National Heart Foundation Research Articles

Assessing the quality of cardiac rehabilitation programs by measuring adherence to the Australian quality indicators.

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Australian National Health and Medical Research Council (NHMRC) Background Cardiac rehabilitation (CR) prevents recurrent cardiac events and supports patients’ return to an active and fulfilling lifestyle. Evidence on the efficacy of CR programs is well established, but variability of quality across programs may compromise patient outcomes. Core components, quality indicators (QIs) and accreditation of programs have been introduced internationally to increase program standardisation, quality and outcomes. (1) The Australian Cardiovascular Health and Rehabilitation Association (ACRA) and National Heart Foundation (NHF) recently published 10 QIs for CR, comprising process and outcome indicators that can guide delivery of evidence-based service content (Figure 1). (2) Purpose The aim was to assess the performance of CR programs in Australia through their adherence to the measurement of the Australian QIs. Methods A cross-sectional survey design with face validity testing was used to formulate questions to evaluate CR program performance based on adherence to 9 of the 10 Australian QIs. Between October 2020- December 2021, all 23 CR programs across country and metropolitan areas of South Australia (SA) participated. In addition, each QI was weighted by an expert group of clinician researchers and a service performance score was calculated out of 16. According to the score quartiles, programs could be categorised across 4 performance levels: Poor (0-4.5), Low (5-8.5), Medium (9-12.5) or High (13-16). Results Among the 23 participating CR programs, median wait time from discharge to enrolment (QI-2) was 27 days, (interquartile range 19.0-46.0) and completions of enrolled were 66% (n=1316 /1972). All QIs were measured, but not by all programs. Pre-program QI adherence was higher than post program for depression, medication adherence, health-related quality of life and comprehensive re-assessment (Figure 1). Health-related quality of life (HRQOL) was poorly measured pre and post program (21.7% versus 17.3%). For functional exercise capacity assessment, the six-minute walk test was used by 69.5% of programs. Mean performance score was 11.4 /16 (SD ±0.79). Most (74%) programs were ranked at a medium level of performance, whereas 13% were ranked at low and high levels and none as poor. Conclusions A survey of 23 CR programs showed gaps in adherence to measurement of the ACRA/NHF Quality indicators in SA, including re-assessment (QI9), HRQOL (QI-8), medication adherence (QI-6) and exercise capacity (QI-7). Service performance scores were lower than an Australian national audit for each category, with United Kingdom data showing more services in the high and less in the medium category than SA. These data give us a baseline from which to improve CR service quality and outcomes.

Evaluating the usability of a co-designed interactive web application for cardiac rehabilitation.

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Novartis Background/significance The rapid development of information technology is driving the evolution of choices of modes of delivery of healthcare services. The internet is an extremely powerful tool for accessing information, and communication. However, involvement of patients in the assessment of such an intervention is crucial, and can be achieved through a person-centred approach, utilising a co-design process with the aim to increase intervention usability. Purpose To assess the usability of the Country Access to Cardiac Health (CATCH) Web, an interactive web application for cardiac rehabilitation (CR), co-designed with rural and remote Australians, following the co-design development phase. Methods The User Experience (UX) Design framework was used to co-design the web portal with CR patients through two rounds of six co-design workshops pre (n=39), and post (n=35). Participants and family members living in rural and remote areas of Australia were invited to participate based on their eligibility for CR as outlined by the National Heart Foundation of Australia. As part of the UX Design Framework the System Usability Scale (SUS) was used to measure objective feedback from participants on the website design. The SUS assesses the three core components of a products usability: effectiveness, efficiency and satisfaction using a 10 question Likert scale. Mean scores were compared between the two rounds of workshops using an independent T-Test. The mean SUS score is categorised into poor to moderate (<68), good (68-80.3) and excellent (>=80.3) and categories were compared between the two rounds of workshops through Chi-Square tests. Results The 35 participants in the usability workshops had a mean age of 68.6 (SD 11.2) years and 16 (47%) were female (Table 1). The majority had experienced a myocardial infarction (15, 42.8%) and had hyperlipidemia (17, 50%), heart failure (15, 44%), hypertension (14, 41%), and Type II diabetes (7, 21%). Of these participants 20 (59%) used a smart phone, 18 (58%) had access to the National Broadband Network and 20 (59%) engaged with Facebook. From the first to the second round of workshops, there was an improvement in the mean SUS scores from 66.7 (SD16.8) to 73.6 (SD 21.0); p=0.26. The proportion of participants rating it as good or excellent increased from 48.7 to 65.8%; p=0.11 (Figure1). Conclusion The usability testing of the interactive CATCH web application showed an improvement in the SUS rating from poor to moderate in the co-design development phase to good or excellent by most of the participants in the usability testing phase. Usability is closely related to engagement with a digital health intervention. Upcoming evaluation of this intervention will report on clinical outcomes.

