Background Time to reperfusion is a predictor of long-term outcomes in ST-segment elevation myocardial infarction (STEMI). Timely primary percutaneous coronary intervention (PCI) is the preferred strategy recommended by guidelines. Fibrinolysis is recommended in patients in whom timely primary PCI is not feasible, though concerns persist about underutilisation of this approach. We examined long-term survival outcomes in STEMI patients according to treatment strategy received in a national STEMI registry in Ireland.Methods This was an observational, nationwide, population-based study. We identified all STEMI cases from January 2013 to March 2018. After exclusion of patients with missing data, we divided patients into three groups as per reperfusion strategy—fibrinolysis, delayed primary PCI (>120 min of diagnosis) and timely primary PCI (<120 min of diagnosis)—and analysed mortality through to 3 years follow-up. A multivariate Cox proportional hazards model was used, with a propensity score matching analysis performed as a sensitivity analysis.Results Of the 4156 patients included in this analysis, 202 (4.9%) were treated with fibrinolysis, 1075 (25.8%) were treated with delayed primary PCI and 2879 (69.3%) were treated with timely primary PCI. At follow-up, delayed primary PCI was associated with an increased risk of mortality through to 3 years in comparison to fibrinolysis (HRadjusted, 1.36; 95% CI 1.02 to 1.83, p=0.04). Timely primary PCI was associated with a comparable risk of mortality through to 3 years in comparison to fibrinolysis (HRadjusted, 1.10; 95% CI 0.81 to 1.49, p=0.53).Conclusions A sizeable proportion of STEMI patients continue to receive treatment with delayed primary PCI. This is associated with an increased risk of mortality through 3 years in comparison to fibrinolysis.

This 2026 update of the European Society of Cardiology (ESC) Core Curriculum for the Cardiologist reflects contemporary and emerging requirements for the practice of cardiology and the resulting training needs. The document has three main parts:Section 1 outlining the main training requirements and their presentation in entrustable professional activities (EPAs).Section 2 explaining the requirements for training centres.Section 3 outlining the general skills, knowledge, and attitudes required in cardiology (chapter 1) - and eight chapters outlining EPAs in the different areas of cardiology (chapter 2 to 9). This update has been written over 9 months in a iterative process, involving over 90 representatives as per the initial curriculum, similar to that used for the previous iteration of the core curriculum in 2020. Though much of the 2020 core curriculum remains relevant and unchanged, there was a clear need to amend this previous curriculum to reflect the expanding roles of some areas of cardiology such as data science, digital health, and artificial intelligence. These items have now been specifically included along with general updates to various clinical EPAs due to changes in practice or evidence base.

Background and objectives:Out of hospital cardiac arrest (OHCA) can complicate ST segment elevation myocardial infarction (STEMI), with a tenfold increase in mortality compared to those presenting without cardiac arrest. This study aimed to characterise STEMI patients presenting with OHCA to a single centre and to investigate the factors affecting their outcomes. Methods:A retrospective analysis was performed on all patients on the National Out of Hospital Cardiac Arrest Register that presented over a six-year period with OHCA. The hospital's electronic health record was used to collect data on baseline characteristics, STEMI diagnosis, treatment and outcomes. Results:There were 478 OHCA presentations; 75 (16 %) were diagnosed with STEMI. Mortality rates were significantly lower amongst the STEMI patients (23 % vs 87 %). There was no significant difference in the characteristics of STEMI patients transferred directly to the coronary catheterisation lab (CCL) and initially treated in ED. Over 90 % of STEMI patients were successfully treated with PCI. Mortality was higher in STEMI patients that were initially transferred to ED, with this factor identified as an independent predictor of mortality. However, transfer to CCL after two hours was not associated with increased mortality, when compared to those transferred within an hour of hospital arrival. Conclusion:Mortality rates amongst studied STEMI patients presenting with OHCA were high. Although transfer to ED was associated with increased mortality, this finding may be explained by confounding factors, including more profound haemodynamic instability precluding STEMI diagnosis, and/or requiring transfer to ED for stabilisation.

