Publications by authors named "Sze-Yuan Ooi"

25 Publications

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Trials and Tribulations: mHealth Clinical Trials in the COVID-19 Pandemic.

Yearb Med Inform 2021 Apr 21. Epub 2021 Apr 21.

Graduate School of Biomedical Engineering, The University of New South Wales, Sydney, Australia.

Introduction: Mobile phone-based interventions in cardiovascular disease are growing in popularity. A randomised control trial (RCT) for a novel smartphone app-based model of care, named TeleClinical Care - Cardiac (TCC-Cardiac), commenced in February 2019, targeted at patients being discharged after care for an acute coronary syndrome or episode of decompensated heart failure. The app was paired to a digital sphygmomanometer, weighing scale and a wearable fitness band, all loaned to the patient, and allowed clinicians to respond to abnormal readings. The onset of the COVID-19 pandemic necessitated several modifications to the trial in order to protect participants from potential exposure to infection. The use of TCC-Cardiac during the pandemic inspired the development of a similar model of care (TCC-COVID), targeted at patients being managed at home with a diagnosis of COVID-19.

Methods: Recruitment for the TCC-Cardiac trial was terminated shortly after the World Health Organization announced COVID-19 as a global pandemic. Telephone follow-up was commenced, in order to protect patients from unnecessary exposure to hospital staff and patients. Equipment was returned or collected by a 'no-contact' method. The TCC-COVID app and model of care had similar functionality to the original TCC-Cardiac app. Participants were enrolled exclusively by remote methods. Oxygen saturation and pulse rate were measured by a pulse oximeter, and symptomatology measured by questionnaire. Measurement results were manually entered into the app and transmitted to an online server for medical staff to review.

Results: A total of 164 patients were involved in the TCC-Cardiac trial, with 102 patients involved after the onset of the pandemic. There were no hospitalisations due to COVID-19 in this cohort. The study was successfully completed, with only three participants lost to follow-up. During the pandemic, 5 of 49 (10%) of patients in the intervention arm were readmitted compared to 12 of 53 (23%) in the control arm. Also, in this period, 28 of 29 (97%) of all clinically significant alerts received by the monitoring team were managed successfully in the outpatient setting, avoiding hospitalisation. Patients found the user experience largely positive, with the average rating for the app being 4.56 out of 5. 26 patients have currently been enrolled for TCC-COVID. Recruitment is ongoing. All patients have been safely and effectively monitored, with no major adverse clinical events or technical malfunctions. Patient satisfaction has been high.

Conclusion: The TCC-Cardiac RCT was successfully completed despite the challenges posed by COVID-19. Use of the app had an added benefit during the pandemic as participants could be monitored safely from home. The model of care inspired the development of an app with similar functionality designed for use with patients diagnosed with COVID-19.
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http://dx.doi.org/10.1055/s-0041-1726487DOI Listing
April 2021

Recommendation to Use Wearable-Based mHealth in Closed-Loop Management of Acute Cardiovascular Disease Patients During the COVID-19 Pandemic.

IEEE J Biomed Health Inform 2021 04 6;25(4):903-908. Epub 2021 Apr 6.

Because of the rapid and serious nature of acute cardiovascular disease (CVD) especially ST segment elevation myocardial infarction (STEMI), a leading cause of death worldwide, prompt diagnosis and treatment is of crucial importance to reduce both mortality and morbidity. During a pandemic such as coronavirus disease-2019 (COVID-19), it is critical to balance cardiovascular emergencies with infectious risk. In this work, we recommend using wearable device based mobile health (mHealth) as an early screening and real-time monitoring tool to address this balance and facilitate remote monitoring to tackle this unprecedented challenge. This recommendation may help to improve the efficiency and effectiveness of acute CVD patient management while reducing infection risk.
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http://dx.doi.org/10.1109/JBHI.2021.3059883DOI Listing
April 2021

Mobile Phone Technologies in the Management of Ischemic Heart Disease, Heart Failure, and Hypertension: Systematic Review and Meta-Analysis.

JMIR Mhealth Uhealth 2020 07 6;8(7):e16695. Epub 2020 Jul 6.

Department of Cardiology, Prince of Wales Hospital, Sydney, Australia.

Background: Cardiovascular disease (CVD) remains the leading cause of death worldwide. Mobile phones have become ubiquitous in most developed societies. Smartphone apps, telemonitoring, and clinician-driven SMS allow for novel opportunities and methods in managing chronic CVD, such as ischemic heart disease, heart failure, and hypertension, and in the conduct and support of cardiac rehabilitation.

Objective: A systematic review was conducted using seven electronic databases, identifying all relevant randomized control trials (RCTs) featuring a mobile phone intervention (MPI) used in the management of chronic CVD. Outcomes assessed included mortality, hospitalizations, blood pressure (BP), and BMI.

