differences in major adverse clinical events. CONCLUSIONS:A rural STEMI CMS, with "hot transfer", can deliver patients from a vast geographical area directly to a rural PCI centre. Patients furthest away, with the greatest risk profile, benefit the most. Extension of this program and development of 24/7 PCI in NSW rural cardiac hubs stands to improve timely, definitive treatment, including access to angiography within 24 hours.

Current European, American and Australasian guidelines recommend revascularisation for acute ST elevation myocardial infarction (STEMI) by immediate or "primary" percutaneous coronary intervention (pPCI), or if pPCI cannot be performed within 120 minutes, by thrombolysis followed by rescue PCI. This latter approach, despite its limitations, remains a cornerstone of STEMI care in rural and remote settings, where pPCI is not immediately available, and where one-third of the Australian population live. This review evaluates the current status of thrombolysis and rescue PCI in rural and remote settings, examines the multiple changes that have occurred since its inception, and highlights persisting gaps in knowledge, to provide an up-to-date evaluation of this field, and an outlook for future directions, in this area of ongoing change.

BACKGROUND:At a global level, regional variation in the management of ST-elevation myocardial infarction (STEMI) is influenced by patient demographics and geography. Rural patients with STEMI are disadvantaged in reaching timely care owing to distance and limited ambulance and healthcare resources. Optimising models of STEMI care is key to overcoming the excess rural vs metropolitan cardiovascular morbidity and mortality. In this descriptive study, we compare patient characteristics and STEMI management in three Local Health Districts (LHDs) across NSW: a rural LHD (Western NSW [WNSWLHD]), a regional LHD (Hunter New England), and a metropolitan site (Sydney LHD). METHOD:Data were collected from file audits conducted from 2019 to 2020 in a rural LHD with a single rural 24/7 cardiac catheter laboratory (WNSWLHD), a regional LHD with a part-time rural cardiac catheter laboratory, and a large regional 24/7 cardiac centre (Hunter New England LHD), and a metropolitan site (Sydney LHD), with two 24/7 cardiac centres. Patients with STEMI presenting in the three geographic regions were compared on demographics, differences in presentation, time to reperfusion treatment, time to percutaneous coronary intervention (PCI) centre, distances travelled, proportion of angiograms within 24 hours, and in-hospital mortality. RESULTS:During 2020, there were 675 recorded STEMI across the three regions. The rural site in WNSWLHD had the highest rate of STEMI per capita, with patients more likely to identify as Indigenous, less likely to call an ambulance, and more likely to present to a non-PCI hospital and to receive thrombolysis. Only 14% of these rural patients received primary PCI (PPCI), with patients presenting a median of 153 km from the PCI centre, vs 69% PPCI in the regional and 89% in metropolitan LHD. Thrombolysis was the main reperfusion treatment in WNSWLHD (76%), and the proportion of patients receiving no treatment was the same in all LHDs at 10%. The percentage of patients receiving angiography within 24 hours in the rural site was 84%. There was no substantial difference in in-hospital mortality among the three LHDs. CONCLUSIONS:We document large differences in the demographic profiles, use of ambulance, and access to PPCI in patients with STEMI across the three NSW centres. Current NSW health and ambulance protocols in a large, sparsely populated rural NSW LHD were able to deliver thrombolysis at the point of contact and facilitate "hot" transfer of patients with STEMI to a PCI centre. Long distances and transfer times mean that PPCI is a limited option in rural NSW, with scope for further improvement in models of care.

Background Cardiac Society of Australia and New Zealand (CSANZ) guidelines recommend elective high-risk percutaneous coronary intervention (PCI) is not performed in sites greater than 1 hour from cardiac surgery. Methods In hospital outcomes for all patients from Orange Health Service (OHS) from January 2017 to January 2020 who were transferred electively to tertiary centres in Sydney for high risk PCI were examined. Results One hundred and fourteen (114) patients were identified, with 1,259 PCIs performed at OHS over the same period without transfer. The mean age of these 114 patients was 71 years, with 74.6% male. Receiving hospitals were Royal Prince Alfred Hospital, Sydney, NSW (66.7%), Concord Repatriation General Hospital, Concord, NSW (19.3%) and Strathfield Private Hospital, Strathfield, NSW (14%). The definition of high risk and indication for transfer included at least one of: moderate or greater calcification of the target lesion or proximal segment (34%), single or multiple target lesions that in aggregate jeopardised over 50% of remaining viable myocardium (27%), degenerated saphenous vein grafts (14.8%), chronic total occlusions (7.0%) and severe left ventricular (LV) impairment (3.9%). American Heart Society/American College of Cardiology (AHA/ACC) lesion types were A (1%), B1 (4.2%), B2 (40.2%), and C (54.6%). PCI was performed via the femoral route in 96.2%. The mean procedure duration was 72 minutes, mean combined fluoroscopy time was 19 minutes and mean radiation dose as defined by Reference Air Kerma was 1,630 mGy. Complications occurred in 13 patients and were: acute vessel dissection requiring stenting (4), perforation (2), acute vessel closure (4), puncture site related (1), and life threatening arrhythmia (2). There were no cases of emergent coronary artery bypass graft (CABG) or death. Conclusion This contemporary cohort of high-risk patients transferred electively from a regional PCI centre to a tertiary cardiac unit underwent lengthy PCI procedures, with high radiation doses, and a modest rate of peri-procedural complications, but had otherwise excellent procedural and clinical outcomes.