In-hospital Outcome and Angiographic Profile of Elderly Patients with Non ST-Segment Elevation Myocardial Infraction

Background: Non ST - segment elevation myocardial infarction is heterogeneous in its presentation and is a major life-threatening cause of emergency medical care and hospitalization. Patients with non ST-segment elevation myocardial infarction are at risk for adverse cardiac events and if associated with increased age, it become a strong predictor of adverse cardiac events in patients with non ST-segment elevation myocardial infarction. Objective: To find out in - hospital outcome and severity of coronary artery disease of older patient with non - ST segment elevation myocardial infarction. Methods: This was a descriptive cross sectional study. The study was carried out in the department of cardiology, National Heart Foundation Hospital and Research Institute from June 2011 to May 2012. Patients of non ST - segment elevation myocardial infarction admitted at National Heart Foundation & Research Institute who fulfill the inclusion criteria were the study population. Patients were recruited by nonrandom sampling. One hundred and thirty four patients were recruited in this study. Data were prospectively collected in a pre - designed data collection form and analyzed by using SPSS - 16 software. Results: In this study patients had a greater prevalence of hypertension, diabetes mellitus. Chest pain and shortness of breath were common presentations observed in study patient during admission. They had a lower left ventricular ejection fraction than their younger counter parts. Older group was associated with an increased risk of triple vessel disease. In-hospital complications were significantly higher in older patients. Duration of hospital stay was longer in older patients. Conclusion: Older patients with non- ST segment myocardial infarction strongly predicts adverse inhospital outcome and severe coronary artery disease profile. Older patients should alert physicians to an increased risk of morbidity and mortality, which may in turn support more judicious treatment including appropriate utilization of cardiovascular diagnostic tests and therapeutics used in current cardiovascular care to optimize outcomes in these high-risk patients. Bangladesh Heart Journal 2022; 37(1): 52-58

Relationship between Urinary Albumin Creatinine Ratio and Severity of Coronary Artery Disease in Non-Diabetic Patients

Background: Coronary artery disease (CAD) is leading cause of mortality worldwide. CAD accounts for 20% of all deaths in the South Asia region. The burden of CAD is emerging as a public health concern in developing countries like Bangladesh. There are some new biomarkers for detection of CAD. The aim of this study was to find out the relationship between ACR and severity of coronary artery disease in non-diabetic.Material & Methods:This cross-sectional analytical study was conducted in the department of cardiology, National Heart Foundation Hospital and Research Institute from April, 2018 to March, 2019. Purposive sampling was done to select a total 101 study subjects. Data were collected in a predesigned data collection form through clinical history, examination, laboratory findings and coronary angiogram report. Study population was divided into two groups: Group–A: Non-diabetic patients with ACR > 30mg/g Group–B: Non-diabetic patients with ACR ≤ 30mg/g.Results:Participants had a mean age of 52.5 ± 9.9 years with 75.24% men. Group A patients had higher ACR level (49.98±15.83 vs 13.36±7.08; p<0.01) than group B patients. Relation between urinary ACR and severity of CAD remained significant. Conclusions:In this study, there found a significant relationship in ACR and severity of coronary artery disease in non-diabetic patients.

Estimation of Radiological Risk on Medical Staff and Public Inside & Outside of Three Large Hospital Campuses of Dhaka, Bangladesh

Ionizing radiation offers great benefit to people in the hospital through diagnostic and therapeutic procedures to patients but undue radiation may create short- and long-term problems for medical staff & public. The goal of the study is to monitor the real-time radiation inside & outside of the three large hospital campuses in Dhaka city of Bangladesh namely the National Institute of Cancer Research & Hospital (NICRH), National Heart Foundation Hospital & Research Institute (NHFH), Kidney Foundation Hospital & Research Institute (KFH) and estimation of radiological risk on medical staff& public. The average real-time radiation dose rate & calculated average twelve-monthly effective doses to medical staff and public arising from the NICRH, NHFH, KFH were found to be1.781 ± 0.310 μSv/h, 1.685 ± 0.307μSv/h, 1.735 ± 0.341μSv/hand 3.111 ± 0.556mSv, 2.952 ± 0.437 mSv, 3.039 ± 0.329 mSv respectively. The excess life-time cancer risk (ELCR) on medical staff & public was estimated based on the twelve-monthly effective dose and varied from 8.972 Χ 10-3 to 18.938 Χ 10-3with average of 12.071 Χ 10-3. The average twelve-monthly effective dose and ELCR on medical staff were lower than those of the permissible limit. Real-time radiation monitoring inside & outside of the large hospital campuses is essential for detecting a malfunction of the radiation generating equipment and incorrect handling of the radioactive substances. The study would assist in minimizing radiological risk to medical staff & public and thereby would ensure the environment in the hospital is free from radioactive contamination.