Introduction : We evaluated the intra-operative situational awareness (as measured with detection accuracy and latency) capacity of interventional cardiologists during the performance of physics-based virtual reality simulation of a coronary angiography procedure. Methods : Using a between groups repeated measures design we assessed experienced and mid-level interventional cardiologists (ICs) using eye tracking glasses and physics-based virtual reality simulation. We assessed their intra-operative procedure performance errors, situation awareness, and attentional capacity as they performed a coronary angiogram. The main outcomes were intra-operative performance errors, situation awareness as measure of the operators capacity and latency to detect and correctly respond to salient visual stimuli. Results : We showed that experienced cardiologists had considerably better situation awareness. They demonstrated faster stimulus identification and report latencies (4.5 times quicker, p < 0.001). Furthermore, trainees detection latency scores strongly predicted total technical error scores (r = 0.93). Conclusions : This study showed that experienced ICs had a greater capacity to detect, recognise, and make judgements about deviations from optimal performance intra-operatively. The results from this study almost certainly apply to all image guided medical interventional procedures and have important patient safety implications.

Background Previous studies have shown a circadian association with the incidence of myocardial infarction, with a higher incidence on a Monday. We sought to establish whether there was any association between rates of ST-segment elevation myocardial infarction (STEMI) and day of the week in an Irish population Methods All STEMIs recorded in the Republic of Ireland national ACS database, and from both centres providing primary PCI in Northern Ireland, from January 2013 through March 2018 were included in the analysis. Dates of admission were grouped by day of the week. Chi-Square goodness-of-fit test was performed across the entire data set. Odds ratios and Chi-Square independence tests were calculated for each day versus the mean of the other 6 days of the week. Results 10,528 patients were included in the analysis (7,112 in the Republic of Ireland, 3,416 in Northern Ireland). Chi-Square goodness-of-fit test showed a significant deviation from an even distribution across the week (p<0.000). The total number of STEMI vs mean by day of week are reported in Figure 1 below. The incidence of STEMI was significantly higher on Mondays: OR 1.13 (p=0.015). Relative odds ratios and p values are reported in Figure 2 below. Summary We found an association between the incidence of STEMI and the start of the working week. There is a significantly higher incidence of STEMI on Mondays. Conflict of Interest None

High-sensitivity cardiac troponin T (hs-cTnT) blood concentrations were shown to exhibit a diurnal rhythm, characterized by gradually decreasing concentrations throughout daytime, rising concentrations during nighttime and peak concentrations in the morning. We aimed to investigate whether this also applies to (h)s-cTnI assays and whether it would affect diagnostic accuracy for acute myocardial infarction (AMI).Blood concentrations of cTnI were measured at presentation and after 1 h using four different cTnI assays: three commonly used sensitive (s-cTnI Architect, Ultra and Accu) and one experimental high-sensitivity assay (hs-cTnI Accu) in a prospective multicenter diagnostic study of patients presenting to the emergency department with suspected AMI. These concentrations and their diagnostic accuracy for AMI (quantified by the area under the curve (AUC)) were compared between morning (11 p.m. to 2 p.m.) and evening (2 p.m. to 11 p.m.) presenters.Among 2601 patients, AMI was the final diagnosis in 17.6% of patients. Concentrations of (h)s-cTnI as measured using all four assays were comparable in patients presenting in the morning versus patients presenting in the evening. Diagnostic accuracy for AMI of all four (h)s-cTnI assays were high and comparable between patients presenting in the morning versus presenting in the evening (AUC at presentation: 0.90 vs 0.93 for s-cTnI Architect; 0.91 vs 0.94 for s-cTnI Ultra; 0.89 vs 0.94 for s-cTnI Accu; 0.91 vs 0.94 for hs-cTnI Accu).Cardiac TnI does not seem to express a diurnal rhythm. Diagnostic accuracy for AMI is very high and does not differ with time of presentation.NCT00470587, http://clinicaltrials.gov/show/NCT00470587