Background: 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.The Case: 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.Importance of this Study: 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.

The Challenges Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors. The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations, and people with known CVD have increased morbidity and mortality from coronavirus disease 2019 (COVID-19). In addition, COVID-19 is associated with serious cardiac manifestations, potentially placing additional demand on limited regional services at a time of diminished visiting metropolitan support with restricted travel. Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity. Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic. Main Recommendations Health districts, cardiologists and government agencies need to minimise impacts on the already vulnerable cardiovascular health of regional and remote Australians and New Zealanders throughout the COVID-19 pandemic. Changes in management should include: Improved access to telehealth consultation for regional and rural outpatients. Specialist-led 24/7 electrocardiograph (ECG) reading and acute cardiology services, uniformly covering all rural inpatients, to minimise potential impacts on acute care. Transfer models incorporating discussion between clinicians and ambulance, balancing urgency with considerations of ambulance capacity in rural locations. Protection of the role of specialist cardiovascular nurses, avoiding COVID-19 redeployment to maintain rural cardiac service capacity. An urgent shift to regional models for pacing services, utilising remote monitoring supported by local device implantation and local technicians.

Australian rural populations suffer high rates of acute coronary syndromes, coupled with poor outcomes [ [1] Kotwal 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; 25: 124-131 Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar ]. The incidence and outcomes of the related condition of Takotsubo cardiomyopathy (TCM) in Australian rural populations is unknown.

BACKGROUND Sudden death during sport is a rare but devastating event. Previous research has mostly focused on sudden deaths in young competitive athletes. OBJECTIVE The purpose of this study was to characterize the demographics and etiologies of sudden cardiac death during sport in Australia. METHODS All autopsies conducted at our forensic medicine facility between 2006 and 2015 inclusive were reviewed. Sporting-related deaths among those 7-65 years of age were identified. Data collected included subject height, weight, gender, circumstances of death, and pathologic findings at autopsy. RESULTS A total of 19,740 autopsies were completed in the study period: 12,395 in subjects age 18-65 years (adults) and 385 in subjects age 7-17 years (children). There were 201 sports-related adult deaths at an incidence rate of 0.76-1.49 per 100,000 participant-years. Of the deaths, 74% were witnessed. Of the adult cases, 68% (n = 136) were due to cardiac causes, with coronary artery disease the most frequent cause (n = 90 [45%]). Structural abnormalities were common in adult cardiac deaths; 51 (38%) had cardiac weight >= 500 g, and 75 (55%) had left ventricular wall thickness >15 mm. Of the 15 child deaths, 5 (33%) were arrhythmogenic or presumed arrhythmic, and 5 (33%) were inherited cardiomyopathies (2 hypertrophic cardiomyopathy, 3 arrhythmogenic right ventricular cardiomyopathy). CONCLUSION Sudden cardiac death during sport is rare. Deaths are mostly due to coronary artery disease in adults and cardiomyopathy or arrhythmia in children. Because the majority of sports deaths are witnessed, they present an opportunity to enhance outcomes by cardiopulmonary resuscitation training and increased availability of automated external defibrillators at sports venues.

Aims MicroRNAs (miRNAs) are transported on high-density lipoproteins (HDLs) and HDL-associated miRNAs are involved in intercellular communication. We explored HDL-associated miRNAs concentration gradients across the coronary circulation in stable and unstable coronary artery disease patients and whether changes in the transcoronary gradient were associated with changes in HDL composition and size. Methods Acute coronary syndrome (ACS, n = 17) patients, those with stable coronary artery disease (stable CAD, n = 19) and control subjects without CAD (n = 6) were studied. HDLs were isolated from plasma obtained from the coronary sinus (CS), aortic root (arterial blood) and right atrium (venous blood). HDL-associated miRNAs (miR-16, miR-20a, miR-92a, miR-126, miR-222 and miR-223) were quantified by TaqMan miRNA assays. HDL particle sizes were determined by non-denaturing polyacrylamide gradient gel electrophoresis. HDL composition was measured immunoturbidometrically or enzymatically. Results A concentration gradient across the coronary circulation was observed for all the HDL-associated miRNAs. In ACS patients, there was a significant inverse transcoronary gradient for HDL-associated miR-16, miR-92a and miR-223 (p < 0.05) compared to patients with stable CAD. Changes in HDL-miRNA transcoronary gradients were not associated with changes in HDL composition or size. Conclusion HDLs are depleted of miR-16, miR-92a and miR-223 during the transcoronary passage in patients with ACS compared to patients with stable CAD.

We report a case of asceptic sialadenitis that occurred in a patient with end-stage renal failure following administration of iodinated contrast for coronary and carotid angiography. This is a rare but important complication of iodinated contrast. Early diagnosis of iodide mumps following angiography avoids unnecessary investigations and treatment. In this case the patient underwent haemodialysis with subsequent complete resolution of the sialadenitis, a treatment that has previously not been reported for this condition.