Echocardiography assessment of right ventricular dysfunction during postoperative period following total correction of tetralogy of Fallot

Background: Despite major advances in intracardiac surgery since Lillehei and Varco reported the first tetralogy of Fallot (TOF) repair by an open-heart procedure in 1954, right ventricular (RV) dysfunction remains an important clinical problem during the postoperative periods following TOF correction.Methods: This was a cross-sectional study conducted at the department of paediatric cardiology in Bangabandhu Sheikh Mujib medical university (BSMMU), Shahbag, Dhaka in collaboration with national heart foundation hospital and research institute (NHFH and RI) Mirpur, Dhaka, Bangladesh during the period from July 2018 to June 2019. Ethical consideration was approved by the proper concerns. The final sample size was 49. Data analysis was carried out by using the social science (SPSS) version 23.0 windows software. Results: The study was conducted on 49 patients, comprising 30 males and 19 females’ children, and their mean age was 75.38±52.22 months. RV dysfunction global was 63.3% at 24 hours of operation, significantly reduced 49% and 32.7% at 7th and 30th POD respectively. Chi-square test was done where p<0.05. Global dysfunction was 13 (54.2) in ≤5 years, 18 (72.0) in >5 years aged patients.Conclusions: RV dysfunction was more frequent after 24 hours of the postoperative period then it gradually decreases over a period of time

National health and budget impact of implementing the WHO HEARTS hypertension control program in Bangladesh

BackgroundAbout a fifth of adults in Bangladesh have hypertension; only 13% of Bangladesh adults living with hypertension have their blood pressure controlled (<140/90 mmHg). To address the growing burden of hypertension in low-income and middle-income countries, the WHO recommends implementing the HEARTS technical package. HEARTS outlines a practical approach to cardiovascular disease (CVD) prevention in primary care settings, including risk factor screening, diagnosis, treatment, and patient counseling. The Bangladesh Ministry of Health and Family Welfare and the National Heart Foundation of Bangladesh implemented the HEARTS programme in four district health complexes in Sylhet Division starting in 2019. To inform Bangladesh's health care policies, we translated Bangladesh HEARTS programme effectiveness and cost estimates into projections of national health and budget impact for nationwide programme scale-up. MethodsWe used an interactive, web-based model to project CVD deaths averted based on observed facility-based hypertension control rates and used local costs to obtain budget impact estimates of national HEARTS programme implementation. We also explored three alternative scenarios: reducing medication costs by 50%, increasing team-based care with larger roles for nurses and community health workers, and removing laboratory costs. Relative improvement in hypertension control observed in the HEARTS programme (from 26% to 46% in the four districts over 24 months) was applied to the 13% baseline national control rate resulting in a projected improvement to 33% at national scale. The costs of the hypertension programme were quantified with a standard HEARTS costing tool that was deployed in the four district health complexes. The costing tool recorded and calculated unit costs for hypertension screening, CVD risk assessment, health-care worker time or compensation, and drug prices. FindingsAn absolute improvement of 20 percentage points in the national hypertension control rate, from 13% to 33%, would save 9400 lives. Extrapolating local programme costs to the national level resulted in a budget of US$599 million by 2030. Reducing medication costs would lower the budget impact by 42·6%. Increasing team-based care would not substantively affect the cost. Removing laboratory costs would lower the budget by 14%. Combining these innovations would lower the projected cost by 56·9%. InterpretationImplementing the HEARTS programme in Bangladesh might improve hypertension control and save 9400 lives at a budget impact of $599 million by 2030. Increased task sharing and lower medication prices have potential to reduce costs and make reaching hypertension control goals more affordable and sustainable for Bangladesh. FundingColumbia University Global & Population Health Summer Research Fellowship.

Left ventricular dimensions and mass measurement from 3D echocardiography: are we there yet?

