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Acute coronary syndrome (ACS) is a life-threatening condition, with ACS-associated morbidity and mortality causing substantial human and economic challenges to the individual and health services. Due to shared disease determinants, those with ACS have a high risk of comorbid Type 2 diabetes mellitus (T2DM). Despite this, the two conditions are managed separately, duplicating workload for staff and increasing the number of appointments and complexity of patient management plans. This rapid review compared current ACS and T2DM guidelines across Australia, Canada, Europe, Ireland, New Zealand, the UK, and the USA. Results highlighted service overlap, repetition, and opportunities for integrated practice for ACS-T2DM lifestyle management across diet and nutrition, physical activity, weight management, clinical and psychological health. Recommendations are made for potential integration of ACS-T2DM service provision to streamline care and reduce siloed care in the context of the health services for ACS-T2DM and similar comorbid conditions.

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BACKGROUND: Percutaneous coronary intervention (PCI) via left internal mammary artery (LIMA) graft is technically challenging, requires special consideration due to association with potential complications and therefore, infrequently performed. Data on in-stent chronic total occlusion (CTO) PCI via the LIMA graft is even rarer. CASE SUMMARY: A 59-year-old male with a background history of coronary artery bypass graft surgery and previous PCI, presented with progressive chest pain on mild exertion, in the setting of a chronic coronary syndrome. Transradial coronary angiography revealed significant native three-vessel disease with CTO of right coronary, left anterior descending (LAD) and left circumflex arteries. Left internal mammary artery-LAD was widely patent. The previous LIMA-LAD stent at the anastomosis had a CTO with severe in-stent restenosis (ISR) at the distal end of the stent in the native LAD. The distal LAD was filled from bridging collaterals. Following discussion at the heart team meeting, he underwent successful complex PCI of LAD CTO via the LIMA graft at the site of ISR of previous LIMA-LAD anastomosis stent, which was finally treated with drug-coated balloon (DCB) angioplasty. DISCUSSION: Recurrent angina post-coronary revascularization can be very challenging to manage by medical therapy alone. Percutaneous intervention of complex coronary lesions in these patients requires experience and skill, especially when approaching lesions using the LIMA as a conduit. The use of DCB for ISR management is a well-known strategy; however, adequate lesion preparation is the key to satisfactory outcome.

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QRS electrical alternans is characterised by alternating amplitude of the QRS complexes, and is well-documented in cardiac conditions such as pericardial effusion. We describe a case of QRS alternans in a patient with gastric volvulus.

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The metabolic syndrome-otherwise called syndrome X, insulin resistance syndrome, Reaven syndrome, and "the deadly quartet"-is the name given to the aggregate of clinical conditions comprising central and abdominal obesity, systemic hypertension, insulin resistance (or type 2 diabetes mellitus), and atherogenic dyslipidemia. It is a prothrombotic and proinflammatory state characterized by increased inflammatory cytokine activity. In addition to inflammatory dermatoses such as psoriasis, lichen planus, and hidradenitis suppurativa, metabolic syndrome is also commonly associated with accelerated atherosclerotic cardiovascular disease, hyperuricemia/gout, chronic kidney disease, and obstructive sleep apnea. Current therapeutic options for metabolic syndrome are limited to individual treatments for hypertension, hyperglycemia, and hypertriglyceridemia, as well as dietary control measures and regular exercise.

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UNLABELLED: With the introduction of transcatheter aortic valve implantation (TAVI), the precise role of balloon aortic valvuloplasty (BAV) remains to be established. METHODS: Between August 2008 and November 2010, consecutive patients undergoing BAV for severe aortic stenosis (AS) in our center were enrolled. The primary endpoint was survival to hospital discharge. Secondary endpoints were 30-day survival and progression to aortic valve replacement (AVR). RESULTS: Enrolled were 64 patients (age, 82 ± 8 years; 45% male). Treatment objectives were: symptom palliation (69%); potential AVR (23%); and facilitation of withdrawal of ventilation or non-cardiac surgery (8%). At baseline, patients had logistic EuroSCORE of 35.7 ± 19.5, NT-proBNP of 11,195 ± 11,694 ng/L, aortic valve area of 0.53 ± 0.17 cm², and peak transaortic gradient (PG) of 75.2 ± 25.3 mm Hg. The primary endpoint of survival to hospital discharge was reached by 97% patients. The secondary endpoint of 30-day mortality occurred in 8 patients (13%). Overall, 12 patients showed clinical improvement within 1 month of BAV. Of these, 8 patients underwent AVR (TAVI in 3/8 [38%]). After multivariate adjustment, the strongest correlates for 30-day survival and progression to AVR pre-BAV were: New York Heart Association ≤II, SBP ≥90 mm Hg, estimated glomular filtration rate ≥45 mL min-1, left ventricular ejection fraction ≥45% and transaortic PG <80 mm Hg. CONCLUSION: In patients with severe AS and high operative risk, BAV has the potential to facilitate progression to TAVI in those who are technically suitable.

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