Methods: Electronic data searches were performed using seven databases from January 2000 to June 2019. Relevant articles were reviewed and analyzed. Meta-analysis was performed using standard techniques. The odds ratio (OR) was used as a summary statistic for dichotomous variables. A random effect model was used.

Results: A total of 26 RCTs including 6713 patients were identified and are described in this review, and 12 RCTs were included in the meta-analysis. In patients with heart failure, MPIs were associated with a significantly lower rate of hospitalizations (244/792, 30.8% vs 287/803, 35.7%; n=1595; OR 0.77, 95% CI 0.62 to 0.97; P=.03; I=0%). In patients with hypertension, patients exposed to MPIs had a significantly lower systolic BP (mean difference 4.3 mm Hg; 95% CI -7.8 to -0.78 mm Hg; n=2023; P=.02).

Conclusions: The available data suggest that MPIs may have a role as a valuable adjunct in the management of chronic CVD.
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http://dx.doi.org/10.2196/16695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381017PMC
July 2020

Resting Full-Cycle Ratio (RFR) in the Assessment of Left Main Coronary Disease: Caution Required.

Heart Lung Circ 2020 Aug 14;29(8):1256-1259. Epub 2020 Feb 14.

Eastern Heart Clinic, Prince of Wales Hospital, Sydney, NSW, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.

Hyperaemia-free indices have been gaining traction in recent times due to the practical advantages they offer over the fractional flow reserve (FFR) in the evaluation of angiographically intermediate coronary lesions. More recently, a new hyperaemia-free index, the resting full-cycle ratio (RFR), was described and found to correlate closely with the instantaneous wave-free ratio (iFR). The comparison between FFR and these hyperaemia-free indices, however, is nuanced and remains an ongoing area of debate and investigation. Herein, we highlight one of the important differences between the RFR and FFR, specifically in relation to the assessment of left main coronary lesion. We contend that the interchangeability of these indices cannot always be assumed and clinicians need to be aware of these limitations in their clinical practice.
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http://dx.doi.org/10.1016/j.hlc.2019.12.014DOI Listing
August 2020

Fractional flow reserve in acute coronary syndrome: a meta-analysis and systematic review.

Open Heart 2019;6(1):e000934. Epub 2019 Jan 13.

Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK.

Background: The utility of fractional flow reserve (FFR) to guide revascularisation in the management of acute coronary syndrome (ACS) remains unclear.

Objective: This study aims to compare the clinical outcomes of patients following FFR-guided revascularisation for either ACS or stable angina (SA) and in particular focuses on the outcome of those with deferred revascularisation after FFR.

Methods: A meta-analysis of existing literature was performed. Outcomes including the rate of major adverse cardiovascular events (MACE), recurrent myocardial infarction (MI), mortality and unplanned revascularisation were analysed.

Results: A review of 937 records yielded 9 studies comparing 5457 patients, which were included in the analyses. Patients with ACS had a higher rate of recurrent MI (OR 1.81, p=0.02) and a strong trend towards more MACE and all-cause mortality compared with patients with SA when treated by an FFR-guided revascularisation strategy. Deferral of invasive therapy on the basis of FFR led to a higher rate of MACE (17.6% vs 7.3 %; p=0.004), recurrent MI (5.3% vs 1.5%, p=0.001) and target vessel revascularisation (16.4% vs 5.6 %; p=0.02) in patients with ACS, and a strong trend towards a higher cardiovascular mortality at follow-up when compared with patients with SA.

Conclusion: The event rate in patients with ACS is much higher than SA despite following an FFR-guided revascularisation strategy. Deferring revascularisation does not appear to be as safe for ACS as it is for SA using contemporary FFR cut-offs validated in SA. Refinement of the therapeutic strategy for patients with ACS with multivessel disease is needed to redress the balance.
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http://dx.doi.org/10.1136/openhrt-2018-000934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350698PMC
February 2021

Evaluation of an mHealth-Based Adjunct to Outpatient Cardiac Rehabilitation.

IEEE J Biomed Health Inform 2018 11 11;22(6):1938-1948. Epub 2017 Dec 11.

A pilot study was conducted to determine if a smartphone-based adjunct to standard care could increase the completion rate of a cardiac rehabilitation program (CRP). Based on historical completion rates, 66 participants who were about to commence a hospital-based CRP were randomized so that half received three devices embedded with near-field communication, namely, a smartphone [pre-installed with an application (app) designed specifically for cardiac rehabilitation], portable blood pressure monitor, and weight scale while completing the CRP. The completion rate among participants who were randomized to the intervention group was 88%, compared to 67% in the control group ( = 0.038). This combined with the week-to-week frequency with which participants in the intervention group measured their blood pressure ( 5/week) demonstrated the ability of the intervention to increase the proportion of patients who completed the CRP. No significant differences were found between the treatment groups for the measurements taken at baseline and prior to discharge from the CRP. A statistically significant correlation ( = 0.472; = 0.013) was found between the average time participants walked each day (as estimated via the smartphone app) and participants' six minute walking distance (6MWD) before they were discharged from the CRP (a clinically validated measurement).
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http://dx.doi.org/10.1109/JBHI.2017.2782209DOI Listing
November 2018

BioMonitor 2 Pilot Study: Early Experience With Implantation of the Biotronik BioMonitor 2 Implantable Cardiac Monitor.

