Publications by authors named "Warren Walsh"

35 Publications

Medical Management of Rheumatic Heart Disease: A Systematic Review of the Evidence.

Cardiol Rev 2018 Jul/Aug;26(4):187-195

School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.

Rheumatic heart disease (RHD) is an important cause of heart disease globally. Its management can encompass medical and procedural (catheter and surgical) interventions. Literature pertaining to the medical management of RHD from PubMed 1990-2016 and via selected article reference lists was reviewed. Areas included symptom management, left ventricular dysfunction, rate control in mitral stenosis, atrial fibrillation, anticoagulation, infective endocarditis prophylaxis, and management in pregnancy. Diuretics, angiotensin blockade and beta-blockers for left ventricular dysfunction, and beta-blockers and If inhibitors for rate control in mitral stenosis reduced symptoms and improved left ventricular function, but did not alter disease progression. Rhythm control for atrial fibrillation was preferred, and where this was not possible, rate control with beta-blockers was recommended. Anticoagulation was indicated where there was a history of cardioembolism, atrial fibrillation, spontaneous left atrial contrast, and mechanical prosthetic valves. While warfarin remained the agent of choice for mechanical valve implantation, non-vitamin K antagonist oral anticoagulants may have a role in RHD-related AF, particularly with valvular regurgitation. Evidence for anticoagulation after bioprosthetic valve implantation or mitral valve repair was limited. RHD patients are at increased risk of endocarditis, but the evidence supporting antibiotic prophylaxis before procedures that may induce bacteremia is limited and recommendations vary. The management of RHD in pregnancy presents particular challenges, especially regarding decompensation of previously stable disease, the choice of anticoagulation, and the safety of medications in both pregnancy and breast feeding.
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http://dx.doi.org/10.1097/CRD.0000000000000185DOI Listing
October 2018

Depression and poor outcome after an acute coronary event: Clarification of risk periods and mechanisms.

Aust N Z J Psychiatry 2019 02 22;53(2):148-157. Epub 2018 Mar 22.

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

Objective: Lifetime depression and depression around the time of an acute coronary syndrome event have been associated with poor cardiac outcomes. Our study sought to examine the persistence of this association, especially given modern cardiac medicine's successes.

Methods: For 332 patients admitted for an acute coronary syndrome, a baseline interview assessed major depression status, and psychological measures were administered. At 1 and 12 months post-acute coronary syndrome event, telephone interviews collected rates of hospital readmission and/or death and major depression status, while biomarker information was examined using medical records.

Results: The 12-month mortality rate was 2.3% and cardiac readmission rate 21.0%. Depression subsequent to an acute coronary syndrome event resulted in a threefold and 2.5-fold increase in 1-month and 12-month odds of cardiac readmission or death, respectively. No relationship with past depressive episodes was found. Poor sleep was associated with higher trait anxiety and neuroticism scores and with more severe depression.

Conclusion: Lifetime depression may increase the risk of depression around the time of an acute coronary syndrome but not influence cardiac outcomes. We suggest that poor sleep quality may be causal or indicate high anxiety/neuroticism, which increases risk to depression and contributes to poor cardiac outcomes rather than depression being the primary causal factor.
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http://dx.doi.org/10.1177/0004867418763730DOI Listing
February 2019

Outcomes after mitral valve surgery for rheumatic heart disease.

Heart Asia 2017 19;9(2):e010916. Epub 2017 Jun 19.

Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.

Objective: To further the understanding of the factors influencing outcome following rheumatic heart disease (RHD) related mitral valve surgery, which globally remains an important cause of heart disease and a particular problem in Indigenous Australians.

Methods: The Australian Cardiac Surgery Database was utilised to assess outcomes following mitral valve repair and replacement for RHD and non-RHD valve disease. The association with aetiology, demographics, comorbidities, preoperative status and operative procedure was evaluated.

Results: Mitral valve repairs and replacements undertaken in Australia were analysed from 119 and 1078 RHD surgical procedures and 3279 and 2400 non-RHD procedures, respectively. RHD mitral valve repair, compared with replacement, resulted in a slightly shorter hospital stay and more reoperation for valve dysfunction, but no difference in 30-day survival. In unadjusted survival analysis to 5 years, RHD mitral valve repair and replacement were no different (HR 0.86, 95% CI 0.4 to 1.7), non-RHD repair was superior to replacement (HR 1.7, 95% CI 1.4 to 2.0), RHD and non-RHD repair were no different (HR 0.9, 95% CI 0.5 to 1.7), and RHD replacement was superior to non-RHD (HR 1.5, 95% CI 1.2 to 1.9). None of these differences persisted in adjusted analyses and there was no difference in long-term survival for Indigenous Australians.

Conclusion: In this large prospective cohort study we have demonstrated that adjusted long-term survival following RHD mitral valve repair surgery in Australia is no different to replacement and no different to non-RHD. Interpretation of valve surgery outcome requires careful consideration of patient factors that may also influence survival.
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http://dx.doi.org/10.1136/heartasia-2017-010916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818046PMC
June 2017

Cardiac care for Indigenous Australians: practical considerations from a clinical perspective.