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health Research Council (HRC) of New Zealand and National Heart Foundation (NHF) of New Zealand Introduction—Echocardiographic measures of left ventricular (LV) structure and size, including LV wall thickness and LV end-diastolic dimension (LVID), provide important information in the assessment of patients with heart disease. For example, LV mass is a predictor of outcome for patients with hypertension and LVID is a predictor of cardiac resynchronisation response in patients with heart failure. Advances in 3D echocardiography (3DE) have enabled full-volume acquisitions, which overcome geometric assumptions present in conventional 2D echocardiography (2DE), providing a more accurate representation of cardiac geometry. Although numerous validation studies have been performed for 3DE-derived LV volumes, comparisons of LV dimension by 3DE against established methods are limited. Purpose—We sought to compare routine LV dimension measurements between 3DE and 2DE, with validation using cardiac magnetic resonance (CMR) imaging. Methods—Transthoracic echocardiography (2D and 3D) and cine CMR imaging were performed in 62 prospectively recruited participants (47 healthy controls, 9 patients with LVH, 6 patients with aortic regurgitation), &amp;lt;1 h apart. 2DE LV dimension measurements (interventricular septum [IVS], posterior wall thickness [PWT], and LVID) were taken at end-diastole from the parasternal long axis, and mass was calculated using the linear method based on ASE/EACVI guidelines. For 3DE, 3D geometric models of the LV were constructed by interactively fitting surfaces to the endocardium and epicardium using previously validated software, from which corresponding LV dimension measurements and mass were extracted. Measurements were obtained from CMR by a similar 3D geometric modelling process. Results—Differences (mean ± SD) in LV dimension measurements between the three modalities and intraclass correlation coefficients (ICC) are presented in Table I. When compared with CMR, 3DE exhibited higher agreement in terms of LVID and mass than 2DE, but lower agreement in wall thickness measurements. Statistically significant differences were found between 2DE and 3DE for PWT, LVID, and mass, as well as 2DE and CMR for LVID and mass (where P &amp;lt; 0.01 for a paired sample t­-test, marked with an asterisk). Meanwhile, there were no statistically significant differences between 3DE and CMR for IVS, PWT, LVID, or mass. Conclusions—Our results demonstrate that 3DE is superior to 2DE in terms of LVID and mass quantification, exhibiting good agreement with CMR. 3DE exhibited moderate and poor agreement for IVS and PWT, respectively, with both 2DE and CMR, likely due to the lower spatial resolution of 3DE. Further advances in 3DE image quality and analysis tools are therefore needed to improve accuracy of wall thickness measurements. Since 2DE imaging plane and probe positioning can result in oblique measurement and underestimation of LVID, the assessment of LVID and mass by 3DE is likely to lead to more accurate diagnostic and prognostic outcomes. Abstract Table 1

Homocysteine predicts vascular target organ damage in hypertension and may serve as guidance for first-line antihypertensive therapy

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): the primary author is supported by the Australian National Heart Foundation post docctoral fellowship OnBehalf Dobney Hypertension Centre Background Homocysteine is an independent risk factor for cardiovascular and cerebrovascular disease and has been proposed to contribute to vascular dysfunction. We sought to determine in a real-world clinical setting whether homocysteine levels were associated with hypertension mediated organ damage (HMOD) and could guide treatment choices in hypertension. Methods We performed a cross-sectional analysis of prospectively collected data in 145 hypertensive patients referred to our tertiary hypertension clinic at our Hospital and analysed the association of homocysteine with HMOD, renin-angiotensin-aldosterone signaling (RAAS) and blockade. Results The average age of participants was 56 ± 17 years and there was a greater proportion of males than females (89vs56). Regression analysis showed that homocysteine was significantly associated with PWV (β=1.99; 95% CI 0.99-3.0; p &amp;lt; 0.001), albumin creatinine ratio (β=1.14; 95% CI 0.47,1.8; p &amp;lt; 0.001), 24 hr urinary protein excretion (β=0.7; 95% CI 0.48, 0.92; p &amp;lt; 0.001) and estimated glomerular filtration rate (β=-29.4; 95% CI -36.35, -22.4; p &amp;lt; 0.001), which persisted after adjusting for potential confounders such as age, sex, 24 hr BP, inflammation, smoking, diabetes mellitus, renal insufficiency and dyslipidaemia. A positive predictive relationship was observed between plasma homocysteine levels and PWV, with every 1.0 µmol/L increase in homocysteine associated with a 0.1 m/s increase in PWV. Homocysteine was significantly associated with elevated aldosterone concentration (β=0.26; p &amp;lt; 0.001), thereby possible RAAS activation, an effect better resisted by angiotensin receptor blockers than ACE-inhibitors in higher physiological ranges of homocysteine. Conclusions Our results indicate that homocysteine is associated with hypertension mediated vascular damage and could potentially serve to guide first-line antihypertensive therapy.