Heart Lung Circ 2018 Dec 6;27(12):1462-1466. Epub 2017 Oct 6.

Hollywood Private Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia.

Background: The BioMonitor 2 Pilot Study assessed the implantation procedure, the sensing amplitude and the remote monitoring transmission success rate of the second generation implantable cardiac monitor, the BioMonitor 2 (Biotronik, Berlin, Germany).

Methods: This was a prospective, multi-centre, single-arm, non-randomised study involving seven operators in five sites across Australia. Data were collected at implantation, during clinic visits at 1 week and 1 month post-implantation, and through wireless remote monitoring.

Results: Thirty patients with indications for long-term cardiac monitoring underwent successful insertion of a study device. The median implantation time was 9 minutes (interquartile range (IQR) 5-14 mins). The mean R-wave amplitude at 1 week was 0.75±0.39mV and remained stable over the follow-up period. Within 1 day, 97% of the patients connected to the remote monitoring network and daily messages were transmitted on 93.8% of all study days. Seventy-six per cent of patients transmitted at least one subcutaneous ECG (sECG), with a median number of sECGs per patient of seven (IQR 3-37) within 28 days.

Conclusions: The results of the BioMonitor 2 Pilot study confirm the excellent sensing amplitudes afforded by this new device and the utility of the implantation tools and technique. Patient compliance with and the transmission success rate of the home monitoring system were excellent.
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http://dx.doi.org/10.1016/j.hlc.2017.09.005DOI Listing
December 2018

Reply: High Intensity Interval versus Moderate Intensity Continuous Training in Patients with Coronary Artery Disease.

Heart Lung Circ 2017 05;26(5):528-529

Eastern Heart Clinic, Prince of Wales Hospital, Sydney, NSW, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.

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http://dx.doi.org/10.1016/j.hlc.2017.01.006DOI Listing
May 2017

Sex Differences in the Clinical Impact of High Platelet Reactivity After Percutaneous Coronary Intervention With Drug-Eluting Stents: Results From the ADAPT-DES Study (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents).

Circ Cardiovasc Interv 2017 02;10(2)

From The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (J.Y., R.M., U.B.); Prince of Wales Clinical School, University of NSW, Australia (J.Y., S.-Y.O.); Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (R.M., G.W., A.M., K.X., O.B.-Y., A.J.K., G.W.S.); Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau, Germany (B.W.); Els & Charles Bendheim Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel (G.W.); Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York, NY (G.W., A.M., O.B.-Y., A.J.K., G.W.S.); Sanger Heart and Vascular Institute/Carolinas HealthCare System, Charlotte, NC (M.J.R.); Heart Center, University of Freiburg, Bad Krozingen, Germany (F.-J.N.); Wellmont CVA Heart Institute, Kingsport, TN (D.C.M.); Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (T.D.H.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lehigh Valley Health Network, Allentown, PA (D.A.C.); Reid Heart Center, FirstHealth of the Carolinas, Pinehurst, NC (P.L.D.); The Ohio State University Wexner Medical Center, Columbus (E.L.M.); and LeBauer Cardiovascular Research Foundation/Cone Health, Greensboro, NC (B.R.B., T.D.S.).

Background: Sex differences in the outcomes after percutaneous coronary intervention with drug-eluting stents and in the response to clopidogrel therapy have been reported; however, the differential risk of high platelet reactivity (HPR) on clopidogrel in women versus men is unknown.

Methods And Results: We compared 8448 patients enrolled in the ADAPT-DES study (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) according to sex and the presence/absence of HPR on clopidogrel (defined as P2Y12 reactivity units >208). Study end points were definite and probable stent thrombosis (ST), clinically relevant bleeding, all-cause mortality, myocardial infarction, and major adverse cardiac events (comprising mortality, myocardial infarction, and target lesion revascularization). HPR was more common among women (1118/2163, 51.7%) than men (2491/6285, 39.6%). HPR was associated with a roughly double risk of 1-year ST in both women and men (women with versus without HPR: 1.4% versus 0.7%; hazard ratio [HR], 2.02; 95% confidence interval [CI], 0.82-4.95; =0.12; and men: 1.2% versus 0.5%; HR, 2.42; 95% CI, 1.36-4.30; =0.002; =0.73). HPR was associated with almost half the rate of clinically relevant bleeding in women (women: HPR versus no HPR, 5.3% versus 9.8%; HR, 0.54; 95% CI, 0.40-0.74; <0.001), whereas men had similar rates of bleeding regardless of HPR status (men: HPR versus no HPR, 5.7% versus 5.9%; HR, 0.96; 95% CI, 0.78-1.18; =0.70; =0.003). In propensity-adjusted models, HPR was an independent predictor of ST and myocardial infarction in men; although both associations were nonsignificant among women, no interaction was observed in the associations between HPR and either ST or myocardial infarction. Conversely, HPR was an independent predictor of reduced bleeding only in women (women: adjusted HR, 0.58; 95% CI, 0.41-0.82; =0.002; and men: adjusted HR, 0.83; 95% CI, 0.65-1.04; =0.11; =0.01).

