Background: Out-of-hospital cardiac arrest (OHCA) is the leading cause of cardiovascular mortality with ~10% survival rates. The 24-hour lactate area under the curve (lactate AUC₀-₂₄) integrates both magnitude and duration of hyperlactataemia, and may be a more robust prognostic marker compared to traditional markers.Methods: We analysed data from consecutive adults admitted after resuscitated OHCA with an initial shockable rhythm to two large health services in Melbourne, Victoria, Australia (Western and Alfred Health) between 2014–2024. Serial lactate values over 24 hours post admission were integrated using the trapezoidal method to calculate lactate AUC₀-₂₄ and compared to admission lactate for the prediction of in-hospital mortality.Results: Among 390 patients, the median age was 60.1, and 310 (79.5%) were male. The cause of OHCA was cardiac in 321 (82.3%) and coronary in 197 (50.5%). In-hospital mortality occurred in 141 (36.2%) including 8 within the first 24 hours. Among non-survivors, 46 (32.6%) died from circulatory failure and 95 (67.4%) from neurological causes. The median number of lactate measurements was 9 (IQR 6-11.2). Non-survivors had higher initial lactate [6.4 (3.9-9.2) vs 3.4 (2.0-5.9) mmol/L] and greater lactate AUC₀-₂₄ [82 (54-155) vs 45 (32-73) mmol·h/L] (all p<0.05) compared to survivors. Lactate AUC₀-₂₄, compared to admission lactate, remained independently associated with mortality when adjusted for other covariates (adjusted OR 1.94, 95% CI 1.07-3.58, p=0.030). Discrimination for in-hospital mortality improved from AUC 0.72 (initial lactate) to 0.76 (lactate AUC₀-₂₄) with superior model fit (Δdeviance = 19.43, p<0.001). Higher lactate AUC0-24 was more strongly associated with circulatory than neurological death among non-survivors (RRR 4.06 vs 1.11 per 1 SD increase).Conclusion: Cumulative lactate exposure over the first 24 hours after hospital admission provided prognostic information beyond initial lactate and appeared more closely related to circulatory death. Serial lactate measurements, particularly AUC0-24, may improve early risk stratification after OHCA.

Importance:Patient delays in recognizing and acting on acute coronary syndrome (ACS) symptoms worsen outcomes. Objective:To evaluate the effectiveness of a heart attack education intervention (Heart Matters) aiming to improve recognition and response to ACS symptoms in communities with elevated cardiovascular risk and low emergency medical service (EMS) use. Design, Setting, and Participants:This stepped-wedge cluster randomized clinical trial was conducted in 8 high-risk communities (local government areas; 4 metropolitan and 4 rural with a combined population of approximately 792 000 adult residents) in Victoria, Australia (December 2021 to March 2023 with follow-up to March 2024), with clusters crossing to the intervention every 4 months. Data were obtained from administrative datasets and registries (analysis complete June 2025). Intervention:A multicomponent community education program including 490 community sessions (approximately 10 088 residents), more than 174 110 households mailouts, more than 50 000 resource handouts, opportunistic media, and a geotargeted social-media campaign (reach of approximately 350 000 residents). The control period did not include any educational campaign. Main Outcome and Measures:The primary outcome was the proportion of patients with ACS transported to hospitals by EMS, as recorded in the Victorian Emergency Minimum Dataset. Outcomes were analyzed at the patient level using mixed-effects regression models, reporting risk differences (RDs) and odds ratios (ORs). A program evaluation was also conducted to assess implementation and inform potential replication and scale-up. Results:Among 1775 patients with ACS (865 intervention and 910 control; 924 [52.1%] aged ≥65 years; 1193 male [67.2%]), EMS use was unexpectedly high during the initial control period, coinciding with a COVID-19 wave. EMS transport occurred in 624 of 910 patients with ACS (68.6%) in the control period and 548 of 865 patients (63.4%) in the intervention period (adjusted RD, -8.98%; 95% CI, -17.50% to -0.46%; P = .04; adjusted OR, 0.67; 95% CI, 0.45 to 1.01; P = .05). Reductions were more pronounced in metropolitan areas (RD -10.73%; 95% CI -20.43% to -1.03%) and during a severe flooding event (RD -13.50%; 95% CI -26.52% to -0.47%). Early treatment-seeking was also lower, although estimates were imprecise. The program evaluation identified COVID-19 pandemic and seasonal impacts, as well as community concerns regarding EMS costs, demand, and wait times. Conclusions and Relevance:In this community ACS education trial conducted in high-risk regions, the intervention did not improve EMS use or prehospital care-seeking. External contextual factors, including the COVID-19 pandemic and natural disasters, appeared to influence patient behavior and may have attenuated intervention effects, highlighting the complexity of achieving behavioral change through community education alone. Trial Registration:ClinicalTrials.gov Identifier: NCT04995900.