National Heart Foundation of Australia welcomes new standards in cardiology for pharmacy services

National Heart Foundation of Australia welcomes new standards in cardiology for pharmacy services

In-Hospital Outcome and Angiographic Profile of Elderly Patients with Non-ST Segment Elevation Myocardial Infraction

Background: Non-ST Segment elevation myocardial infarction is heterogeneous in its presentation. Like ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction is life-threatening of a major cause of emergency medical care and hospitalization. Patients with non-ST segment elevation myocardial infarction are at risk for adverse cardiac events, so the initial treatment is very important. Increasing age is a strong predictor of adverse events in non-ST segment elevation myocardial infarction patients. Objective: To determine the in-hospital outcome and severity of coronary artery disease of older patients with Non-ST Segment elevation myocardial infarction. Methods: This was a descriptive cross-sectional study. The study was carried out in the cardiology department, National Heart Foundation Hospital, and Research Institute from June 2011 to May 2012. Patients of Non-ST Segment elevation myocardial infarction admitted at National Heart Foundation &amp; Research Institute who fulfill the inclusion criteria were the study population. Patients were recruited by nonrandom sampling. One hundred and thirty-four patients were recruited in this study. Data were prospectively collected in a pre-designed data collection form and analyzed using SPSS - 16 software. Results: In this study, patients had a greater prevalence of hypertension diabetes mellitus. Chest pain and shortness of breath were common presentations observed in study patients during admission. They had a lower left ventricular ejection fraction than their younger counterparts. The older group was associated with an increased risk of triple vessel disease. In-hospital complications were significantly higher in older patients. Duration of hospital stay was longer in older patients. Conclusion: Older patients with Non-ST Segment myocardial infarction strongly predict adverse in-hospital outcomes and severe coronary artery disease profiles. Older patients should alert physicians to an increased risk of morbidity and mortality, which may, in turn, support more judicious treatment, including appropriate utilization of cardiovascular diagnostic tests and therapeutics used in current cardiovascular care to optimize outcomes in these high- risk patients.

The Mid-Term Outcomes of Cone Repair or Replacement of Tricuspid Valve in Patients with Ebstein's Anomaly: Our Experience.

Cone repair of the tricuspid valve (TV) is a contemporary reproducible technique for surgical reconstruction of Ebstein's anomaly. Different authorities have shown that this technique restores excellent tricuspid valve function. In Bangladesh, this technique still is unfamiliar to many. We hereby present a case series of cone repair and TV replacement with the mid-term outcome (one year to six years) at the National Heart Foundation Hospital & Research Institute, Dhaka, Bangladesh. We prospectively studied 21 patients, who underwent surgical intervention (cone repair or tricuspid valve replacement) for Ebstein's anomaly of TV from March 2014 to June 2020. We divided the total patient population into the cone repair and TV replacement groups. Preoperative, postoperative, and follow-up data were collected from the hospital records, telephone conversations, and clinic visits. All collected data statistically were analyzed. Our patients showed there were statistically significant improvements after surgical intervention with regard to tricuspid regurgitation (TR) (P < 0.001), tricuspid annular plane systolic excursion (TAPSE) (P < 0.001), right ventricular (RV) function (P < 0.001), and New York Heart Association (NYHA) class (P < 0.001). These developments were sustained throughout the follow-up period. Cone repair should be offered to the symptomatic patients of Ebstein's anomaly because symptoms relief, reduction of morbidity, and survival benefits are excellent. Above all, the cone reconstruction shows fantastic results and may well become the surgical technique for patients with Ebstein's anomaly. We hope that new valve repair programs may provide extended longevity and restored quality of life to the patient of Ebstein's anomaly (EA) with the appropriate measures. In case of failed repair, valve replacement is an encouraging option.

Interventions for Reducing Sedentary Behavior in People With Stroke

Interventions for Reducing Sedentary Behavior in People With Stroke

Abstract 11763: The impact of the Australian Warning Signs Campaign on Emergency Medical Service Use for Acute Coronary Syndrome and Unspecified Chest Pain

Background: Between 2009 and 2013, the National Heart Foundation of Australia ran mass media campaigns to improve Australian’s awareness of Acute Coronary Syndrome (ACS) symptoms and the need to call emergency medical services (EMS). This study examined the impact of this campaign on emergency department (ED) presentations and EMS use in Victoria, Australia. Methods: The Victorian Department of Health and Human Services provided data for adult Victorian patients presenting to public hospitals with an ED diagnosis of ACS or unspecified chest pain (U-CP). We modelled changes in the incidence of ED presentations, and the association between the campaign period and 1) EMS arrival and 2) referred to ED by a general practitioner (GP). Models were adjusted for increasing population size, ACS subtype and demographics. Results: Between 2003 and 2015, there were 124,632 eligible ED presentations with ACS and 536,148 with U-CP. In ACS patients, the campaign period was associated with an increase in ED presentations (Incidence Rate Ratio: 1.11; 95% CI: 1.07-1.15), a decrease in presentations via a GP (Adjusted Odds Ratio [AOR]: 0.77; 95% CI: 0.70-0.86), and an increase in EMS use (AOR: 1.10; 95%CI: 1.05-1.17). Similar, but smaller associations were seen in U-CP. Conclusions: The Warning Signs Campaign was associated with improvements in treatment seeking in ACS patients -including increased EMS use. The increase in ACS ED presentations corresponds with a decrease in out-of-hospital cardiac arrest over this time. Future education need to focus on improving EMS use in ACS patient groups where use remains low.

