Single coronary artery (SCA) systems are a rare congenital anomaly where one coronary artery arises from a single coronary ostium and provides supply to the entire myocardium. Although typically found incidentally, SCA can have a range of manifestations including angina, syncope and sudden cardiac death (SCD). We present three cases of Lipton classification L-1 SCA admitted with acute coronary syndromes.

Pericarditis/myocarditis is a known adverse reaction of mCV with literature suggesting pericarditis is more likely to occur in middle-aged men later after vaccination whereas myocarditis often affects young men sooner. Pericardial effusion with tamponade is a life-threatening and uncommon complication of pericarditis. This case describes cardiac tamponade as a sequelae of pericarditis attributed to mCV.

Primary cardiac lymphomas are a rare cause of cardiac tumour, accounting for ∼1% of all cardiac tumours. The most common type is diffuse large B cell lymphoma originating in the right heart. They often present with features of right heart failure from obstructive effects, with the mainstay of treatment being surgical resection and chemotherapy. Given their rapid growth and often late presentation, they carry an extraordinarily poor prognosis with a median survival of only a few months.

Anomalous left coronary artery from pulmonary artery (ALCAPA) is a rare congenital abnormality with approximately 10% surviving to adulthood when left untreated. Patients with adult ALCAPA can present with chest pain, arrhythmias, heart failure and sudden cardiac death. We describe the first known case of recurrent cardioembolic strokes from chronic coronary ischaemia secondary to adult ALCAPA. A 34-year-old woman was admitted with syncope while driving, on a background of previous episodes of expressive dysphasia and right arm weakness diagnosed as a transient ischaemic attack 5 years prior. MRI revealed an acute right cortical infarct, with no specific ischaemic changes on ECG, and no evidence of arrhythmias during inpatient telemetry monitoring. Transoesophageal echocardiography showed a hypokinetic anterior wall with thinning and scarring in the left anterior descending (LAD) artery territory, and moderate left ventricular dysfunction. Subsequent coronary angiography demonstrated a dilated right coronary artery with collaterals to the LAD, and retrograde flow from the mid LAD into the pulmonary artery. An aortogram did not reveal any evidence of the left main coronary artery (LMCA) ostia in the aortic sinuses. Left ventriculography also revealed an aneurysmal apex with a filling defect suggestive of thrombus and a CT coronary angiogram confirmed ALCAPA. She was commenced on warfarin for apical thrombus and was referred for coronary artery bypass surgery and LMCA ligation. Patients with untreated adult ALCAPA can experience a range of complications from chronic LMCA and LAD ischaemia, including recurrent cardioembolic stroke from LV thrombus.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Small observational data suggest that in acute coronary syndrome (ACS) patients, left atrial (LA) enlargement can predict adverse outcomes. We sought to assess outcomes associated with LA enlargement in ACS patients from a single tertiary centre in Melbourne. We retrospectively analysed 415 consecutive ACS patients from June 2019 where echo data were available. Patients were grouped by LA volume: normal (LAVN), mild (LAVM) and moderately/severe enlargement (LAVS). We examined in-hospital outcomes, discharge medications and 30-day death. Of the cohort, 51% (n=213) had LAVN, 24.5% (n=101) had LAVM and 24.5% (n=101) had LAVS. Patients with LAVS were older with higher prevalence of prior myocardial infarcts, revascularisation, atrial fibrillation, valvular disease, heart failure (HF) and sleep apnoea. They were less likely to undergo coronary angiography (98.6% vs 97% vs 90.1%, p = 0.001) and had higher rates of LV (p=0.001) and RV dysfunction and moderate to severe MR on echo compared to others (p<0.0001). In-hospital outcomes and discharge medications are shown in the figure. There were no differences in 30-day death (0 vs. 2.0% vs. 2.0%, p=0.21) between the groups. Patients with LAVS had higher incidence of in-hospital HF, arrhythmia, and new renal impairment with lower beta blocker usage at discharge. LA enlargement in ACS patients should be recognised at the time of index presentation to optimise HF therapy post discharge for prevention of adverse events related to HF recurrence and arrhythmias.

Pericarditis/myocarditis have been associated with mCVs, most commonly in males under 30 years old after the second dose, with a variety of aetiologies proposed including immunogenetics and hormonal. This case describes mCV-related myocarditis in identical DCDA twins.

A Bochdalek hernia is a congenital posterior diaphragmatic hernia, usually discovered and repaired during childhood. Although they typically cause gastrointestinal symptoms or respiratory symptoms due to lung compression, cardiac arrhythmias have not been described. We present a case of atrial fibrillation (AF) and ventricular tachycardia (VT) associated with compression from a large recurrent Bochdalek hernia.