This stepped-wedge cluster-randomized trial evaluates the effectiveness of a heart attack education intervention to improve recognition and response to acute coronary syndrome symptoms in communities with elevated cardiovascular risk and low emergency medical service (EMS) use in Australia. QuestionDoes community-based heart attack education in regions with high cardiovascular risk and low emergency medical services (EMS) use improve patients' response to acute coronary syndrome (ACS)?FindingsIn this stepped-wedge, cluster-randomized trial including 1775 patients with ACS, there was a 9% reduction in EMS use during the intervention. Coordinators reported that the COVID-19 pandemic and seasonal weather effects reduced event attendance, and that the community raised concerns about costs, emergency demand, and wait times.MeaningThese findings suggest that community education interventions are complex and can be influenced by external factors that may negate the intervention's impact. ImportancePatient delays in recognizing and acting on acute coronary syndrome (ACS) symptoms worsen outcomes.ObjectiveTo evaluate the effectiveness of a heart attack education intervention (Heart Matters) aiming to improve recognition and response to ACS symptoms in communities with elevated cardiovascular risk and low emergency medical service (EMS) use.Design, Setting, and ParticipantsThis stepped-wedge cluster randomized clinical trial was conducted in 8 high-risk communities (local government areas; 4 metropolitan and 4 rural with a combined population of approximately 792 000 adult residents) in Victoria, Australia (December 2021 to March 2023 with follow-up to March 2024), with clusters crossing to the intervention every 4 months. Data were obtained from administrative datasets and registries (analysis complete June 2025).InterventionA multicomponent community education program including 490 community sessions (approximately 10 088 residents), more than 174 110 households mailouts, more than 50 000 resource handouts, opportunistic media, and a geotargeted social-media campaign (reach of approximately 350 000 residents). The control period did not include any educational campaign.Main Outcome and MeasuresThe primary outcome was the proportion of patients with ACS transported to hospitals by EMS, as recorded in the Victorian Emergency Minimum Dataset. Outcomes were analyzed at the patient level using mixed-effects regression models, reporting risk differences (RDs) and odds ratios (ORs). A program evaluation was also conducted to assess implementation and inform potential replication and scale-up.ResultsAmong 1775 patients with ACS (865 intervention and 910 control; 924 [52.1%] aged >= 65 years; 1193 male [67.2%]), EMS use was unexpectedly high during the initial control period, coinciding with a COVID-19 wave. EMS transport occurred in 624 of 910 patients with ACS (68.6%) in the control period and 548 of 865 patients (63.4%) in the intervention period (adjusted RD, -8.98%; 95% CI, -17.50% to -0.46%; P = .04; adjusted OR, 0.67; 95% CI, 0.45 to 1.01; P = .05). Reductions were more pronounced in metropolitan areas (RD -10.73%; 95% CI -20.43% to -1.03%) and during a severe flooding event (RD -13.50%; 95% CI -26.52% to -0.47%). Early treatment-seeking was also lower, although estimates were imprecise. The program evaluation identified COVID-19 pandemic and seasonal impacts, as well as community concerns regarding EMS costs, demand, and wait times.Conclusions and RelevanceIn this community ACS education trial conducted in high-risk regions, the intervention did not improve EMS use or prehospital care-seeking. External contextual factors, including the COVID-19 pandemic and natural disasters, appeared to influence patient behavior and may have attenuated intervention effects, highlighting the complexity of achieving behavioral change through community education alone.Trial RegistrationClinicalTrials.gov Identifier: NCT04995900