Weight gain and lifestyle factors in women with and without polycystic ovary syndrome

AbstractSTUDY QUESTIONDo extrinsic factors including lifestyle, psychosocial factors and healthcare professional engagement independently contribute to weight gain in women with and without polycystic ovary syndrome (PCOS)?SUMMARY ANSWERWomen with PCOS had a higher rate of weight gain than women without PCOS which was most marked in those with unhealthy lifestyles.WHAT IS KNOWN ALREADYWomen with PCOS have a higher prevalence of overweight/obesity and greater weight gain than women without PCOS. The association of lifestyle factors with weight change in PCOS is not known.STUDY DESIGN, SIZE, DURATIONThe study was a population-based observational study with data collected from seven surveys over 19 years (N = 14 127; Survey 1) involving women with and without PCOS.PARTICIPANTS/MATERIALS, SETTING, METHODSWe used data from the 1973–1978 birth cohort of the Australian Longitudinal Study on Women’s Health.MAIN RESULTS AND THE ROLE OF CHANCEWomen with PCOS gained more weight annually (0.26 kg/year; 95% CI 0.12, 0.39; P &amp;lt; 0.0001) and over 19 years (4.62 kg; 95% CI 3.04, 6.21; P &amp;lt; 0.0001) than women without PCOS (adjusted analyses). For all women, there were positive associations between weight gain and energy intake, sitting time and stress; inverse associations with fibre intake and physical activity (PA); and no associations with diet quality, glycaemic index, healthcare utilization, depression or anxiety. There were interactions between lifestyle factors (energy intake P = 0.006, glycaemic index P = 0.025, sitting time P = 0.041 and PA P = 0.021), PCOS status and time such that weight gain varied between women with and without PCOS according to these factors.LIMITATIONS, REASONS FOR CAUTIONThe limitations of this study include the use of self-reported measures such as diet, PA, sitting time, psychological factors and health care utilization.WIDER IMPLICATIONS OF THE FINDINGSWhile women with PCOS are more prone to weight gain, lifestyle factors have a more profound impact on weight gain in women with PCOS than without PCOS. These study findings have implications for understanding the mechanisms of weight gain in women with PCOS. They also highlight the importance of early lifestyle intervention as soon as PCOS is diagnosed to address modifiable extrinsic factors and prevent excess weight gain and worsening of the clinical features of PCOS.STUDY FUNDING/COMPETING INTEREST(S)M.A.A. is funded by the Monash International Tuition Scholarship and Monash Graduate Scholarship and L.J.M. is funded by a National Heart Foundation Future Leader Fellowship. The authors declared no conflict of interest.TRIAL REGISTRATION NUMBERN/A.

Coronavirus Disease 2019: One Year Experience at Tertiary Care Cardiac Hospital

Background: The Coronavirus Disease 2019 (COVID-19) pandemic is a significant challenge particularly for low and middle-income countries like Bangladesh. Interventions such as home isolation, frequent hand washing, wearing face mask, maintaining social distancing are difficult to implement in densely populated areas. The aim of the study was to delineate demographics, clinical manifestations, treatment modalities and outcomes of COVID-19 affected patients of our hospital. Methods: This prospective observational study was carried out at National Heart Foundation Hospital &amp; Research Institute of Bangladesh between 08 March 2020 to 07 March 2021. During this period all admitted patients who subsequently were diagnosed as COVID positive and health care personnel of this hospital, who experienced fever or respiratory symptoms or came in close contact with COVID-19 patients at home or their workplace &amp; become COVID positive were included. Results: During this one-year period a total of 769 COVID positive patients were detected in our hospital. Mean age of the patients was 48.16 ±15.63 years (range 1-92 years). Two third were male (64.9% vs 35.1%) and had multiple co-morbidities. One fifth of the patients were (19%) asymptomatic. The mean duration of onset of symptoms to test was 3.72±3.7 days. Most common symptoms were fever (65.3%), cough (37.1%), shortness of breath (33.6%) and fatigue (27.8%). Other symptoms were bodyache (18.6%), headache (16.6%), anosmia 16%), sore throat (12.1%), diarrhoea (6.8%), dizziness (5.3%), generalized itching (3.8%). Nearly two third of the COVID positive patients (63.2%) had a diagnosed cardiovascular disease at onset and remaining 36.8% patients presented with only COVID-19 disease. About 75% patients received ivermectin, 5.1% patients received favipiravir and 4.4% patients received remdesivir. Three fourth (74.38%) of patients were hospitalized and remaining one fourth (25.62%) patients were treated either in home isolation or in institutional isolation. Most of the patients recovered, with a case fatality rate of 3.5%. Diabetes, hypertension and age ≥50 years were the independent predictors of mortality. Conclusion: Although most of the patients had good outcome the study revealed 3.5% case fatality. Male with multiple co-morbidities were predominantly affected by COVID 19. Fever, cough, shortness of breath and fatigue were common presenting symptoms. Bangladesh Heart Journal 2021; 36(2): 89-97