Background A case of stent thrombosis as a complication of coronary bifurcation stenting is described. We review potential complications of bifurcation stenting and established guidelines. Case summary A 64-year-old man presented with a non-ST segment elevation myocardial infarction. High-sensitivity troponin I peaked at 99 000 ng/L (normal <5). He previously had coronary stenting for stable angina when residing in another country 2 years previously. Coronary angiography revealed no significant stenosis with TIMI 3 flow in all vessels. Cardiac magnetic resonance imaging demonstrated a left anterior descending artery (LAD) territory regional motion abnormality, late gadolinium enhancement consistent with recent infarction, and a left ventricular apical thrombus. Repeat angiography and intravascular ultrasound (IVUS) confirmed bifurcation stenting at the junction of the LAD and second diagonal (D2) with protrusion of several millimetres of the uncrushed proximal segment of the D2 stent in the LAD vessel lumen. There was under-expansion of the LAD stent in the mid-vessel and stent malapposition in the proximal LAD, extending into the distal left main stem coronary artery and involving the ostium of the left circumflex coronary artery. Percutaneous balloon angioplasty was performed along the length of the stent, including an internal crush of the D2 stent. Coronary angiography confirmed a uniform expansion of the stented segments and TIMI 3 flow. Final IVUS confirmed full stent expansion and apposition. Discussion This case highlights the importance of provisional stenting as a default strategy and familiarity with procedural steps in bifurcation stenting. Furthermore, it emphasizes the benefit of intravascular imaging for lesion characterization and stent optimization.

Transradial access (TRA) has emerged as an alternative to transfemoral access (TFA) for percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) patients. However, the rate of TRA adoption has been much slower in the acute coronary syndrome (ACS) patient population. This meta-analysis was conducted to assess clinical outcomes of TRA compared with TFA in STEMI patients undergoing PCI. A manual search of PubMed, EMBASE, Cochrane library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and recent major scientific conference sessions from inception to October 15th, 2019 was performed. Primary outcomes in our analysis were all-cause mortality and trial-defined major bleeding. Secondary outcomes included vascular complications, myocardial infarction, stroke, procedure, and fluoroscopy time. 17 randomized controlled trials (RCTs) (N = 12,018) met inclusion criteria. TRA was associated with lower all-cause mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.57 to 0.88), major bleeding (RR: 0.59, 95%CI: 0.45 to 0.77), and vascular complications (RR: 0.42, 95%CI: 0.32 to 0.56) compared with TFA. There was no difference in the incidence of myocardial infarction (MI), stroke, or procedure duration between the 2 groups. The difference in all-cause mortality between TRA and TFA was statistically nonsignificant when major bleeding was held constant. In conclusion, TRA was associated with lower risk of all-cause mortality, major bleeding, and vascular complications compared with TFA in STEMI patients undergoing PCI.

INTRODUCTION:Hereditary amyloidogenic transthyretin (ATTR) amyloidosis is an autosomal dominant, multi-systemic and progressive disorder characterised by polyneuropathy, cardiomyopathy and dysautonomia to varying degrees. In Ireland, the p.Thr80Ala mutation has been well documented, but little has been reported about a second variant, the p.His110Asp mutation first discovered in a family native to county Cork. Here we elaborate on the phenotype of this recently identified mutation using an extended pedigree of the original kindred and include for the first time a second affected family.MATERIALS AND METHODS:Patients attending our centre with confirmed or suspected ATTR amyloidosis as a result of a p.His110Asp mutation were identified. Detailed chart reviews and patient interviews were completed. Data on symptoms, examination findings, neurophysiology, histology, biochemistry, and cardiac investigations were gathered. A large extended pedigree was plotted.RESULTS:A total of 17 members across four generations of one kindred, and 2 members of a previously unreported family were identified. A phenotype of progressive late-onset polyneuropathy with cardiac involvement was common to both families. An early manifestation was carpal tunnel syndrome, preceededing neuropathy by many years. Gastrointestinal and urinary symptoms were common.DISCUSSION:We describe a wider phenotype of the p.His110Asp mutation of transthyretin in two Irish families. Importantly, we describe cardiac involvement which was not previously emphasised. The discovery of a new unrelated family highlights the importance of clinical suspicion even in those without known family history. We suggest that this second important transthyretin mutation should be considered in patients of Irish origin.