Med J Aust 2017 Jul;207(1):40-45

Royal Darwin Hospital, Darwin, NT.

Indigenous Australians have a much high burden of cardiovascular disease, which occurs at an earlier age than in the non-Indigenous population. Comorbidities such as diabetes are common. Early diagnosis of ischaemic heart disease may be difficult because of barriers such as distance to medical centres, communication problems and family and cultural responsibilities. Disparities in cardiac care between Indigenous and non-Indigenous populations are well documented, with examples including reduced angiography and revascularisation rates in Indigenous patients. Indigenous patients can have poor health literacy and need careful explanation of procedures, with the assistance of Aboriginal health workers, visual aids and family members. Acute rheumatic fever and chronic rheumatic heart disease remain ongoing health problems in Indigenous communities, especially in remote areas. Ambulatory care of Indigenous Australians with chronic cardiovascular disease is challenging. It requires well supported health care systems, including Aboriginal health workers and cardiac nurse coordinators to case-manage patients. A holistic approach to care, with attention directed towards both cardiac and non-cardiac comorbidities, is crucial for optimal management of cardiovascular disease in Indigenous Australians. Multidisciplinary care, involving an empowered and supported primary care team working together with specialists through outreach services or telehealth, is important for patients who are at high clinical risk and those living in remote areas. Indigenous Australians deserve the same level of evidence-based cardiovascular health care and access to care as non-Indigenous Australians.
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http://dx.doi.org/10.5694/mja17.00250DOI Listing
July 2017

Outcome following valve surgery in Australia: development of an enhanced database module.

BMC Health Serv Res 2017 01 17;17(1):43. Epub 2017 Jan 17.

Clinical Research Domain, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC, 3004, Australia.

Background: Valvular heart disease, including rheumatic heart disease (RHD), is an important cause of heart disease globally. Management of advanced disease can include surgery and other interventions to repair or replace affected valves. This article summarises the methodology of a study that will incorporate enhanced data collection systems to provide additional insights into treatment choice and outcome for advanced valvular disease including that due to RHD.

Methods: An enhanced data collection system will be developed linking an existing Australian cardiac surgery registry to more detailed baseline co-morbidity, medication, echocardiographic and hospital separation data to identify predictors of morbidity and mortality outcome following valve surgery.

Discussion: This project aims to collect and incorporate more detailed information regarding pre and postoperative factors and subsequent morbidity. We will use this to provide additional insights into treatment choice and outcome.
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http://dx.doi.org/10.1186/s12913-017-2002-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5240444PMC
January 2017

The burden and implications of preoperative atrial fibrillation in Australian heart valve surgery patients.

Int J Cardiol 2017 Jan 9;227:100-105. Epub 2016 Nov 9.

Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia; School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; School of Medicine, James Cook University, Cairns, Queensland, Australia. Electronic address:

Background: Atrial fibrillation (AF) is the most common preoperative arrhythmia in heart valve surgery patients and its prevalence is rising. This study aims to investigate the impact of AF on valve surgery early complications and survival and on valve disease of different aetiologies and populations with particular reference to Indigenous Australians with rheumatic heart disease (RHD).

Methods: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed to determine the association between preoperative AF and valve surgery outcome. Its association with demographics, co-morbidities, preoperative status and short and long term outcome was assessed.

Results: Outcome of 1594 RHD and 19,029 non-RHD-related surgical procedures was analysed. Patients with preoperative AF were more likely to be older, female, Indigenous, to have RHD and to bear a greater burden of comorbidities. Patients with RHD and preoperative AF had a longer hospital stay and were more likely to require reoperation. Adjusted short (OR 1.4, 95% CI 1.2-1.7) and long term (HR 1.5, 95% CI 1.3-1.7) survival was inferior for patients with non-RHD preoperative AF but was no different for Indigenous and non-Indigenous Australians with RHD.

Conclusions: In this prospective Australian study, patients with valve disease and preoperative AF had inferior short and long term survival. This was particularly the case for patients with non-RHD valve disease. Earlier intervention or more aggressive AF management should be investigated as mechanisms for enhancing postoperative outcomes. This may influence treatment choice and the need for ongoing anticoagulation.
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http://dx.doi.org/10.1016/j.ijcard.2016.11.070DOI Listing
January 2017

Case load and valve surgery outcome in Australia.

Int J Cardiol 2016 Oct 25;221:144-51. Epub 2016 Jun 25.

Baker IDI, Melbourne, Victoria, Australia; School of Medicine, James Cook University, Cairns, Queensland, Australia; School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia. Electronic address:

Background: In Australia it has been suggested that heart valve surgery, particularly for rheumatic heart disease (RHD), should be consolidated in higher volume centres. International studies of cardiac surgery suggest large volume centres have superior outcomes. However the effect of site and surgeon case load on longer term outcomes for valve surgery has not been investigated.

Methods: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed. The adjusted association between both average annual site and surgeon case load on short term complications and short and long-term survival was determined.