Conclusions: In the current analysis, the associated risk of HPR for ST was similar in both sexes. However, HPR was associated with significantly reduced bleeding only among women.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00638794.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.116.003577DOI Listing
February 2017

Impact of Incomplete Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease: A Systematic Review and Meta-Analysis.

J Am Heart Assoc 2016 12 16;5(12). Epub 2016 Dec 16.

Royal Stoke University Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom

Background: Up to half of patients undergoing percutaneous coronary intervention have multivessel coronary artery disease (MVD) with conflicting data regarding optimal revascularization strategy in such patients. This paper assesses the evidence for complete revascularization (CR) versus incomplete revascularization in patients undergoing percutaneous coronary intervention, and its prognostic impact using meta-analysis.

Methods And Results: A search of PubMed, EMBASE, MEDLINE, Current Contents Connect, Google Scholar, Cochrane library, Science Direct, and Web of Science was conducted to identify the association of CR in patients with multivessel coronary artery disease undergoing percutaneous coronary intervention with major adverse cardiac events and mortality. Random-effects meta-analysis was used to estimate the odds of adverse outcomes. Meta-regression analysis was conducted to assess the relationship with continuous variables and outcomes. Thirty-eight publications that included 156 240 patients were identified. Odds of death (OR 0.69, 95% CI 0.61-0.78), repeat revascularization (OR 0.60, 95% CI 0.45-0.80), myocardial infarction (OR 0.64, 95% CI 0.50-0.81), and major adverse cardiac events (OR 0.63, 95% CI 0.50-0.79) were significantly lower in the patients who underwent CR. These outcomes were unchanged on subgroup analysis regardless of the definition of CR. Similar findings were recorded when CR was studied in the chronic total occlusion (CTO) subgroup (OR 0.65, 95% CI 0.53-0.80). A meta-regression analysis revealed a negative relationship between the OR for mortality and the percentage of CR.

Conclusion: CR is associated with reduced risk of mortality and major adverse cardiac events, irrespective of whether an anatomical or a score-based definition of incomplete revascularization is used, and this magnitude of risk relates to degree of CR. These results have important implications for the interventional management of patients with multivessel coronary artery disease.
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http://dx.doi.org/10.1161/JAHA.116.004598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5210416PMC
December 2016

Drug-eluting Balloon Versus Second Generation Drug Eluting Stents in the Treatment of In-stent Restenosis: A Systematic Review and Meta-analysis.

Heart Lung Circ 2016 Dec 23;25(12):1184-1194. Epub 2016 Apr 23.

Eastern Heart Clinic, Prince of Wales Hospital, Sydney, NSW, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.

Background: In-stent restenosis (ISR) remains a significant mode of stent failure following PCI. The optimal treatment strategy, however, remains undefined and the role of drug-eluting balloons (DEB) in the management of ISR is also unclear.

Methods: A meta-analysis was performed to compare the efficacy of DEB in the treatment of ISR against second generation drug eluting stents (DES).

Results: Seven studies comprised of 1,065 patients were included for analysis. The follow-up period ranged from 12-25 months. The use of DEB was associated with an inferior acute gain in minimal luminal diameter (MLD) (0.36, 95% CI: 0.16-0.57mm), higher late loss in MLD (0.11, 0.02-0.19mm) and a higher binary restenosis rate at follow-up (risk ratio: 2.24, 1.49-3.37). No significant differences were noted in the overall incidence of the analysed clinical parameters between the two groups. When only the randomised controlled trials (RCT) were considered however, there was a strong trend towards higher target lesion revascularisation (TLR; 9.9% vs. 3.6%; RR: 2.5, p=0.07) and a significantly higher major adverse cardiovascular event (MACE) rate (15.7% vs. 8.8%; RR 1.78; p=0.02) with DEB.

Conclusion: While equipoise has been demonstrated in selected clinical outcomes between DEB and second generation DES in the treatment of ISR, the suboptimal angiographic outcome at follow-up and the higher TLR and MACE rates associated with DEB observed in the RCT are concerning. The results of the present analysis should be regarded as preliminary, although the generalised adoption of DEB in the treatment of ISR currently cannot be recommended.
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http://dx.doi.org/10.1016/j.hlc.2016.04.001DOI Listing
December 2016

Detection of Obstructive Coronary Artery Disease Using Peak Systolic Global Longitudinal Strain Derived by Two-Dimensional Speckle-Tracking: A Systematic Review and Meta-Analysis.