Background Studying variability in the care provided to secondary prevention coronary heart disease (CHD) outpatients can identify interventions to improve their outcomes.Methods We studied outpatients who had an index CHD event in the preceding 6–24 months. Eligible CHD events included acute coronary syndrome (ACS) and coronary revascularisation for stable chronic coronary syndrome (CCS). Site training was provided by a core team and data were collected using standardised methods.Results Between 2017 and 2019, we enrolled 721 outpatients at nine Irish study sites; 81% were men and mean age was 63.9 (SD ±8.9) years. The study examination occurred a median of 1.16 years after the index CHD event, which was ACS in 399 participants (55%) and stable-CCS in 322. On examination, 42.5% had blood pressure (BP) >140/90 mm Hg, 63.7% had low-density lipoprotein cholesterol (LDL-C) >1.8 mmol/L and 44.1% of known diabetics had an HbA1c >7%. There was marked variability in risk factor control, both by study site and, in particular, by index presentation type. For example, 82% of outpatients with prior-ACS had attended cardiac rehabilitation versus 59% outpatients with prior-CCS (p<0.001) and there were also large differences in control of traditional risk factors like LDL-C (p=0.002) and systolic BP (p<0.001) among outpatients with prior-ACS versus prior-CCS as the index presentation.Conclusions Despite international secondary prevention guidelines broadly recommending the same risk factor targets for all adults with CHD, we found marked differences in outpatient risk factor control and management on the basis of hospital location and index CHD presentation type (acute vs chronic). These findings highlight the need to reduce hospital-level and patient-level variability in preventive care to improve outcomes; a lesson that should inform CHD prevention programmes in Ireland and around the world.

Cardiology, University Heart Center Zürich, Rämistrasse 100, Zürich, CH-8091, Switzerland; Retired Cardiologist, Manchester, UK; Consultant Cardiologist, Imperial College, London, UK; Department of Cardiology, Coimbra University Hospital Center, Coimbra, Portugal; Physician Cardiologist, Cork University Hospital, Cork, Ireland; 2nd Department of Cardiology, University Hospital of Ioannina, Greece; Clinical Cardiologist, Département de pathologie Cardiovasculaire, Cliniques Universitaires Saint Luc, Brussels, Belgium; Consultant Cardiologist and Intensivist, Royal Brompton Hospital, London, UK; Chef de Service, Service de Cardiologie, Hopital Louis Pradel, Bron, France; Consultant Cardiologist, Barts Heart Centre, St. Bartholomew’s Hospital, London, UK; Consultant Cardiologist, Freeman Hospital, Newcastle Upon Tyne, UK; University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK; and Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, Gebäude Ost 70, Hamburg, 20246, Germany

Aims The provision of high-quality education allows the European Society of Cardiology (ESC) to achieve its mission of better cardiovascular practice and provides an essential component of translating new evidence to improve outcomes Methods and results The 4th ESC Education Conference, held in Sophia Antipolis (December 2016), brought together ESC education leaders, National Directors of Training of 43 ESC countries, and representatives of the ESC Young Community. Integrating national descriptions of education and cardiology training, we discussed innovative pathways to further improve knowledge and skills across different training programmes and health care systems. We developed an ESC roadmap supporting better cardiology training and continued medical education (CME), noting: (i) The ESC provides an excellent framework for unbiased and up-to-date cardiovascular education in close cooperation with its National Societies. (ii) The ESC should support the harmonization of cardiology training, curriculum development, and professional dialogue and mentorship. (iii) ESC congresses are an essential forum to learn and discuss the latest developments in cardiovascular medicine. (iv) The ESC should create a unified, interactive educational platform for cardiology training and continued cardiovascular education combining Webinars, eLearning Courses, Clinical Cases, and other educational programmes, along with ESC Congress content, Practice Guidelines and the next ESC Textbook of Cardiovascular Medicine. (v) ESC-delivered online education should be integrated into National and regional cardiology training and CME programmes. Conclusion These recommendations support the ESC to deliver excellent and comprehensive cardiovascular education for the next generation of specialists. Teamwork between international, national and local partners is essential to achieve this objective.

Provision and participation in formal external continuing medical education (CME) is costly. Employer or state support of CME is the exception rather than the rule. The medical industry has supported both providers and consumers of educational activities, leading to concerns of commercial bias. Recent medical industry initiatives in Europe to improve the transparency of the relationship between industry and the profession, including the field of medical education, have had the paradoxical effect of the industry playing an increasingly direct role in the provision of physician education. Funding of medical professional society annual congresses has been directly and indirectly jeopardized. Acknowledging that there are areas of cooperation in the field of education between the medical profession and the medical industry from which both can benefit, we argue that medical education requires an objective approach that the primary fiduciary duty of medical industry companies precludes. Medical professional societies, as not-for-profit organizations whose core mission is the development and promotion of best practice, are best placed to guide and deliver medical education to their members.