Results: Outcomes associated with 20,116 valve procedures at 25 surgical sites and by 93 surgeons were analysed. Overall adjusted analysis showed increasing site and surgeon case load was associated with longer ventilation, less reoperation and more anticoagulant complications. Increasing surgeon case load was also associated with less acute kidney injury. Adjusted 30-day mortality was not associated with site or surgeon case load. There was no consistent relationship between increasing site case load and long term survival. The association between surgeon case load and outcome demonstrated poorer adjusted survival in the highest volume surgeon group.

Conclusions: In this Australian study, the adjusted association between surgeon and site case load was not simple or consistent. Overall larger volume sites or surgeons did not have superior outcomes. Mandating a particular site case load level for valve surgery or a minimum number of procedures for individual surgeons, in an Australian context, cannot be supported by these findings.
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http://dx.doi.org/10.1016/j.ijcard.2016.06.179DOI Listing
October 2016

Aboriginal and Torres Strait Islander Cardiovascular Health 2016: Is the Gap Closing?

Heart Lung Circ 2016 Aug;25(8):765-7

Cardiology and Medicine, Royal Darwin Hospital, Darwin, NT, Australia; NT Clinical School, Flinders University, Adelaide, SA, Australia; Menzies School of Health Research, Darwin, NT, Australia.

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http://dx.doi.org/10.1016/j.hlc.2016.05.110DOI Listing
August 2016

A review of outcome following valve surgery for rheumatic heart disease in Australia.

BMC Cardiovasc Disord 2015 Sep 23;15:103. Epub 2015 Sep 23.

Baker IDI, Melbourne, VIC, 3004, Australia.

Background: Globally, rheumatic heart disease (RHD) remains an important cause of heart disease. In Australia it particularly affects younger Indigenous and older non-Indigenous Australians. Despite its impact there is limited understanding of the factors influencing outcome following surgery for RHD.

Methods: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed to assess outcomes following surgical procedures for RHD and non-RHD valvular disease. The association with demographics, co-morbidities, pre-operative status, valve(s) affected and operative procedure was evaluated.

Results: Outcome of 1384 RHD and 15843 non-RHD valve procedures was analysed. RHD patients had longer ventilation, experienced fewer strokes and had more readmissions to hospital and anticoagulant complications. Mortality following RHD surgery at 30 days was 3.1% (95% CI 2.2 - 4.3), 5 years 15.3% (11.7 - 19.5) and 10 years 25.0% (10.7 - 44.9). Mortality following non-RHD surgery at 30 days was 4.3% (95% CI 3.9 - 4.6), 5 years 17.6% (16.4 - 18.9) and 10 years 39.4% (33.0 - 46.1). Factors independently associated with poorer longer term survival following RHD surgery included older age (OR1.03/additional year, 95% CI 1.01 - 1.05), concomitant diabetes (OR 1.7, 95% CI 1.1 - 2.5) and chronic kidney disease (1.9, 1.2 - 2.9), longer invasive ventilation time (OR 1.7 if greater than median value, 1.1- 2.9) and prolonged stay in hospital (1.02/additional day, 1.01 - 1.03). Survival in Indigenous Australians was comparable to that seen in non-Indigenous Australians.

Conclusion: In a large prospective cohort study we have demonstrated survival following RHD valve surgery in Australia is comparable to earlier studies. Patients with diabetes and chronic kidney disease, were at particular risk of poorer long-term survival. Unlike earlier studies we did not find pre-existing atrial fibrillation, being an Indigenous Australian or the nature of the underlying valve lesion were independent predictors of survival.
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http://dx.doi.org/10.1186/s12872-015-0094-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4580994PMC
September 2015

One-step extraction and quantitation of toxic alcohols and ethylene glycol in plasma by capillary gas chromatography (GC) with flame ionization detection (FID).

Clin Biochem 2016 Jan 15;49(1-2):132-8. Epub 2015 Sep 15.

Calgary Laboratory Services, Room 616, 6th Floor, Foothills Medical Centre, 1403 29 Street NW, Calgary, AB T2N 2T9, Canada. Electronic address:

Objectives: Clinical analysis of volatile alcohols (i.e. methanol, ethanol, isopropanol, and metabolite acetone) and ethylene glycol (EG) generally employs separate gas chromatography (GC) methods for analysis. Here, a method for combined analysis of volatile alcohols and EG is described.

Design And Methods: Volatile alcohols and EG were extracted with 2:1 (v:v) acetonitrile containing internal standards (IS) 1,2 butanediol (for EG) and n-propanol (for alcohols). Samples were analyzed on an Agilent 6890 GC FID. The method was evaluated for precision, accuracy, reproducibility, linearity, selectivity and limit of quantitation (LOQ), followed by correlation to existing GC methods using patient samples, Bio-Rad QC, and in-house prepared QC material.