INTRODUCTION:Acute coronary syndrome-cardiogenic shock (ACS-CS) confers a 30-day mortality rate of ~50%. A simple bed-side risk score for 30-day all-cause mortality may aid in rapid prognostication in these high-risk patients. METHODS:We analyzed data from consecutive patients with ACS-CS enrolled in the Victorian Cardiac Outcomes Registry (VCOR), a state-wide procedure-based clinical quality registry, between 2013 and 2021. Internal validation was performed in 1000 bootstrapped samples to derive variables that were in > 60% of models for the prediction of 30-day mortality. Model performance was evaluated using C-statistic, and Hosmer Lemeshow (HL) statistic. RESULTS:Of 1564 patients with ACS-CS undergoing percutaneous coronary intervention (PCI), 1403 presented with ST-elevation myocardial infarction (STEMI) and 161 with non-STEMI. Age was 66 ± 13 years, and 74% were males. In-hospital and 30-day mortality rates were 42% and 45%. Selected predictors of 30-day mortality included age (odds ratio (OR) 1.4 [1.3, 1.6] per 10 year increase), female sex (OR 1.4 [1.1, 1.8]), diabetes (OR 1.5 [1.2, 2.0]), estimated glomerular filtration rate < 30 mL/min/1.73 m2 (OR 2.2 [1.3, 3.5]), <60 mL/min/1.73 m2 (OR 1.5 [1.1, 2.0], left ventricular ejection fraction < 35% (OR 4.6 [3.5, 6.1]), out-of-hospital cardiac arrest (OR 2.3 [1.8, 3.1]), pre-procedural intubation (OR 2.1 [1.6, 2.7], mechanical circulatory support (OR 1.5 [1.1, 2.1]), STEMI (OR 2.6 [1.7, 3.8]), and multivessel PCI (OR 1.5 [1.1, 2.1], all p < 0.01). Internal validation of 1000 bootstrapped samples resulted in 15 clinical and procedural variables, which demonstrated excellent fit and performance (C-statistic = 0.8, HL p = 0.44) for the prediction of 30-day mortality. CONCLUSION:A risk score incorporating only peri-procedural (clinical and procedural) variables accurately stratified 30-day mortality risk among patients with ACS-CS who underwent PCI. Further studies are required to externally validate the VCOR ACS-CS risk score, however, its simplicity potentially facilitates translation into clinical practice.

BACKGROUND:Contemporary guidelines lack support for the performance of complex percutaneous coronary intervention (PCI) in hospitals with no on-site cardiac surgery (NOSCS). We compared safety and efficacy of complex PCI performed at sites with and without on-site cardiac surgery. METHODS:Data from the Victorian Cardiac Outcomes Registry from 2014 and 2022 was retrospectively analysed. Complex PCI was defined as PCI to unprotected left main, bifurcations, rotational atherectomy or intravascular lithotripsy use, severe left ventricular systolic dysfunction, chronic total occlusion, or vein grafts. The primary outcome was 30-day MACCE comprising all-cause mortality, stroke, MI, target vessel revascularisation, and definite/probable stent thrombosis. The secondary outcome was long-term all-cause mortality. Risk ratio was estimated using propensity score analysis. RESULTS:81,869 PCI procedures were analysed, including 11,710 complex PCI cases (29.0 % at NOSCS). Patients from NOSCS presented more frequently with acute coronary syndromes (NSTE-ACS 35.2 % vs 30.6 %, STEMI 30.0 % vs 19.6 %, p < 0.001). After propensity score adjustment, patients treated at NOSCS centres had equivalent risk of MACCE at 30-days in all-comers PCI (RR 0.95, 95 % CI 0.88-1.03, p = 0.16) and complex PCI (RR 0.97, 95 % CI 0.86-1.10, p = 0.65). There was no difference in propensity-weighted mortality following all-comers or complex at median follow up of 3.5 years. CONCLUSIONS:Patients undergoing PCI and complex PCI at NOSCS centres had comparable risk-adjusted 30-day outcomes and long-term mortality to those treated at OSCS centres. These data underscore the safety of contemporary complex PCI at NOSCS and support health policy changes to increase equitable PCI access for more patients.