Longitudinal strain measurement by 3D modelling from cine CMR: feasibility and comparison to 2D speckle tracking echocardiography

Abstract Background Global longitudinal strain (GLS) has emerged as a sensitive index of left ventricular (LV) systolic function with greater prognostic value than LV ejection fraction (LVEF) in a variety of cardiac disorders. While GLS is routinely derived from 2D speckle tracking echocardiography (STE) and feature tracking in cardiac magnetic resonance (CMR) imaging, calculation of strain via 3D geometric modelling enables analyses of deformation that are independent of 2D image plane constraints. Purpose We sought to compare longitudinal strain measurements extracted from geometric 3D analysis of CMR against values obtained from conventional 2D-STE. Methods Consecutive 2D-echocardiography (2D-echo) and steady-state free precession multiplanar cine CMR scans were performed in 80 prospectively recruited participants (48 healthy controls with LVEF range 53–74%, 30 patients with non-ischaemic cardiac disease with LVEF range 25–77%, and 2 heart transplant recipients with LVEF 53% and 58%), &amp;lt;1 hour apart. Average endocardial peak GLS from 2D-STE was calculated offline using vendor-independent clinical software from apical triplane (2, 3 and 4-chamber) images for each of the standardised LV walls (anterior, anteroseptal, inferoseptal, inferior, inferolateral, anterolateral). Dynamic 3D geometric models of the LV were reconstructed from 3 long- and 6 short-axis CMR slices over one cardiac cycle. Corresponding longitudinal strain measurements were then evaluated by extracting analogous endocardial arc lengths (apex to base of each LV wall) from the 3D LV model. Finally, an average peak GLS was calculated as the mean of the peak longitudinal strains in each LV wall. Results GLS measured by 2D-STE ranged between −6.5% and −27.9% for the study population. A two-way mixed-effects intraclass correlation coefficient (ICC) for absolute agreement of 0.820 (95% CI: [0.720, 0.885]) demonstrated good correlation between average GLS obtained from 2D-STE and CMR. A Bland-Altman analysis revealed a minimal bias (&amp;lt;1%) and 95% limits of agreement (LOA) between −6.3% and 5.5% (Fig. 1), with no apparent proportional bias. Comparatively lower correlation and wider LOA between longitudinal strains from 2D-STE and CMR were observed for each LV wall (Table I). Conclusions Fully automated calculation of LV GLS can be obtained from geometric 3D CMR analysis. Average peak GLS from cine CMR exhibits good agreement with 2D-STE, despite showing only moderate agreement at each LV wall. The increased discrepancy in regional longitudinal strain may be attributed to subjective plane positioning in 2D-echo, which can be expected to improve with advances in 3D-STE. The calculation of GLS by 3D geometric modelling may enhance the diagnostic value of routine cine CMR examinations for LV systolic function assessment. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health Research Council (HRC) of New Zealand and National Heart Foundation (NHF) of New Zealand Figure 1. Bland-Altman analysisTable I. Regional correlations

Role of cFOS in mechanosensitive transcriptional regulation in diabetes associated atherosclerosis