Loeffler's carditis is a rare cause of restrictive cardiomyopathy characterised by eosinophil infiltration, thrombus formation and endomyocardial fibrosis. Prompt and targeted treatment can significantly reduce morbidity and mortality; however, this relies on early recognition of underlying cause and cardiac manifestations. We describe a case of Loeffler's carditis in a patient with acute myeloid leukaemia (AML) and unrecognised pre-existing myeloproliferative-hypereosinophilia syndrome (M-HES).

Abstract Introduction The dual antiplatelet therapy (DAPT) score was developed to identify patients more likely to derive benefit (score ≥2) or harm (score <2) from DAPT beyond 1-year post PCI. There is no study which looked at the DAPT score and long term outcomes post PCI in Australia. Purpose We sought to examine long-term mortality after PCI by the DAPT score in patients treated with DAPT per local guidelines. Methods We examined data from the MIG PCI database from 2005 to 2018 in whom the DAPT score could be derived and grouped them as score ≥2 or <2. Long-term mortality was assessed from National Death Index linkage. The primary endpoint was long-term mortality examined using survival analysis. Secondary endpoints included 30-day ischaemic outcomes and in-hospital major bleeding. Results Out of 27,740 patients in the study, 9,401 (33.9%) had DAPT score ≥2. They were younger and included more females and higher prevalence of renal impairment. DAPT score ≥2 patients had higher in-hospital major bleeding, 30-day mortality, MI and target vessel revascularisation. DAPT score ≥2 patients had lower long-term survival to 12 years (p<0.001 for all). Conclusion A third of all-comer PCI patients had DAPT score ≥2 with greater short-term risk of ischaemic and bleeding outcomes, as well as long-term mortality. Theoretically, those with DAPT score ≥2 would benefit from longer duration of DAPT as ischaemic risk outweighs bleeding risk. However, given our finding of increased short-term bleeding risk and long-term mortality, dynamic bleeding risk assessment should be undertaken to guide pharmacotherapy strategies. Funding Acknowledgement Type of funding sources: None.

With the advancement of percutaneous techniques and development of newer generation drug-eluting stents, PCI has become more feasible in patients with either left main or triple vessel coronary artery disease. As such, deciding when to offer PCI over CABG to these patients can be difficult. The development of the SYNTAX Scores (SS) I and II has offered a quantifiable assessment of CAD complexity, and current guidelines (Class IB ESC/EACTS 2018) recommend these should be taken into consideration when deciding revascularisation strategy. Data on the real-world systematic uptake of this however are lacking.

Holidays, sporting and historical events can result in increased physical, emotional and chemical stress that may increase the risk of MI. We examined if STEMIs were more likely to be triggered on important days in Victoria, and whether having STEMI on these days portends a worse prognosis.

Intensive statin therapy reduces death and MACE in patients with CAD, although there is a paucity of evidence within the elderly population. We examined the use of statin therapy and long-term mortality benefits in an elderly population with CAD.

Background: The CSANZ Heart Failure (HF) guidelines state that sodium-glucose co-transporter-2 inhibitors (SGLT2i) are preferred second line agents in patients with type 2 diabetes mellitus (T2DM) and cardiovascular (CV) disease to reduce CV events and HF hospitalisation. Aim: To review glucose lowering therapies in patients with T2DM who had been hospitalised with HF at Austin Health, and the percentage of patients who may be eligible for SGLT2i therapy. Methods: A retrospective analysis of glucose lowering therapies in patients with a discharge diagnosis of HF and T2DM from 1/1/2016 to 31/12/2018. Eligibility for SGLT2i therapy was based on insufficient glycaemic control (HbA1c ≥7%), eGFR ≥30 mL/min/1.73 m2 and age ≥84 years. Results: We identified 1182 patients with T2DM who had a discharge diagnosis of HF, and a reported HbA1c within six months before discharge. After exclusion of patients based on age, eGFR and/or HbA1c, 318 (27%) patients were potentially eligible for SGLT2i therapy. Of these, 36 were on SGLT2i therapy leaving 282/318 (89%) which where not. They had a mean (±SD) age of 70 ± 10 years and HbA1c of 8.6 ± 1.8%. Medication for HF included diuretics (94%), ACEi/ARB (58%), beta-blockers (72%). Patients were on a median of 2 glucose lowering agents including metformin (61%), sulfonylureas (35%), gliptins (23%), GLP-1 analogues (4%), insulin (71%). Conclusion: As many as 89% of eligible patients with T2DM and HF seen in real world clinical practice are not on SGLT2i therapy. We suggest that increasing familiarity and utilisation of SGLT2i may improve cardiovascular outcomes in this high-risk population.