BACKGROUND AND AIMS:The optimal revascularization strategy in patients with ischaemic cardiomyopathy remains unclear with no contemporary randomized trial data to guide clinical practice. This study aims to assess long-term survival in patients with severe ischaemic cardiomyopathy revascularized by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). METHODS:Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons and Melbourne Interventional Group registries (from January 2005 to 2018), patients with severe ischaemic cardiomyopathy [left ventricular ejection fraction (LVEF) <35%] undergoing PCI or isolated CABG were included in the analysis. Those with ST-elevation myocardial infarction and cardiogenic shock were excluded. The primary outcome was long-term National Death Index-linked mortality up to 10 years following revascularization. Risk adjustment was performed to estimate the average treatment effect using propensity score analysis with inverse probability of treatment weighting (IPTW). RESULTS:A total of 2042 patients were included, of whom 1451 patients were treated by CABG and 591 by PCI. Inverse probability of treatment weighting-adjusted demographics, procedural indication, coronary artery disease extent, and LVEF were well balanced between the two patient groups. After risk adjustment, patients treated by CABG compared with those treated by PCI experienced reduced long-term mortality [adjusted hazard ratio 0.59, 95% confidence interval (CI) 0.45-0.79, P = .001] over a median follow-up period of 4.0 (inter-quartile range 2.2-6.8) years. There was no difference between the groups in terms of in-hospital mortality [adjusted odds ratio (aOR) 1.42, 95% CI 0.41-4.96, P = .58], but there was an increased risk of peri-procedural stroke (aOR 19.6, 95% CI 4.21-91.6, P < .001) and increased length of hospital stay (exponentiated coefficient 3.58, 95% CI 3.00-4.28, P < .001) in patients treated with CABG. CONCLUSIONS:In this multi-centre IPTW analysis, patients with severe ischaemic cardiomyopathy undergoing revascularization by CABG rather than PCI showed improved long-term survival. However, future randomized controlled trials are needed to confirm the effect of any such benefits.

ABSTRACT Background Acute myocardial infarction complicated by cardiogenic shock (AMICS) confers short‐term mortality of 40%–50%. Protocolised network management of AMICS patients as part of a hub‐and‐spoke model supported by upstream mechanical circulatory support (MCS) is gaining traction globally to treat AMICS. Method We conducted a prospective multicenter study in Melbourne, Australia describing our 5‐year experience utilizing a protocolised hub‐and‐spoke model of care for patients with AMICS supported by planned upstream use of Impella CP (Abiomed, Danvers, MA). Results From December 2019 to August 2024, 31 patients were treated for AMICS with Impella MCS support. Median age was 60 years and 87% were males. ST‐elevation myocardial infarction accounted for 84% of presentations, and 29% were complicated by cardiac arrest. The majority of patients treated were in SCAI‐CSWG stage D (52%), and stage C (26%) shock. Upstream Impella prior to PCI occurred in 84% of patients. The 30‐day survival rate was 74%. An adverse event occurred in 39% of patients. Device‐related complications were due to hemolysis (32%) and arrhythmia (3%). Escalation of MCS support was required in five patients (16%). Multivariate analysis identified patients requiring transfer to the hub center prior to revascularisation as an independent predictor of mortality (OR 13.2 [1.34–129.3] p = 0.027). Conclusion In this first protocolised hub‐and‐spoke model of care for AMICS supported by planned upstream use of Impella in Australia, 30‐day survival was high compared to published historical rates. Patient and device‐related complication rates were low. Expansion of the hub‐and‐spoke model for the treatment of AMICS appears warranted.