Results: Inter-day precision was from 6.5-11.3% CV, and linearity was verified from down to 0.6mmol/L up to 150mmol/L for each analyte. The method showed good recovery (~100%) and the LOQ was calculated to be between 0.25 and 0.44mmol/L. Patient correlation against current GC methods showed good agreement (slopes from 1.03-1.12, and y-intercepts from 0 to 0.85mmol/L; R(2)>0.98; N=35). Carryover was negligible for volatile alcohols in the measuring range, and of the potential interferences tested, only toluene and 1,3 propanediol interfered. The method was able to resolve 2,3 butanediol, diethylene glycol, and propylene glycol in addition to the peaks quantified.

Conclusions: Here we describe a simple procedure for simultaneous analysis of EG and volatile alcohols that comes at low cost and with a simple liquid-liquid extraction requiring no derivitization to obtain adequate sensitivity for clinical specimens.
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http://dx.doi.org/10.1016/j.clinbiochem.2015.09.007DOI Listing
January 2016

A review of valve surgery for rheumatic heart disease in Australia.

BMC Cardiovasc Disord 2014 Oct 2;14:134. Epub 2014 Oct 2.

Baker IDI Central Australia, PO Box 1294, Alice Springs, NT 0811, Australia.

Background: Globally, rheumatic heart disease (RHD) remains an important cause of heart disease. In Australia it particularly affects older non-Indigenous Australians and Aboriginal Australians and/or Torres Strait Islander peoples. Factors associated with the choice of treatment for advanced RHD remain variable and poorly understood.

Methods: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed. Demographics, co-morbidities, pre-operative status and valve(s) affected were collated and associations with management assessed.

Results: Surgical management of 1384 RHD and 15843 non-RHD valve procedures was analysed. RHD patients were younger, more likely to be female and Indigenous Australian, to have atrial fibrillation (AF) and previous percutaneous balloon valvuloplasty (PBV). Surgery was performed on one valve in 64.5%, two valves in 30.0% and three valves in 5.5%. Factors associated with receipt of mechanical valves in RHD were AF (OR 2.69) and previous PBV (OR 1.98) and valve surgery (OR 3.12). Predictors of valve repair included being Indigenous (OR 3.84) and having fewer valves requiring surgery (OR 0.10). Overall there was a significant increase in the use of mitral bioprosthetic valves over time.

Conclusions: RHD valve surgery is more common in young, female and Indigenous patients. The use of bioprosthetic valves in RHD is increasing. Given many patients are female and younger, the choice of valve surgery and need for anticoagulation has implications for future management of RHD and related morbidity, pregnancy and lifestyle plans.
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http://dx.doi.org/10.1186/1471-2261-14-134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4196004PMC
October 2014

A framework for overcoming disparities in management of acute coronary syndromes in the Australian Aboriginal and Torres Strait Islander population. A consensus statement from the National Heart Foundation of Australia.

Med J Aust 2014 Jun;200(11):639-43

Clinical Programs, National Heart Foundation of Australia, Melbourne, VIC, Australia.

Aboriginal and Torres Strait Islander patients with acute coronary syndromes (ACS) experience lower intervention rates and poorer outcomes compared with non-Indigenous patients. A broad range of geographical, cultural and systemic factors contribute to delays and suboptimal treatment for ACS. Every Indigenous ACS patient, regardless of where they live, should be able to expect a coordinated, patient-centred pathway of care provided by designated provider clinical networks and supported by Indigenous cardiac coordinators, Aboriginal liaison officers (ALOs) and health workers. These designated provider clinical networks provide: appropriate prehospital and inhospital treatment an individualised patient care plan developed jointly with the patient and his or her family culturally appropriate education initiated within the hospital setting and involving families with support from ALOs effective follow-up care and access to relevant secondary prevention programs. We outline generic pathways to provide policymakers, health planners and health care providers with a framework for ACS diagnosis and management that can be implemented across the diverse settings in which Aboriginal and Torres Strait Islander people reside and their care is delivered, in order to optimise care and assertively address the current disparities in outcomes.
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http://dx.doi.org/10.5694/mja12.11175DOI Listing
June 2014

Analytical measurement of serum 25-OH-vitamin D₃, 25-OH-vitamin D₂ and their C3-epimers by LC-MS/MS in infant and pediatric specimens.

Clin Biochem 2013 Sep 23;46(13-14):1264-71. Epub 2012 Dec 23.

Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.

Objectives: To develop a simple and sensitive LC-MS/MS procedure for quantification of serum 25-OH-vitamin D₃ (25-OH-D₃), 25-OH-vitamin D₂ (25-OH-D₂), and their C3-epimers.

Methods: Serum 25-OH-vitamin D metabolites were extracted with MTBE and quantified by LC-MS/MS. Commercially available calibrators and QC materials were employed. The ion-transition 401.2→365.2 was monitored for 25-OH-D₃ and C3-epi-25-OH-D₃, 407.2→371.3 for d6-25-OH-D₃, 413.2→331.2 for 25-OH-D₂ and C3-epi-25-OH-D₂ and 419.2→337.1 for, d6-25-OH-D₂. As a proof-of-principle, 25-OH-D₃ and C3-epi-25-OH-D₃ were quantified in 200 pediatric subjects (0-20 years of age). Cholecalciferol supplements were examined as a potential source of C3-epimer.