Introduction: Elderly patients presenting with Non-ST-elevation myocardial infarction (NSTEMI) are often admitted under a General Medical Unit rather than a Cardiology Unit. The impact of obtaining a cardiology consultation is unknown. Methods: A single centre retrospective analysis of 763 consecutive patients aged >85 years who presented with a NSTEMI between 2010–2018 was undertaken. Patients were stratified according to whether a cardiology consultation was undertaken. Clinical characteristics, presentation and outcomes were collected through medical records review. The primary outcome was in-hospital mortality Results: Of the 763 patients included, only 274 (35%) had a cardiology consultation. Those receiving a cardiology consultation were more likely to be male, younger and without cognitive or mobility issues (all p < 0.001). Guideline-directed medical therapy (GDMT) with aspirin, statin and beta-blockers was also more likely on patients who had cardiology consultation (p < 0.001). On multivariable logistic regression, after adjusting for age, gender, mobility status and cognitive impairment, a cardiology consult was associated with improved in-hospital mortality (OR 0.56, 95%CI 0.36–0.88, p = 0.01). However, when the same model was adjusted for GDMT, the association was no longer significant (OR 0.65 95%CI 0.41–1.03, p = 0.07). Conclusion: Very elderly patients presenting with NSTEMI and admitted under a general medicine unit less often received a cardiology consult. Cardiology input was associated with higher uptake of GDMT and improved outcome. Cardiology input should be sought in the management of very elderly patients with NSTEMI

Introduction: Mobility limitations are common in the elderly and contribute significantly to frailty. The impact of mobility status on long-term outcomes in elderly patients with NSTEMI is unknown. Methods: A retrospective analysis included 956 consecutive patients aged >85 years presenting with NSTEMI between 2010–2018. Mobility status was classified as independent, single point stick (SPS), 4-wheel frame (4WF) or wheelchair dependent. Guideline-directed medical therapy (GDMT) included aspirin, beta-blockers and statins. The primary outcome was all-cause mortality. Results: Of 956 patients, 304 (33.7%) had independent mobility, 161 (17.9%) used a SPS and 402 (44.6%) used a 4WF. GDMT adherence did not vary significantly between the SPS and independent groups. However, adherence to GMDT was significantly lower in 4WF users (p < 0.001). Independent patients had higher rates of coronary angiography (19.5% vs 10% SPS vs 2% 4WF, p < 0.001) and had improved long-term survival (HR 0.68, 0.55–0.84, p < 0.001). SPS users did not experience reduced long-term survival (p = 0.3, whereas 4WF users had significantly greater long-term mortality (HR 1.5, 1.2–1.9, p < 0.001). This risk remained significant, albeit reduced (HR 1.3 1.1–1.7, p = 0.02) after Cox-proportional hazard modelling. Conclusion: There is an association between mobility status and prescription of GDMT and coronary angiography in elderly patients. Using a 4WF, but not a SPS, was associated with higher mortality.

Introduction: Studies have shown that older patients are less likely to be admitted into specialised cardiology units. It is uncertain whether admission under cardiology leads to more aggressive management and potentially improved outcomes. Methods: In this retrospective analysis, 956 consecutive patients aged >85 years presenting with a non-ST elevated myocardial infarction (NSTEMI) between 2010–2018 were included. Patients were stratified based on whether they were admitted under cardiology or another unit. The primary outcome was all-cause mortality. Results: Out of the 956 patients, only 185 (19.4%) were admitted under cardiology unit. The remaining patients were admitted under either a general medical unit (71%) or a surgical unit (9.6%). Patients admitted under cardiology were more likely to be younger and less likely to have cognitive or physical impairments (all p < 0.001). They were also more likely to receive guideline directed medical therapy (GDMT; aspirin, statin, beta-blocker) and undergo invasive coronary angiography (46% vs 1%, p < 0.001). Long-term mortality was significantly lower in patients admitted under cardiology (HR 0.39 95%CI 0.29–0.52, p < 0.001) and this remained significant after adjusting for demographics, mobility aids, cognition, living status, coronary angiogram and medication use (HR 0.63 95%CI 0.44–0.92, p = 0.01). Conclusion: Patients admitted under a cardiology unit received a higher rate of medical therapy and invasive management. A combined cardio-geriatric unit may help stratify a larger proportion of patients who may benefit from aggressive management of NSTEMI.