J Am Soc Echocardiogr 2016 08 4;29(8):724-735.e4. Epub 2016 May 4.

Eastern Heart Clinic, Prince of Wales Hospital, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.

Background: Global longitudinal strain (GLS) is well validated and has important applications in contemporary clinical practice. The aim of this analysis was to evaluate the accuracy of resting peak GLS in the diagnosis of obstructive coronary artery disease (CAD).

Methods: A systematic literature search was performed through July 2015 using four databases. Data were extracted independently by two authors and correlated before analyses. Using a random-effect model, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and summary area under the curve for GLS were estimated with their respective 95% CIs.

Results: Screening of 1,669 articles yielded 10 studies with 1,385 patients appropriate for inclusion in the analysis. The mean age and left ventricular ejection fraction were 59.9 years and 61.1%. On the whole, 54.9% and 20.9% of the patients had hypertension and diabetes, respectively. Overall, abnormal GLS detected moderate to severe CAD with a pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 74.4%, 72.1%, 2.9, and 0.35 respectively. The area under the curve and diagnostic odds ratio were 0.81 and 8.5. The mean values of GLS for those with and without CAD were -16.5% (95% CI, -15.8% to -17.3%) and -19.7% (95% CI, -18.8% to -20.7%), respectively. Subgroup analyses for patients with severe CAD and normal left ventricular ejection fractions yielded similar results.

Conclusion: Current evidence supports the use of GLS in the detection of moderate to severe obstructive CAD in symptomatic patients. GLS may complement existing diagnostic algorithms and act as an early adjunctive marker of cardiac ischemia.
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http://dx.doi.org/10.1016/j.echo.2016.03.002DOI Listing
August 2016

Design and Rationale for the Endothelin-1 Receptor Antagonism in the Prevention of Microvascular Injury in Patients with non-ST Elevation Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention (ENDORA-PCI) Trial.

Cardiovasc Drugs Ther 2016 Apr;30(2):169-75

Eastern Heart Clinic, Prince of Wales Hospital, Level 3, Campus Center, Barker Street, Randwick, Sydney, NSW, 2031, Australia.

Purpose: Peri-procedural myocardial infarction (PMI) occurs in a small but significant portion of patients undergoing percutaneous intervention (PCI). The underlying mechanisms are complex and may include neurohormonal activation and release of vasoactive substances resulting in disruption of the coronary microcirculation. Endothelin in particular has been found in abundance in atherosclerotic plaques and in systemic circulation following PCI, and may be a potential culprit for PMI through its action on microvascular vasoconstriction, and platelet and neutrophil activation. In this study we aim to characterize the behavior of the coronary microcirculation during a PCI with the index of microvascular resistance (IMR) and the effect of peri-procedural endothelin antagonism.

Methods: The ENDORA-PCI trial is a randomized, double-blind, placebo-controlled, single-center clinical trial designed to evaluate the efficacy of endothelin antagonism in attenuating the peri-procedural rise in IMR as a surrogate marker for PMI. The patients of interest are those with non-ST elevation acute coronary syndrome (NSTEACS) undergoing PCI, and we aim to recruit 52 patients overall to give the study a power of 80 % at an α level of 5 %. Patients will be randomized in a 1:1 fashion to either Ambrisentan, an endothelin antagonist, or placebo, prior to their PCI. IMR will be measured before and after PCI. The primary endpoint is the difference in peri-procedural changes in patients' IMR between the two groups.

Conclusion: The ENDORA-PCI study will investigate whether endothelin antagonism with Ambrisentan attenuates the peri-procedural rise in IMR in patients with NSTEACS undergoing PCI, and thus potentially the risk of PMI.
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http://dx.doi.org/10.1007/s10557-016-6641-xDOI Listing
April 2016

Complete Angiographic Resolution of Cocaine Induced Coronary Artery Dissection within Eight Days without Coronary Stenting--A Case Report.

Heart Lung Circ 2016 Feb 15;25(2):e24-8. Epub 2015 Jul 15.

Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia. Electronic address:

Introduction: Coronary dissection is a rarely reported complication of cocaine use for which there are no specific guidelines on management despite the widespread use of the drug.

Methods: We report a case of a 26-year-old otherwise fit and healthy Caucasian male smoker who presented to our facility with an infero-lateral ST elevation myocardial infarction (STEMI) following nasal inhalation of 1 gram of cocaine. Coronary angiography showed a mid left anterior descending (LAD) artery dissection with distal occlusive embolism and another dissection of the distal right coronary artery (RCA) with embolism and occlusion of the distal posterolateral branch.

Outcome: Wiring of both vessels with a High-Torque Floppy wire successfully re-established TIMI 3 flow with relief of pain and resolution of his ST-segment elevation. Given the absence of any flow-limiting lesions, stenting was avoided. He was subsequently put on a combination of therapeutic dose enoxaparin, aspirin, ticagrelor, atorvastatin and metoprolol. A repeat angiogram eight days later showed complete healing of the dissections.