Unobtrusive metrics that can auto-assess performance during clinical procedures are of value. Three approaches to deriving wearable technology-based metrics are explored: (1) eye tracking, (2) psychophysiological measurements [e.g. electrodermal activity (EDA)] and (3) arm and hand movement via accelerometry. We also measure attentional capacity by tasking the operator with an additional task to track an unrelated object during the procedure.

Education is one of the key pillars of how the European Society of Cardiology (ESC) aims to reduce the burden of cardiovascular disease. We are currently in the midst of a transformation in how we deliver and receive education, with new digital technologies, the growth of smart devices, and 24 hrs per day access to different sources of learning. With huge potential for enhancing the educational environment, these changes also lead to challenges and important practical implications on patient care and work-life balance. The 5th ESC Education Conference (January 2018) was dedicated to exploring how we should train the digital cardiologist of the future, including workshops and plenaries on social media, mobile and online resources, and pathways to reliably educate trainee cardiologists, certified cardiologists and patients. The conference included National Training Directors, the Young Cardiology community and patient representatives from 45 ESC countries. In this report, we discuss the key outputs from the conference and how to integrate digital learning in contemporary cardiology practice.

In recent years, wide ranging biomedical innovation has provided powerful new approaches for prevention, diagnosis and management of diseases. In order to translate such innovation into effective practice, physicians must frequently update their knowledge base and skills through continuing medical education and training. Medical Professional Societies, run as not-for-profit organizations led by peers, are uniquely placed to deliver balanced, disease oriented and patient centred education. The medical industry has a major role in the development of new, improved technology, devices and medication. In fact, the best innovations have been achieved through collaboration with scientists, clinical academics and practicing physicians. Industry has for many years been committed to ensure the optimal and safe application of its products by providing unrestricted support of medical education developed and delivered by international and national learned societies. Recently adopted Codes of Practice for the Pharmaceutical and Device industry were intended to enhance public trust in the relationship between biomedical industry and physicians. Unexpectedly, changes resulting from adoption of the Codes have limited the opportunity for unconditional industry support of balanced medical education in favour of a more direct involvement of industry in informing physicians about their products. We describe the need for continuing medical education in Cardiovascular Medicine in Europe, interaction between the medical profession and medical industry, and propose measures to safeguard the provision of high quality, balanced medical education.

Introduction The American College of Cardiology Foundation (ACCF) with other professional societies developed appropriate use criteria (AUC) for diagnostic coronary angiography. This study aims to examine the appropriate use of elective coronary angiography for patients with suspected stable coronary artery disease in an Irish tertiary referral center. Methods A retrospective chart review of all elective outpatient diagnostic coronary angiograms performed in Cork University Hospital in 2014 was carried out. Data on demographics, risk factors, clinical presentation, and prior non-invasive investigations were extracted. Each patient was evaluated according to the 2012 ACCF appropriate use criteria and classified as appropriate, uncertain, or inappropriate. Univariable and multivariable logistic regression analysis was performed to investigate the factors that predict patients undergoing appropriate diagnostic coronary angiography. Results Of 417 elective outpatient diagnostic coronary angiograms, 259 (62%) were included in the analysis. Of these, 108 (42%) were classified as appropriate, 97 (37%) as uncertain, and 54 (21%) as inappropriate. In multivariable analysis, those with private health insurance were more likely to have an appropriate indication for coronary angiogram (OR 2.1, 95% CI 1.2-3.7) as were those with atrial fibrillation (OR 3.9, 95% CI 1.2-12.8). Ever smokers were less likely to have an appropriate indication for coronary angiogram than never smokers (OR 0.5, 95% CI 0.3-0.9). Conclusion This is the first Irish study to evaluate the appropriate use of elective coronary angiography. Rates were similar to those of studies in other jurisdictions; however, there remains significant potential for quality improvement.