Introduction: There is a paucity of data regarding the presentation, management and the long-term outcomes of very elderly patients who suffer from a type II myocardial infarction. Methods: A single-centre retrospective analysis of 956 consecutive patients aged >85 years presenting with NSTEMI between 2010–2018 was undertaken. Patients were stratified by type I vs Type II MI as defined by the 4th Universal Definition of MI. The primary outcome was all-cause long-term mortality ascertained by review of electronic medical records. Results: Mean age of the cohort was 89 ± 3 years and 43.8% were male. Of the 956 patients included, 477 (50%) suffered a type II MI. The predominant presentations of patients presenting with type II MI included delirium (34.3%), sepsis (18.4%), non-cardiac surgery (8.5%) and bleeding/anaemia (6.7%). Those with Type II MI were less likely to undergo invasive coronary angiography (2.5 vs 17.0%, p < 0.001) and less likely to be prescribed aspirin (77 vs 84%) although rates of statin use were higher (78 vs 69%, p < 0.001). In-hospital mortality was significantly higher in those with type II MI (21.1 vs 13.5%, p = 0.002). Over a mean follow-up of 1.3 years, 444 patients died (46.4%). Despite higher in-hospital mortality, on multivariable Cox-regression, Type II MI was not significantly associated with higher long-term mortality (adjusted HR 1.1 95%CI 0.8–1.2, p = ns). Conclusion: Type II MI is common in elderly patients and confers a high risk of in-hospital mortality. At present, there is a lack of evidence to risk stratify and guide treatment in this population.

Background: The ACC/AHA coronary lesion classification was developed to quantify lesion complexity and has became a predictor of procedural success. The long-term prognostic significance of percutaneous coronary intervention (PCI) to complex coronary lesions in stable coronary artery disease is unknown. We aim assess whether PCI to complex lesions is associated with higher long-term mortality. Methods: Clinical and procedural characteristics of 682 consecutive patients with stable coronary artery disease (CAD) who underwent elective percutaneous coronary intervention (PCI) between May 2007 and January 2011 were prospectively collected. All patients were dichotomised as either simple (A and B1) or complex (B2 and C) based on the ACC/AHA classification of the lesion undergoing PCI. The primary endpoint was all-cause mortality determined via the Australian National Death Index. Results: Of the 682 patients, 287 (42%) underwent PCI to a complex lesion. There was no significant difference in baseline clinical characteristics between the groups. In the complex PCI group there were 67 (24%) bifurcations, 63 (22%) chronic total occlusions and 30 (11%) ostial lesions. Complex lesions were associated with significantly lower procedural success (94.1% vs. 99.2%, p<0.01). At mean follow-up of 5.5 years, there were 35 (12.2%) deaths in the complex PCI group and 41 (10.4%) in the simple PCI group (log-rank p=0.31). Conclusion: Complex coronary lesions are associated with lower PCI success rates, even in the contemporary PCI era. However, patients with complex lesions do not appear to have higher long-term mortality.

Background: Guidelines mandate urgent revascularisation and proven therapies in patients presenting with STEMI irrespective of age. We aim to describe clinical characteristics and predictors of improved survival in elderly patients presenting with STEMI. Methods: Consecutive patients from the Melbourne Interventional Group Registry who presented with STEMI and underwent primary PCI between 2005 and 2014 were included. Patients who were aged <75 years were included in the "young" group, those aged 75-84 years were included in the elderly group, and those ≥85 years were included in the very elderly group. The primary end-point was 12-month mortality. Multivariate analysis was undertaken to determine independent predictors of mortality Results: Of the 2,972 eligible patients, 2,307(77.6%) were "young", 495(16.7%) were elderly and 170(5.7%) were very elderly. There was a significant decrease in DTBT from 2005 to 2014 in young and elderly patients (p-for-trend <0.01 and 0.03), but not in very elderly patients (p=0.07). There was a significant difference in utilisation of GPIIb/IIIa-inhibitors (76% vs. 70% vs. 50%) and drug-eluting stents (DES) (42% vs. 34% vs. 24%) between the three groups respectively (both p<0.01). There was a respective significantly higher rate of 12-month mortality (3.6% vs. 10.7% vs. 29.4%, p<0.01). Multivariate analysis showed GPIIb/IIIa-inhibitors (OR 0.61, 95% CI 0.39-0.9, p=0.04) and DES use (OR 0.61, 95% CI 0.37-0.99, p=0.04) were independent predictors of improved 12-month mortality. Conclusion: A greater effort to increase the use of proven therapies, such as GPIIb/IIIa-inhibitors and DES, has the potential to improve survival in very elderly STEMI patients undergoing PCI.