Results: The assay provided an LLOQ of ≤2.8 nmol/L for all 25-OH-D metabolites, with a linear response up to 400 nmol/L. The CV was <10% for 25-OH-D₂/₃ and <15% for C3-epi-25-OH-D₃. C3-epi-25-OH-D₃ was quantified in all subjects, with higher concentrations observed in infants ≤1 year of age (11.44 nmol/L vs. 4.4 nmol/L; p<0.001). Within the first year of life, 25-OH-D₃ concentrations increased linearly, while C3-epi-25-OH-D₃ concentrations remained constant. At 12 months of age, C3-epi-25-OH-D₃ concentration dropped by almost 50% (11.4 nmol/L in infants ≤1year of age vs. 5.4 nmol/L in infants 1-2years of age; p<0.001). Liquid vitamin D₃ supplements did not contain appreciable amounts of C3-epi-D₃.

Conclusions: The proposed LC-MS/MS procedure is suitable for quantifying 25-OH-D₃ metabolites. Although the C3-epimer is present in all pediatric subjects, it is significantly elevated in individuals ≤1 year of age and drops at 12 months of age. Oral vitamin D supplements are unlikely to be a significant source of C3-vitamin D epimer.
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http://dx.doi.org/10.1016/j.clinbiochem.2012.11.030DOI Listing
September 2013

The future of acute rheumatic fever and rheumatic heart disease in Australia.

Med J Aust 2012 Aug;197(3):133-4

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http://dx.doi.org/10.5694/mja12.10980DOI Listing
August 2012

GAD is good? Generalized anxiety disorder predicts a superior five-year outcome following an acute coronary syndrome.

Psychiatry Res 2011 Aug 8;188(3):383-9. Epub 2011 Jun 8.

School of Psychiatry, University of New South Wales, and Black Dog Institute, Hospital Rd, Prince of Wales Hospital, Randwick, NSW 2031, Australia.

While differing anxiety disorders have been reported to have quite variable impact on outcome following an acute coronary syndrome (ACS), a recent study quantified generalized anxiety disorder (GAD) as having a distinctly negative impact. We examined anxiety disorder status at baseline for any differential five-year impact on cardiac outcome following initial hospitalization for an ACS in 489 subjects. Of those initially assessed, 89% were examined at a five-year review. There were non-significant trends for all non-GAD anxiety disorders to be associated with a worse cardiac outcome. Meeting GAD criteria (both at baseline assessment and over the subjects' lifetime) was associated with a superior five-year cardiac outcome, particularly in the sub-set of those experiencing GAD as their only anxiety disorder, and after controlling for depression and medical comorbidities. As our results are at distinct variance with two previous studies specifically examining the impact of GAD on outcome in cardiac patients, we consider methodological and other explanations. We conclude that, if our findings are valid, then they may more reflect GAD patients having a 'constructive worrying' capacity and therefore being more likely to seek help in response to less severe somatic symptoms and to also be more adherent with cardiac rehabilitation programs.
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http://dx.doi.org/10.1016/j.psychres.2011.05.018DOI Listing
August 2011

Pediatric reference intervals for lymphocyte vitamin C (ascorbic acid).

Clin Biochem 2010 Dec 19;43(18):1411-4. Epub 2010 Sep 19.

Pediatric Ophthalmology and Ocular Genetics, Wills Eye Institute, Philadelphia, PA, USA.

Objective: To establish pediatric reference intervals for lymphocyte vitamin C.

Design And Methods: This was a prospective study of 194 well children aged 0-7 years old of mixed ethnicity who had blood drawn for the purpose of this study. Blood was collected during elective surgery under general anesthesia and lymphocytes isolated and stored as frozen ascorbic acid lymphocyte lysates for later HPLC analysis by previously described methodology. Reference intervals were established according to the Clinical and Laboratory Standards Institute (CLSI) and the International Federation of Clinical Chemistry (IFCC) guidelines (C28-A3). Horn-Pesce robust method was used to estimate the 95% confidence interval and 95% reference interval.

Results: Reference intervals were independent of age or gender and shown to be 12.9-52.8 μg/10(8) cells (lymphocytes).

Conclusion: We have defined pediatric reference ranges for lymphocyte vitamin C in healthy, fasted children at a relevant age group (0-7 years). The new reference interval can now be used to more reliably explore possible implications of variation of vitamin C levels on bleeding and other clinical signs.
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http://dx.doi.org/10.1016/j.clinbiochem.2010.09.008DOI Listing
December 2010

Specificity of depression following an acute coronary syndrome to an adverse outcome extends over five years.

Psychiatry Res 2011 Feb 5;185(3):347-52. Epub 2010 Aug 5.

School of Psychiatry, University of New South Wales, Randwick, NSW 2031, Australia.

