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BACKGROUND: This study examined revascularization rates after acute myocardial infarction (AMI) for Aboriginal and non-Aboriginal patients sequentially controlling for admitting hospital and risk factors. METHODS AND RESULTS: Hospital data from the state of New South Wales, Australia (July 2000 through December 2008) were linked to mortality data (July 2000 through December 2009). The study sample were all people aged 25 to 84 years admitted to public hospitals with a diagnosis of AMI (n=59 282). Single level and multilevel Cox regression was used to estimate rates of revascularization within 30 days of admission. A third (32.9%) of Aboriginal AMI patients had a revascularization within 30 days compared with 39.7% non-Aboriginal patients. Aboriginal patients had a revascularization rate 37% lower than non-Aboriginal patients of the same age, sex, year of admission, and AMI type (adjusted hazard ratio, 0.63; 95% confidence interval, 0.57-0.70). Within the same hospital, however, Aboriginal patients had a revascularization rate 18% lower (adjusted hazard ratio, 0.82; 95% confidence interval, 0.74-0.91). Accounting for comorbidities, substance use and private health insurance further explained the disparity (adjusted hazard ratio, 0.96; 95% confidence interval, 0.87-1.07). Hospitals varied markedly in procedure rates, and this variation was associated with hospital size, remoteness, and catheterization laboratory facilities. CONCLUSIONS: Aboriginal Australians were less likely to have revascularization procedures after AMI than non-Aboriginal Australians, and this was largely explained by lower revascularization rates at the hospital of first admission for all patients admitted to smaller regional and rural hospitals, a higher comorbidity burden for Aboriginal people, and to a lesser extent a lower rate of private health insurance among Aboriginal patients.

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BACKGROUND: Retroperitoneal hematoma (RPH) increases morbidity and mortality in percutaneous coronary intervention (PCI). High femoral arteriotomy is an independent predictor of RPH, but the optimal angiographic criterion for defining a high puncture is unknown. METHODS: We retrospectively identified 557 consecutive PCI cases with femoral angiograms. Arteriotomy sites were categorized as high based on three angiographic criteria: at or above the proximal third of the femoral head (criterion A), at or above the most inferior border of the inferior epigastric artery (criterion B), and at or above the origin of the inferior epigastric artery (criterion C). Cases of RPH were then identified. RESULTS: Of the 557 PCI patients, 26 had a high femoral arteriotomy by criterion A, 17 by criterion B, and 6 by criterion C. Among these patients with a high arteriotomy, RPH occurred in four with criterion A, in three with criterion B, and in one with criterion C. Of the three criteria, criterion A most strongly correlated with RPH (odds ratio [OR] 96, 95% confidence interval [CI] 10.3-898.4; p < 0.0001) compared with criterion B (OR 58, 95% CI 8.9 to 372.6; p < 0.0001) or C (OR 27, 95% CI 2.6 to 290.1; p = 0.053). All criteria had high specificity (A, 96%; B, 97%; C, 99%), but the sensitivity was higher with criterion A (80%) than criterion B (60%) or C (20%), and statistically, the use of criterion A led to the most accurate risk-stratification for RPH (A, κ = 0.79; B, κ = 0.59; C, κ = 0.19). CONCLUSIONS: Among the three common definitions of high arteriotomy, femoral artery puncture at or above the proximal third of the femoral head is the landmark that most accurately risk stratifies PCI patients for development of RPH.

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BACKGROUND: Heart disease is a leading cause of the gap in burden of disease between Aboriginal and non-Aboriginal Australians. Our study investigated short- and long-term mortality after admission for Aboriginal and non-Aboriginal people admitted with acute myocardial infarction (AMI) to public hospitals in New South Wales, Australia, and examined the impact of the hospital of admission on outcomes. METHODS: Admission records were linked to mortality records for 60047 patients aged 25-84 years admitted with a diagnosis of AMI between July 2001 and December 2008. Multilevel logistic regression was used to estimate adjusted odds ratios (AOR) for 30- and 365-day all-cause mortality. RESULTS: Aboriginal patients admitted with an AMI were younger than non-Aboriginal patients, and more likely to be admitted to lower volume, remote hospitals without on-site angiography. Adjusting for age, sex, year and hospital, Aboriginal patients had a similar 30-day mortality risk to non-Aboriginal patients (AOR: 1.07; 95% CI 0.83-1.37) but a higher risk of dying within 365 days (AOR: 1.34; 95% CI 1.10-1.63). The latter difference did not persist after adjustment for comorbid conditions (AOR: 1.12; 95% CI 0.91-1.38). Patients admitted to more remote hospitals, those with lower patient volume and those without on-site angiography had increased risk of short and long-term mortality regardless of Aboriginal status. CONCLUSIONS: Improving access to larger hospitals and those with specialist cardiac facilities could improve outcomes following AMI for all patients. However, major efforts to boost primary and secondary prevention of AMI are required to reduce the mortality gap between Aboriginal and non-Aboriginal people.

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BACKGROUND: Prediction of the location of culprit lesions responsible for ST-segment elevation myocardial infarctions may allow for prevention of these events by safe and easily deliverable local therapies. METHODS: A retrospective analysis of coronary movement was performed on coronary angiograms of patients who subsequently represented with ST-segment elevation myocardial infarction treated by primary or rescue angioplasty at a single institution. RESULTS: Twenty patients were identified. The stretch-compression type of coronary artery movement (CAM) was a statistically significant independent predictor of the segment containing the culprit lesion (odds ratio 6.10, p-value 0.005). CONCLUSIONS: The stretch-compression type of coronary artery movement is an independent predictor of the location of culprit lesions responsible for ST-segment elevation myocardial infarctions.

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Atrial septostomy is a palliative treatment for severe pulmonary hypertension. We report the insertion of a novel custom-made fenestrated Amplatzer atrial septostomy device following repeat atrial septostomy for severe pulmonary hypertension in a terminally ill patient with scleroderma resulting in 6 months of palliation.

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