Conclusion: This case shows that percutaneous management without stenting coupled with aggressive anti-coagulation of cocaine induced coronary dissection may result in an acceptable outcome especially in a young otherwise fit and healthy patient.
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http://dx.doi.org/10.1016/j.hlc.2015.06.829DOI Listing
February 2016

Twelve-Month Outcomes With a Bioresorbable Everolimus-Eluting Scaffold: Results of the ESHC-BVS Registry at Two Australian Centers.

J Invasive Cardiol 2016 Aug 15;28(8):316-22. Epub 2015 Nov 15.

Eastern Heart Clinic, Prince of Wales Hospital, Level 3 Campus Centre Building, Barker St, Randwick NSW 2031, Australia.

Background: The Absorb bioresorbable vascular scaffold (BVS; Abbott Vascular) is a relatively new type of coronary stent designed to provide temporary vessel scaffolding following percutaneous coronary intervention. International use of the device has grown despite a relative paucity of clinical data regarding the performance of the device and the optimal strategy for its use. We report 12-month clinical data on the Absorb BVS from a real-world registry in order to contribute to the overall understanding of the BVS device.

Methods And Results: Absorb BVS implantation was attempted in 152 lesions in 100 patients at two Sydney hospitals, as part of the prospective ESHC-BVS registry. Patients selected harbored a range of complex lesions as encountered in real-world practice. Type-C lesions made up 37% of all lesions treated, with 64% of these being long lesions (>20 mm). Device success was achieved in 98.8% of cases. Predilation was performed in all scaffolds and postdilation was performed in 95% of scaffolds to a mean of 19.6 ± 4.6 atm. Twelve-month follow-up data were available for 99% of patients. At 12 months, the cumulative incidence of target-lesion revascularization was 4%, while the incidence of myocardial infarction was 2% and the incidence of scaffold thrombosis was 1%. There were no deaths in the follow-up period.

Conclusion: In a cohort including complex lesions encountered in real-world practice, the Absorb BVS was associated with low rates of target-lesion revascularization, myocardial infarction, and scaffold thrombosis at 12 months when used with a strategy of meticulous lesion preparation, routine postdilation, and 12 months of dual-antiplatelet therapy.
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August 2016

High Intensity Interval versus Moderate Intensity Continuous Training in Patients with Coronary Artery Disease: A Meta-analysis of Physiological and Clinical Parameters.

Heart Lung Circ 2016 Feb 22;25(2):166-74. Epub 2015 Jul 22.

Eastern Heart Clinic, Prince of Wales Hospital, Sydney, NSW, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.

Introduction: Exercise-based cardiac rehabilitation for patients with coronary artery disease (CAD) significantly improves their outcome, although the optimal mode of exercise training remains undetermined. Previous analyses have been constrained by small sample sizes and a limited focus on clinical parameters. Further, results from previous studies have been contradicted by a recently published large RCT.

Method: We performed a meta-analysis of published randomised controlled trials to compare high intensity interval training (HIIT) and moderate intensity continuous training (MCT) in their ability to improve patients' aerobic exercise capacity (VO2peak) and various cardiovascular risk factors. We included patients with established coronary artery disease without or without impaired ejection fraction.

Results: Ten studies with 472 patients were included for analyses (218 HIIT, 254 MCT). Overall, HIIT was associated with a more pronounced incremental gain in participants' mean VO2peak when compared with MCT (+1.78mL/kg/min, 95% CI: 0.45-3.11). Moderate intensity continuous training however was associated with a more marked decline in patients' mean resting heart rate (-1.8/min, 95% CI: 0.71-2.89) and body weight (-0.48kg, 95% CI: 0.15-0.81). No significant differences were noted in the level of glucose, triglyceride and HDL at the end of exercise program between the two groups.

Conclusion: High intensity interval training improves the mean VO2peak in patients with CAD more than MCT, although MCT was associated with a more pronounced numerical decline in patients' resting heart rate and body weight. The underlying mechanisms and clinical relevance of these results are uncertain, and remain a potential focus for future studies.
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http://dx.doi.org/10.1016/j.hlc.2015.06.828DOI Listing
February 2016

Optimal duration of dual antiplatelet therapy following drug-eluting stents implantation: A meta-analysis of 7 randomised controlled trials.

Int J Cardiol 2015 Dec 5;201:578-80. Epub 2015 Mar 5.

Eastern Heart Clinic, Prince of Wales Hospital, Barker Street, Randwick, Sydney, NSW 2031, Australia; University of New South Wales, Kensington, Sydney, NSW, Australia.

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http://dx.doi.org/10.1016/j.ijcard.2015.03.073DOI Listing
December 2015

Peri-procedural myocardial infarction following percutaneous coronary intervention as defined by the Universal Definition predicts increased mortality at 2 years.

Int J Cardiol 2015 Nov 12;199:96-8. Epub 2015 Jul 12.