Many studies have demonstrated that depression is associated with a worse cardiovascular outcome and increased risk of death in those experiencing an acute coronary syndrome (ACS). Recent studies have suggested, however, that any association is strongly influenced by the timing of the depression, with post-ACS depression providing the greatest risk. Establishing any timing impact should assist etiological clarification. We initially recruited 489 subjects hospitalized for an ACS, assessed lifetime and current depression, and then - at 1 and 12 months - assessed subsequent depression. Subjects were followed for up to 5 years to assess cardiovascular outcome and the impact of depression at differing time points, with three defined poor outcome categories (i.e. cardiac admission and/or cardiac rehospitalization). While outcome was associated with a number of non-depression variables, a poor outcome was most clearly associated with depressive episodes emerging at the time of the ACS but with some risk affected by episodes that commenced prior to the ACS and being persistent. Neither lifetime depressive episodes nor transient depressive episodes occurring around the baseline ACS event appeared to provide any risk. Study findings indicate that any differential deleterious impact of post-ACS depression has both short-term and longer-term outcomes, and, by implicating the centrality of post-ACS depression, should assist studies seeking to identify causal explanations.
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http://dx.doi.org/10.1016/j.psychres.2010.07.015DOI Listing
February 2011

Medical management of chronic rheumatic heart disease.

Authors:
Warren F Walsh

Heart Lung Circ 2010 May-Jun;19(5-6):289-94. Epub 2010 May 6.

Department of Cardiology, The Prince of Wales Hospital, Barker Street, Randwick, NSW 2031, Australia.

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http://dx.doi.org/10.1016/j.hlc.2010.04.130DOI Listing
August 2010

The Cardiac Society Inaugural Cardiovascular Health Conference: conference findings and ways forward.

Heart Lung Circ 2010 May-Jun;19(5-6):264-8. Epub 2010 Apr 8.

Baker IDI Heart and Diabetes Institute, Alice Springs, Australia.

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http://dx.doi.org/10.1016/j.hlc.2010.02.020DOI Listing
August 2010

Coronary disease in indigenous populations: summary from the CSANZ indigenous Cardiovascular Health Conference.

Heart Lung Circ 2010 May-Jun;19(5-6):299-305. Epub 2010 Apr 8.

Centre for Indigenous Vascular and Diabetes Research, Baker IDI Heart and Diabetes Institute, PO Box 1294, Alice Springs, NT, 0871, Australia.

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http://dx.doi.org/10.1016/j.hlc.2010.02.022DOI Listing
August 2010

Overview and determinants of cardiovascular disease in indigenous populations.

Heart Lung Circ 2010 May-Jun;19(5-6):337-43. Epub 2010 Apr 7.

University of Sydney, Sydney, Australia.

Cardiovascular disease (CV) is an important problem among the 400 million Indigenous Populations around the world, and has been included in the World Health Organization (WHO) "2008-2013 Action Plan for Non-Communicable Diseases". Our understanding of the causes of CV disease in the Indigenous populations of Australia and New Zealand will be facilitated by better understanding the causes of CV disease in Indigenous populations around the world. The opening scientific presentations of the Inaugural CSANZ Conference on Indigenous Cardiovascular Health were from two international speakers notable for their commitment to Indigenous Health as a global problem.
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http://dx.doi.org/10.1016/j.hlc.2010.02.017DOI Listing
August 2010

Recommendations arising from the inaugural CSANZ Conference on Indigenous Cardiovascular Health.

Heart Lung Circ 2010 May-Jun;19(5-6):269-72. Epub 2010 Apr 7.

University of Sydney, Australia.

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http://dx.doi.org/10.1016/j.hlc.2010.02.018DOI Listing
August 2010

Improving cardiovascular care for indigenous populations.

Heart Lung Circ 2010 May-Jun;19(5-6):344-50. Epub 2010 Mar 31.

University of Sydney, Australia.

The challenges and opportunities for provision of, and access to, reliable chronic cardiovascular health care for Indigenous people were addressed by expert speakers from New Zealand and Australia. It is well recognised that cardiovascular disease is a life-long concern, requiring reliable follow-up, early transition of clinical research into practice and ongoing support of patients. The clinical outcomes and long-term prognosis of individuals with cardiovascular disease are critically dependent upon the quality and availability of follow-up and chronic care facilities. This paper summarises the principal issues identified by the expert speakers for the provision of chronic cardiovascular health care to Indigenous peoples in Australia and New Zealand; identifies common challenges and describes important initiatives which the Cardiac Society of Australia and New Zealand (CSANZ), in partnership with health care professionals, communities and governments, can undertake in order to achieve the goals of uniform and equitable health care for chronic cardiovascular disease in all the Indigenous peoples, relevant to the needs of these peoples, in New Zealand and Australia. The issues addressed by the meeting include: 1) Determination of appropriate models for effective delivery of cardiovascular health care. (2) Who should deliver cardiovascular health care and what are the workforce requirements. (3) What support systems and infrastructure are required. (4) How can primary care and secondary specialist services be effectively integrated.
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http://dx.doi.org/10.1016/j.hlc.2010.02.015DOI Listing
August 2010

Rheumatic heart disease in indigenous populations.

Heart Lung Circ 2010 May-Jun;19(5-6):273-81. Epub 2010 Mar 30.

Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand.

Rates of acute rheumatic fever and chronic rheumatic heart disease in Aboriginal people, Torres Strait Islanders and Māori continue to be unacceptably high. The impact of rheumatic heart disease is inequitable on these populations as compared with other Australians and New Zealanders. The associated cardiac morbidity, including the development of rheumatic valve disease, and cardiomyopathy, with possible sequelae of heart failure, development of atrial fibrillation, systemic embolism, transient ischaemic attacks, strokes, endocarditis, the need for interventions including cardiac surgery, and impaired quality of life, and shortened life expectancy, has major implications for the individual. The adverse health and social effects may significantly limit education and employment opportunities and increase dependency on welfare. Additionally there may be major adverse impacts on family and community life. The costs in financial terms and missed opportunities, including wasted young lives, are substantial. Prevention of acute rheumatic fever is dependent on the timely diagnosis and treatment of sore throats and skin infections in high-risk groups. Both Australia and New Zealand have registries for acute rheumatic fever but paradoxically neither includes all cases of chronic rheumatic heart disease many of whom would benefit from close surveillance and follow-up. In New Zealand and some Australian States there are programs to give secondary prophylaxis with penicillin, but these are not universal. Surgical outcomes for patients with rheumatic valvular disease are better for valve repair than for valve replacement. Special attention to the selection of the appropriate valve surgery and valve choice is required in pregnant women. It may be necessary to have designated surgical units managing Indigenous patients to ensure high rates of surgical repair rather than valve replacement. Surgical guidelines may be helpful. Long-term follow-up of the outcomes of surgery in Indigenous patients with rheumatic heart disease is required. Underpinning these strategies is the need to improve poverty, housing, education and employment. Cultural empathy with mutual trust and respect is essential. Involvement of Indigenous people in decision making, design, and implementation of primary and secondary prevention programs, is mandatory to reduce the unacceptably high rates of rheumatic heart disease.
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http://dx.doi.org/10.1016/j.hlc.2010.02.019DOI Listing
August 2010

Timing is everything: the onset of depression and acute coronary syndrome outcome.

Biol Psychiatry 2008 Oct 7;64(8):660-6. Epub 2008 Jul 7.

Black Dog Institute, Prince of Wales Hospital, Randwick, Australia.

Background: Conflicting findings have emerged from studies examining the impact of depression on death and readmission following a coronary event, possibly reflecting differences in the measurement of "depression" and the onset of depression in relation to the coronary event. The aim of this study was to examine the relationship between the timing of the depressive episode and 1-year cardiovascular outcome in recruited patients with acute coronary syndrome (ACS).

Methods: Patients hospitalized with ACS (N = 489) were recruited and assessed for lifetime and current depression by the Composite International Diagnostic Interview (CIDI) depression schedule. Patients were reinterviewed at 1 and 12 months by telephone to assess depression status and cardiovascular outcomes (ACS readmission and cardiac mortality). Mortality registers were also checked.

Results: Cardiovascular outcome was not associated with the presence of lifetime depression before the ACS admission or with existing depression at the time of the ACS admission. In contrast, depression that developed in the month after the ACS event showed a strong relationship with subsequent cardiovascular outcome, even after controlling for traditional cardiac risk factors. Outcome over the 12 months was more strongly predicted by the timing of depression onset than whether the depression was a first-ever (incident) or recurrent episode.

Conclusions: Only a depressive episode that commenced following an ACS admission was associated with a poorer cardiovascular outcome. If confirmed, this finding would narrow the list of causal mechanisms previously proposed to account for the relationship between depression and coronary events.
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http://dx.doi.org/10.1016/j.biopsych.2008.05.021DOI Listing
October 2008

The diagnosis and management of chronic rheumatic heart disease--an Australian guideline.

Heart Lung Circ 2008 Aug 1;17(4):271-89. Epub 2008 Apr 1.

Department of Cardiovascular Medicine, The Prince of Wales Hospital, Sydney, Australia.

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http://dx.doi.org/10.1016/j.hlc.2007.12.002DOI Listing
August 2008

Clinical adaptation of a pharmacokinetic model of Propofol plasma concentrations in children.

Paediatr Anaesth 2008 Mar 7;18(3):235-9. Epub 2008 Jan 7.

Department of Anaesthesia, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Background: A previously published pharmacokinetic simulation suggested a simple manual infusion regimen to achieve propofol plasma concentrations of 3 microg.ml(-1). This study investigated if a simple variation in propofol infusion rates is able to achieve distinct propofol plasma concentrations and whether these are close to the propofol plasma concentrations predicted by the Kataria model.

Methods: With Research Ethics Board approval and written parental consent, a total of 17 healthy children requiring general anaesthesia were enrolled. Following inhalational induction of anaesthesia, a propofol bolus of 5 mg.kg(-1) was given and anaesthesia maintained using an adaptation of the McFarlan continuous propofol infusion regimen to achieve three distinct depths of propofol anaesthesia. Weight and propofol infusion data were used to calculate simulated propofol concentrations using the Kataria dataset and the TIVA simulation program. The performance of the infusion regimen was assessed by calculating the median performance error, median absolute performance error, wobble, and divergence.