BACKGROUND:Complex, high-risk, and indicated (CHIP) percutaneous coronary intervention (PCI) is increasingly performed with variable reported outcomes and consensus on definition. AIMS:We evaluated the relationship between cardiac surgery availability and CHIP-PCI volume (stratified into tertiles < 16, 16‒36, > 36 annual cases) at treating hospitals with 30-day major adverse cardiac and cerebrovascular events (MACCE) and long-term mortality. METHODS:All procedures (2014‒2021) captured by a multicenter PCI registry (Victoria, Australia) were analyzed. CHIP-PCI was defined by composite risk score of ≥ 5 points, with prognostic factors assigned three points (e.g., mechanical circulatory support), two points (e.g., age ≥ 80, peripheral vascular disease, severe left ventricular dysfunction, renal impairment) and one point (female, previous stroke, left main/three-vessel PCI, total stent length > 60 mm, rotational atherectomy). RESULTS:Of 91,961 procedures, 6476 (7.0%) were CHIP-PCI (mean age 82 years; 66% females). CHIP-PCI group had high burden of comorbidities including diabetes (26%), renal impairment (93%), and prior coronary bypass surgery (11%). CHIP-PCI was performed for STEMI (21%), non-STEMI (26%) and nonacute coronary syndrome (47%) indications. Overall, 30-day MACCE and 5-year mortality were 13% and 36% respectively. There was no difference in 30-day MACCE and long-term mortality among CHIP-PCI patients treated at cardiac surgical centers versus Nonsurgical centers (all p > 0.05). Likewise, there was no association between tertiles of annual CHIP-PCI volume with 30-day MACCE and long-term mortality (all p > 0.05). CONCLUSIONS:In contemporary practice, CHIP-PCI outcomes appear similar across institutional CHIP-PCI volume tertiles and availability of cardiac surgery. High rates of adverse outcomes underscore the need for further research regarding revascularization appropriateness.

Clinical progression and medium-long term morbidity from myocarditis following mRNA COVID-19 vaccinations remains an important but undefined public health concern. We conducted prospective follow-up of individuals with either confirmed or probable myocarditis following monovalent Pfizer-BioNTech BNT162b2 or Moderna mRNA-1273 vaccination between 21 April 2021 and 5 July 2022 in Australia. Of 256 individuals who consented to follow up, mostly males following a second dose, 60% (133/221) had ongoing symptoms at 3-6 months and 35% (81/231) at 12-18 months. Self-reported ongoing exercise restrictions, medication requirements, and hospital re-presentations were associated with ongoing symptoms, as was a lower self-reported health status and quality of life. Clinical severity remained mild, with low hospitalisation rates and no deaths in the follow-up period and health-related quality of life improved over time. These findings support ongoing use of mRNA COVID-19 vaccines in at-risk individuals to prevent disease caused by SARS-CoV-2 infection.