Eastern Heart Clinic, Prince of Wales Hospital, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.

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http://dx.doi.org/10.1016/j.ijcard.2015.07.023DOI Listing
November 2015

Everolimus-eluting Bioresorbable Vascular Scaffold Implantation in Real World and Complex Coronary Disease: Procedural and 30-day Outcomes at Two Australian Centres.

Heart Lung Circ 2015 Sep 23;24(9):854-9. Epub 2015 Feb 23.

Eastern Heart Clinic, Prince of Wales Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia.

Background: The Absorb BVS is a new generation of coronary stent designed to provide coronary arteries with mechanical support of a temporary nature, following balloon angioplasty. Clinical trials of the device have shown promising results thus far, however concern surrounds the deliverability of the device in real-world and complex coronary disease, and the possible higher incidence of early scaffold thrombosis when compared to conventional metallic drug-eluting stents.

Methods: Implantation of the Absorb BVS was attempted in 152 lesions in 100 patients at two Sydney teaching hospitals, as part of a prospective registry. Lesions treated reflected a wide spectrum of real-world disease. Young patient age, long lesion length and involvement of the mid-portion of the left anterior descending artery were the strongest factors likely to influence the decision to use the Absorb BVS over conventional metallic stents. There were no restrictions on the lesion length, or on the number of lesions or vessels treated. Type C lesions made up 37% of all lesions treated with 64% of these being long lesions (>20mm). The Absorb BVS was successfully implanted in 98.8% of cases. Post-dilatation was performed in 95% of scaffolds. Peri-procedural non-ST elevation myocardial infarction occurred in four cases. Scaffold thrombosis did not occur in any patient at 30 days follow-up. There was no death, or need for target lesion revascularisation in-hospital or at 30 days.

Conclusions: High rates of procedural success were achieved with minimal complications with use of the Absorb BVS in real-world coronary disease, including complex disease. These results suggest that the reduced deliverability of the device can be largely overcome by meticulous lesion preparation, and that early scaffold thrombosis may be minimised through scaffold post-dilatation.
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http://dx.doi.org/10.1016/j.hlc.2015.02.011DOI Listing
September 2015

Prognostic Significance of Peri-procedural Myocardial Infarction in the Era of High Sensitivity Troponin: A Validation of the Joint ACCF/AHA/ESC/WHF Universal Definition of Type 4a Myocardial Infarction with High Sensitivity Troponin T.

Heart Lung Circ 2015 Jul 2;24(7):673-81. Epub 2015 Feb 2.

Eastern Heart Clinic, Prince of Wales Hospital, Randwick, NSW Australia; University of New South Wales, Randwick, NSW, Australia.

Aims: This study aims to validate the joint ACCF/AHA/ESC/WHF Universal Definition of peri-procedural myocardial infarction (PMI) with high sensitivity troponin T (hsTnT).

Methods: A retrospective cohort study encompassing patients admitted to our institution between May 2012 and April 2013 was performed.

Results: 630 patients underwent percutaneous coronary interventions during the study period. Among them, 459 patients met the inclusion criteria and were eligible for analyses. 76.9% of these patients were male, while the mean age was 68.6. PMI was observed in 4.3% of the patients based on the Universal Definition. The predictors of PMI were chronic kidney disease (OR: 3.0, p=0.026), family history of cardiovascular disease (OR: 2.7, p=0.043) and use of IIb/IIIa inhibitors (OR 4.2, p=0.01). MACE was reported in 4.4% of the patients at 12 months, and was significantly and independently associated with PMI (OR 7.3, p=0.003) in a multivariate model which accounted for lesion complexity, patients' baseline clinical information, dual-antiplatelet status at follow-up and various procedural characteristics. The post-procedural hsTnT was much higher in those who suffered MACE than those who did not (156 v.s. 43 ng/L, p<0.001).

Conclusion: PMI as defined by the current Universal Definition using hsTnT is an independent predictor of adverse clinical outcome at 12 months in patients undergoing PCI. Accordingly, PMI remains a clinically relevant factor in current practice and should be considered a key outcome measure in clinical trials and a potential target for therapy.
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http://dx.doi.org/10.1016/j.hlc.2015.01.007DOI Listing
July 2015

Ankyrin-B syndrome: a case of sinus node dysfunction, atrial fibrillation and prolonged QT in a young adult.

Heart Lung Circ 2015 Feb 30;24(2):e31-4. Epub 2014 Sep 30.

Eastern Heart Clinic, Prince of Wales Hospital, Barker Street Randwick NSW, Australia; University of New South Wales, Randwick NSW, Australia.