Results: Measured propofol concentrations were (mean +/- sd) 7.15 +/- 1.4, 4.3 +/- 0.85, and 2.85 +/- 0.53 microg.ml(-1) against simulation values of 6.6, 4.1, and 2.8 microg.ml(-1), respectively, at 30, 50, and 70 min using the Kataria dataset. These differences were not significant. Formal assessment of the infusion regimen's performance was acceptable.

Conclusion: The manual propofol infusion regimen achieved three distinct depths of propofol anaesthesia. The manual infusion regimen produced higher plasma propofol concentrations than predicted during the early part of the infusion period but was more accurate for later time points.
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http://dx.doi.org/10.1111/j.1460-9592.2007.02407.xDOI Listing
March 2008

Final myocardial blush grade predicts troponin I elevation in unstable angina patients undergoing percutaneous intervention.

Heart Lung Circ 2006 Oct 24;15(5):291-6. Epub 2006 Jul 24.

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

Background: Improved myocardial blush grade is associated with better MACE outcomes in acute myocardial infarction patients but there are no data on myocardial blush grade (MBG) assessment in unstable angina (UA) patients treated with coronary intervention. We sought to evaluate the use of angiographic MBG assessment in a cohort of UA patients treated with angioplasty.

Methods: Three hundred and seventy-two consecutive UA patients (mean age 68+/-1 years) treated with PCI were included. No patients had a pre-procedural troponin I (TnI) elevation. Final MBG was recorded for the territory subserving the PCI treated culprit lesion in each patient and graded 0 (no blush), 1 (minimal blush), 2 (moderate blush) and 3 (normal blush). TnI (normal range <0.1 microg/L) was measured 24h post-procedure. Patients who did not have a TnI elevation (i.e. <0.1 microg/L) were ascribed a value of 0.1 microg/L. Patients were followed up (mean 962+/-83 days) by postal questionnaire.

Results: Baseline risk factors were comparable between final MBG groups. There was no significant difference in mortality rate between groups. Post-procedural troponin I elevations were 0.34+/-0.12, 0.68+/-0.26, 0.14+/-0.01 and 0.11+/-0.01 for MBG groups 0, 1, 2 and 3 (p<0.001). Patients with minimal MBG underwent proportionately more target vessel revascularisation (p<0.05).

Conclusions: Improved blush grade in UA patients undergoing PCI is associated with lower post-procedural TnI elevation. Identification of UA patients with poor final MBG may allow a window of opportunity for the administration of adjuvant therapies to improve microvascular perfusion in the future.
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http://dx.doi.org/10.1016/j.hlc.2006.05.008DOI Listing
October 2006

A validation study of two brief measures of depression in the cardiac population: the DMI-10 and DMI-18.

Psychosomatics 2006 Mar-Apr;47(2):129-35

Black Dog Institute, Prince of Wales Hospital, Sydney, Australia.

The authors report on the psychometric characteristics and clinical efficacy of two versions of a recently developed screening measure of depression (the DMI-18 and DMI-10) in the cardiac population. Patients with acute coronary syndrome or heart failure (N = 322) completed the DMI measures, psychosocial questionnaires, and a semistructured clinical interview during the hospital stay. The DMI-18 and DMI-10 measures have adequate psychometric properties, demonstrating high sensitivity and specificity when evaluated against clinical judgment based on a semistructured interview. The DMI-18 and DMI-10 are appropriate for use as screening instruments in cardiac patients.
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http://dx.doi.org/10.1176/appi.psy.47.2.129DOI Listing
March 2006

Low levels of docosahexaenoic acid identified in acute coronary syndrome patients with depression.

Psychiatry Res 2006 Mar 24;141(3):279-86. Epub 2006 Feb 24.

School of Psychiatry, University of New South Wales, Prince of Wales Hospital, Randwick, NSW 2031, Australia.

As deficiencies in n-3 PUFAs have been linked separately to depression and to cardiovascular disease, they could act as a higher order variable contributing to the established link between depression and cardiovascular disease. We therefore examine the relationship between depression and omega-3 polyunsaturated fatty acids (n-3 PUFA), including total n-3 PUFA, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), in patients with acute coronary syndrome (ACS). Plasma phospholipid levels of n-3 PUFA were measured in 100 patients hospitalized with ACS. Current major depressive episode was assessed by the Composite International Diagnostic Interview (CIDI). Depression severity was assessed by the 18-item Depression in the Medically Ill (DMI-18) measure. Patients clinically diagnosed with current depression had significantly lower mean total n-3 PUFA and DHA levels. Higher DMI-18 depression severity scores were significantly associated with lower DHA levels, with similar but non-significant trends observed for EPA and total n-3 PUFA levels. The finding that low DHA levels were associated with depression variables in ACS patients may explain links demonstrated between cardiovascular health and depression, and may have prophylactic and treatment implications.
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http://dx.doi.org/10.1016/j.psychres.2005.08.005DOI Listing
March 2006