OBJECTIVES:To determine the influence of presenting electrocardiographic (ECG) changes on prognosis in acute coronary syndrome cardiogenic shock (ACS-CS) patients undergoing percutaneous coronary angiography (PCI). BACKGROUND:The effect of initial ECG changes such as ST-elevation myocardial infarction (STEMI) versus non-STEMI among patients ACS-CS on prognosis remains unclear. METHODS:We analysed data from consecutive patients with ACS-CS enrolled in the Victorian Cardiac Outcomes registry between 2014 and 2020. Inverse probability of treatment weighting analysis (IPTW) was used to assess the effect of ECG changes on 30-day mortality. RESULTS:Of 1564 patients with ACS-CS who underwent PCI, 161 had non-STEMI and 1403 had STEMI on ECG. The mean age was 66 ± 13 years, and 74 % (1152) were males. Patients with non-STEMI compared to STEMI were older (70 ± 12 vs 65 ± 13 years), had higher rates of diabetes (34 % vs 21 %), prior coronary artery bypass graft surgery (14 % vs 3.3 %), peripheral arterial disease (10.6 % vs 4.1 %, p < 0.01), and lower baseline eGFR (53.8 [37.1, 75.4] vs 65.3 [46.3, 87.8] ml/min/1.73m2), all p ≤ 0.01. Non-STEMI patients were more likely to have a culprit left circumflex artery (29 % vs 20 %) and more often underwent multivessel percutaneous coronary intervention (30 % vs 20 %) but had lower rates of out-of-hospital cardiac arrest (21 % vs 39 %), all p ≤ 0.01. Propensity score analysis with IPTW confirmed that non-STEMI ECG was associated with lower odds for 30-day all-cause mortality (OR 0.47 [0.32, 0.69], p < 0.001), and 30-day major adverse cardiovascular and cerebrovascular events (OR 0.48 [0.33, 0.70]). CONCLUSIONS:In patients undergoing PCI, Non-STEMI as compared to STEMI on index ECG was associated with approximately half the relative risk of both 30-day mortality and 30-day MACCE and could be a useful variable to integrate in ACS-CS risk scores.

OBJECTIVES:To describe myocarditis as an adverse event after coronavirus disease 2019 (COVID-19) vaccination, including a detailed description of clinical phenotypes and diagnostic test results and differences by age, sex, and degree of troponin level elevation. STUDY DESIGN:Retrospective cross-sectional study. SETTING, PARTICIPANTS:Cases of suspected myocarditis following the administration of a COVID-19 vaccine in Victoria during 22 February 2021 - 30 September 2022 reported to Surveillance of Adverse Events Following Vaccination In the Community (SAEFVIC), with symptom onset within 14 days of vaccination, and deemed to be confirmed myocarditis according to the Brighton Collaboration Criteria. MAIN OUTCOME MEASURES:Demographic (sex, broad age group), vaccine, and clinical presentation characteristics; cardiac investigation results (troponin levels, electrocardiography, echocardiography, cardiac magnetic resonance imaging [cMRI]). RESULTS:Of 454 SAEFVIC reports of suspected COVID-19 vaccine-associated myocarditis, 206 were deemed confirmed cases. The median age of people with confirmed myocarditis was 21 years (interquartile range [IQR], 16-32 years; range, 10-76 years); 129 were aged 24 years or younger (63%), 155 were male (75%). The median time from vaccination to symptom onset was two days (IQR, 1-4 days); 201 cases (98%) followed the administration of mRNA vaccines; five cases followed vaccination with AZD122. Forty-six cases followed first vaccine doses (22%), 138 second doses (67%), and 22 cases third vaccine doses (11.0%). In 201 cases, people initially presented to emergency departments; 129 people were admitted to hospital (63%; median length of stay, two days; IQR, 1-3 days). Five people were admitted to intensive care. Echocardiographic abnormalities were identified in 26 of 200 patients (13%); electrocardiographic abnormalities were identified in 105 of 206 patients (51%; less frequently in female than male patients: adjusted odds ratio, 0.75; 95% confidence interval, 0.64-0.89). Troponin levels were elevated in 205 of 206 patients; the median increase was greater in male (95.3-fold; IQR, 5.8-273-fold) than female patients (9.9-fold; IQR, 4.7-50-fold). No cMRI abnormalities were found in patients for whom the troponin increase was threefold or less. CONCLUSION:The clinical severity of COVID-19 vaccine-associated myocarditis in Victoria was generally mild. Markers of a more severe phenotype were more frequently recorded for male patients and people aged 24 years or younger. A threefold troponin increase could be used as a threshold for risk stratification of people with COVID-19 vaccine-associated myocarditis, especially in hospitals with limited access to cMRI facilities.