Ankyrin-B protein is involved in regulating expression and localisation of cardiac ion channels and transporters. Mutations of the ANK2 gene in the rare condition Ankyrin-B syndrome result in loss of function of the ankyrin-B protein which in turn leads to abnormal regulation of intracellular sodium and calcium and a predisposition to cardiac arrhythmia including torsades de pointes. We describe a rare case of this condition characterised by sinus node dysfunction, atrial fibrillation and prolonged QT syndrome in a young patient with a family history of sudden death. The management of Ankyrin-B syndrome may include avoidance of QT prolonging medications, insertion of a permanent pacemaker for sinus node dysfunction, or a cardioverter defibrillator for those at high-risk of sudden death from torsades de pointes.
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http://dx.doi.org/10.1016/j.hlc.2014.09.013DOI Listing
February 2015

Heart-type fatty acid binding protein in early diagnosis of myocardial infarction in the era of high-sensitivity troponin: a systematic review and meta-analysis.

Ann Clin Biochem 2015 May 9;52(Pt 3):370-81. Epub 2014 Sep 9.

Eastern Heart Clinic, Prince of Wales Hospital, Sydney.

Introduction: Heart-type fatty acid binding protein (HT FABP) is an emerging biomarker of ischaemic myocardial necrosis. While previous studies have demonstrated its additive value when compared to contemporary troponin assays in the diagnosis of acute myocardial infarction (AMI), its utility in the era of high-sensitivity troponin (hsTn) assays remains undetermined.

Methodology: A systematic review and meta-analysis of relevant studies was performed comparing the diagnostic performance of HT FABP both alone and in conjunction with hsTn in the early diagnosis and exclusion of AMI.

Results: A systematic literature search yielded eight eligible studies including 3395 patients. Of these, 716 patients (21.1%) were eventually diagnosed with AMI. The pooled sensitivity and specificity for hsTn on admission was 82.5% (95% confidence interval [CI]: 79.8-85.0%) and 89.7% (95% CI: 88.7-90.6%), respectively, while the area under the curve (AUC) for the summary receiver operating characteristics (ROC) curve is 0.92 (SE 0.02). While the pooled specificity (84.6%, 95% CI: 83.2-85.9%) of admission HT FABP is similar to hsTn for the early diagnosis of AMI (P = 0.07), its pooled sensitivity (63.5%, 95% CI: 59.9-67.1%, P < 0.001) is significantly worse. Accordingly, the AUC of the summary ROC curve for HT FABP (0.79, SE 0.03) is inferior to hsTn (P < 0.0001). The addition of HT FABP to hsTn resulted in no improvement in the sensitivity (P = 0.058) and worsened the specificity (P = 0.001) in the early diagnosis of AMI compared to hsTn alone.

Conclusion: HT FABP does not appear to improve the diagnostic accuracy of hsTn, and consequently its routine use currently cannot not be recommended.
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http://dx.doi.org/10.1177/0004563214553277DOI Listing
May 2015

Is there attenuation of benefit of invasive therapy in patients with chronic kidney disease? Results from randomized trials and registry data.

Curr Cardiol Rep 2012 Aug;14(4):521-7

Mount Sinai Medical Center,One Gustave L. Levy Place, New York, NY 10029, USA.

Chronic kidney disease (CKD) is not only a common comorbidity among patients presenting with acute coronary syndrome (ACS), it is also an entity that portends worse short- and long-term prognosis. Differences in the pathophysiology of arterial atherosclerosis and calcification, chronic inflammation, platelet reactivity, and thrombogenicity in patients with and without CKD underpin the increased vulnerability of CKD patients with ACS to subsequent ischemic and bleeding complications. These differences, as well as the frequent exclusion of CKD patients from randomized control trials, create uncertainty regarding the benefit of invasive treatment for ACS in patients with CKD. The limited evidence from randomized trials suggests a benefit with invasive treatment in CKD patients with ACS. However, some data from registry studies suggest no benefit or even harm with invasive therapy. Thus, the optimal management of ACS in patients with CKD, in particular end-stage CKD, remains uncertain. In this article we review the characteristics of coronary artery disease in patients with CKD, the available evidence pertaining to the outcomes of CKD patients with ACS with invasive versus conservative therapy, and potential areas for reducing complications of invasive therapy in this high-risk subset of patients.
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http://dx.doi.org/10.1007/s11886-012-0284-8DOI Listing
August 2012

Scedosporium apiospermum pacemaker endocarditis.

Int J Cardiol 2009 Jan 1;131(2):e81-2. Epub 2007 Nov 1.

A patient developed a fungal pacemaker infection with Scedosporium apiospermum following a series of pacemaker manipulations. Despite percutaneous removal of the pacemaker system and subsequent operative extraction of the atrial thrombus, his course was complicated by persistent sepsis, pulmonary septic emboli and bilateral frontal lobe infarction, following which treatment was withdrawn.
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http://dx.doi.org/10.1016/j.ijcard.2007.07.056DOI Listing
January 2009

Statins and rheumatoid arthritis.

Lancet 2004 Nov 20-26;364(9448):1853-4; author reply 1855

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http://dx.doi.org/10.1016/S0140-6736(04)17433-3DOI Listing
December 2004