Introduction: Trans-radial access for coronary angiography and percutaneous coronary intervention (PCI) has gained popularity due to its advantages over the traditional transfemoral approach. However, radial artery occlusion (RAO) remains a common complication following trans-radial procedures. This study aimed to investigate the incidence of early and late RAO along with their risk factors. Methods: Six databases, Medline (Ovid), National Library of Medicine (MeSH), Cochrane Database of Systematic Reviews (Wiley), Embase, Scopus, and Global Index Medicus, were searched. The systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted and analyzed. Using a random-effect model, the primary endpoint was the overall incidence of RAO after invasive coronary procedures. Subgroup analysis and meta-regression were also performed to identify possible predictors of RAO. Results: A total of 41 studies with 30,020 patients were included. The overall incidence of RAO was 13% (95% CI = 0.09–0.16). The incidence of early RAO (within 24 h) was 14% (95% CI = 0.10–0.18) in 26 studies, while the incidence of late RAO (after 24 h) was 10% (95% CI = 0.04–0.16) in 22 studies. The average incidence rates of early RAO in studies with catheter sizes of <6 Fr, 6 Fr, and >6 Fr were 9.8%, 9.4%, and 8.8%. The overall effect size of female gender as a predictor was 0.22 with a 95% CI of 0.00–0.44. Age was a potential predictor of early RAO (B = 0.000357; 95% CI = −0.015–0.0027, p: 0.006). Conclusions: This meta-analysis provides essential information on the incidence of early (14%) and late (10%) RAO following angiographic procedures. Additionally, our findings suggest that female sex and age are possible predictors of RAO. A larger catheter, especially (6 Fr) and hemostatic compression time <90 min post-procedure, substantially reduced the incidence of RAO. The use of oral anticoagulation and the appropriate dosage of low-molecular-weight heparin (LMWH) does reduce RAO, but a comparison between them showed no statistical significance.

Background Acute coronary syndrome (ACS) admissions and percutaneous coronary intervention (PCI) volume declined during periods of COVID-19 lockdown internationally in 2020. The effect of lockdown on emergency medical service (EMS) utilisation, and PCI volume during the initial phase of the pandemic in Australia has not been well described. Method We analysed data from the Victorian Cardiac Outcomes Registry (VCOR), a state-wide PCI registry, linked with the Ambulance Victoria EMS registry. PCI volume, 30-day major adverse cardiovascular and cerebrovascular events (MACCE; composite of mortality, myocardial infarction, stent thrombosis, unplanned revascularisation, and stroke), and EMS utilisation were compared over four time periods: lockdown (26 Mar 2020-12 May 2020); pre-lockdown (26 Feb 2020-25 Mar 2020); post-lockdown (13 May 2020-10 Jul 2020); and the year prior (26 Mar 2019-12 May 2019). Interrupted time series analysis was performed to assess PCI trends within and between consecutive periods. Results The EMS utilisation for ACS during lockdown was higher compared with other periods: lockdown 39.4% vs pre-lockdown 29.7%; vs post-lockdown 33.6%; vs year prior 27.1%; all p<0.01. < 0.01. Median daily PCI cases were similar: 31 (IQR 10, 38) during lockdown; 39 (15, 49) pre-lockdown; 39.5 (11, 44) post-lockdown; and, 42 (10, 49) the year prior; all p>0.05. > 0.05. Median door-to-procedure time for ACS indication during lockdown was shorter at 3 hours (1.2, 20.6) vs pre-lockdown 3.9 (1.7, 21); vs post-lockdown 3.5 (1.5, 21.26); and, the year prior 3.5 (1.5, 23.7); all p<0.05. < 0.05. Lockdown period was associated with lower odds for 30-day MACCE compared to pre-lockdown (odds ratio [OR] 0.55 [0.33-0.93]; p=0.026); post-lockdown (OR 0.66; [0.40-1.06]; p=0.087); and the year prior (OR 0.55 [0.33-0.93]; p=0.026). Conclusions Contrary to international trends, EMS utilisation for ACS increased during lockdown but PCI volumes remained similar throughout the initial stages of the pandemic in Victoria, with no observed adverse effect on 30-day MACCE during lockdown. These data suggest that the public health response in Victoria was not associated with poorer quality cardiovascular care in patients receiving PCI.

Background: Myocarditis and myopericarditis are well described adverse events of special interest (AESI) following COVID-19 vaccinations. Although reports are reassuring regarding initial clinical outcomes, information about longer term outcomes remains limited. We aimed to further this knowledge and report outcomes to 6 months post diagnosis from a single population cohort.Methods: Reports of myocarditis following COVID-19 vaccination were followed up by SAEFVIC (Surveillance of Adverse Events Following Vaccination in the Community), the state-wide vaccine safety service for Victoria, Australia. Confirmed myocarditis cases (Brighton Collaboration Criteria levels 1-3) were followed up via surveys at 1, 3 and 6 months post symptom onset. Responses received between 22 February 2021 and 30 September 2022 were analysed. Results: 87.5% (N = 182) of eligible participants completed at least 1 survey report. 377 reports were analysed. 76.9% of completed reports were from male patients. The median age of patients was 21 years [IQR: 16 to 32]. 54.8% (n = 74) of survey reports at 6 months, reported ongoing symptoms. At all follow-up time points, females were significantly more likely to have ongoing symptoms. At 6 months, 51.9% of male respondents reported symptom resolution compared to 22.6% of female patients (p = 0.002). Females were also more likely to continue medication and have ongoing exercise restrictions. However, males were significantly more likely to have higher initial peak troponin results and abnormal initial cardiac imaging investigations.Conclusions: There appears to be a significant proportion of patients who experience ongoing symptoms to 6 months post onset amongst patients that experience these AESI. Male patients were more likely to report earlier and more complete symptom recovery, despite significantly higher average initial peak troponin. This difference in phenotypic presentation in females compared to males warrants further investigation and there is a need for longer term follow up data.

BACKGROUND:The Impella (Abiomed, Danvers, MA, USA) temporary percutaneous left ventricular assist device is increasingly used as mechanical circulatory support in patients with acute myocardial infarction-cardiogenic shock (AMICS) or those undergoing high-risk protected percutaneous coronary intervention (PCI). The optimal weaning regimen remains to be defined.METHOD:We implemented a structured weaning protocol in a series of 10 consecutive patients receiving Impella support for protected PCI or AMICS treated with PCI in a high volume non-cardiac surgery centre. Weaning after revascularisation was titrated to native heart recovery using both haemodynamic and echocardiographic parameters.RESULTS:Ten patients (eight male, two female; aged 43-70 years) received Impella support for AMICS (80%) or protected PCI (20%). Cardiogenic shock was of Society for Cardiac Angiography & Interventions grade C-E of severity in 80%, and median left ventricular end-diastolic pressure was 31 mmHg. Protocol implementation allowed successful weaning in eight of 10 patients with a median support time of 29 hours (range, 4-48 hours). Explantation was associated with an increase in heart rate (81 vs 88 bpm; p=0.005), but no significant change in Cardiac Index (2.9 vs 2.9 L/min/m2), mean arterial pressure (79 vs 82 mmHg), vasopressor requirement (10% vs 10%), or serum lactate (1.0 vs 1.0). Median durations of intensive care and hospital stay were 3 and 6 days, respectively. At 30 days, the mortality rate was 20%, with median left ventricular ejection fraction of 40%.CONCLUSIONS:A structured and dynamic weaning protocol for patients with AMICS and protected PCI supported by the Impella device is feasible in a non-cardiac surgery centre. Larger studies are needed to assess generalisability of such a weaning protocol.