Abstract Atherosclerosis, as manifested clinically by myocardial infarction, stroke and peripheral vascular disease, is a major contributor to cardiovascular disease, the leading cause of death in patients with diabetes. The lipid-laden plaque development within the arterial vessel wall is a progressive process initiated with endothelial cell activation and monocyte adhesion. These cellular events occur primarily at the regions of blood vessels exposed to turbulent blood flow (TBF) and low shear stress such as vascular bends and bifurcations. Exposure of the vascular cells to chronic hyperglycaemia and TBF induces a proatherogenic transcriptional profile. Studies have shown that shear stress regulates vascular pathophysiology via differential regulation of transcription factors (TFs) such as KLF4, EGR1 and AP-1, hence named as mechanosensitive TFs. AP-1 is a heterodimer composed of FOS, Jun and ATF family of TFs. Studies have shown that it is activated by low shear stress in cultured endothelial cells. Increasing evidence supports the vital role of AP-1 family members in inflammation and diabetes-induced myocardial dysfunction. However, gene targets and the mechanisms underlying hyperglycemia-induced activation of AP-1 transcription factor cFOS in vascular regions exposed to TBF are not known.Although a novel approach not previously studied in diabetes associated atherosclerosis, we used a single cell RNA sequencing (scRNA-seq) approach to identify endothelial cells from TBF regions of aorta. Diabetes was induced with streptozotocin (STZ) in Apoe−/− mice and followed for 10 weeks. Cells from digested aortae of control and diabetic mice were subjected to scRNA-seq using 10X Genomics system and Illumina Nova-seq 6000. Unsupervised graph based clustering grouped cells into fourteen cell clusters with similar gene expression profile. We applied a list of mechanosensitive gene markers including EGR1, cFOS, Junb and ICAM1 in scRNA-seq analysis to identify endothelial cells from TBF regions of aorta. This approach identified atheroprone endothelial cells exposed to persistent TBF that showed a distinct transcriptional profile with more than six hundred genes differentially expressed. Importantly, cFOS was the most significantly upregulated gene in endothelial cells exposed to TBF. We next generated adiabetes associated transcriptional signature unique to endothelial cells exposed to TBF as compared to all other cell types in the aorta. We identified several genes in endothelial cells exposed to TBF and hyperglycaemia uniquely dysregulated in diabetic Apoe−/− mice as compared to control mice (cut off = FDR&amp;lt;0.05, fold change at least 2-fold). Gene set enrichment analysis identified “fluid shear stress and atherosclerosis” as most significantly dysregulated pathway in endothelial cells. These novel findings indicate that AP-1 TF subunit cFOS is a potential therapeutic target in diabetes associated atherosclerosis that warrant further experimental exploration. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): National Heart Foundation of Australia

Development and uptake of the National Heart Foundation of Australia Smart Heart Guideline App

Abstract Background Many organisations have developed Smartphone mobile applications (apps) to improve access and uptake of clinical guidelines, including the European Society of Cardiology and the American Heart Foundation. The National Heart Foundation of Australia publish clinical guidelines in collaboration with the Cardiac Society of Australia and New Zealand. We aimed to develop an app for three national guidelines: 1) the Australian clinical guidelines for the prevention and detection of atrial fibrillation 2018; 2) the Australian clinical guidelines for the detection and management of heart failure in Australia 2018; and 3) the Australian clinical guidelines for the management of acute coronary syndromes 2016. Purpose To develop a mobile app for Australian health professionals to improve access and uptake of national cardiac clinical guidelines. Methods A national health professional mobile app online survey was developed and distributed in 2017. Survey items included the frequency of searching for information about the prevention or management of cardiovascular disease, the methods of searching, and the likelihood of using an Australian-specific mobile app to access clinical guidelines. Following analysis of survey responses, a software developer was contracted to develop the app, which included user-testing. The Smart Heart Guidelines App was registered with the regulatory body in Australia, the Therapeutic Goods Administration, and made freely available from October 2019 on iOS and Android operating systems. The app was promoted using electronic direct mail, social media techniques (Twitter and LinkedIn), on our organisation's website and via printed flyers and materials at regional and national event stands at conferences. Data from the Apple App Store was analysed between 1 October 2019 – 1 October 2020 to evaluate app use. Results The health professional survey (respondents n=504; nurses 39%, allied health professionals 26%; GP/cardiologist 9%; researcher 8%; other 18%) showed most (n=447; 89%) reported accessing the Heart Foundation's resources electronically. The majority (n=355; 70%) reported they would be likely to use an Australian-specific app. Data from the Apple App Store indicated over 30,300 impressions (the number of times the Smart Heart App appeared in an App Store search) during the first year the app was available. This resulted in approximately 4,400 app downloads, with consistent “search-to-download rates” throughout the year (monthly average rate 22%). Of the downloads, 3,200 (82%) were a direct result of searching for the Smart Heart App, indicating promotional activities were effective. Conclusion Development of the Smart Heart Guideline App in Australia was indicated by health professionals to improve access to national cardiac clinical guidelines. Consistent app downloads and use during the first-year support further research, development, promotion, and evaluation of the app. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The National Heart Foundation of Australia

Associations and outcomes of cardiovascular calcifications by computed tomography in atrial fibrillation patients

Abstract Background Coronary (CAC), mitral annular (MAC), aortic valve (AVC) and thoracic aortic (TAC) calcifications are known imaging biomarkers for cardiovascular risk in the general population. Despite this, their prognostic value are not well established in atrial fibrillation (AF) patients who have elevated risk for cardiovascular events. Purpose We assessed the associated factors and outcomes of cardiovascular calcifications detected by computed tomography (CT) in AF patients undergoing pulmonary vein isolation (PVI). Methods Consecutive AF patients enrolled in a prospective PVI registry during 2014–2018 with CT performed within 1-year of their procedure were reviewed for the presence of cardiovascular calcifications on CT. Risk factors and outcomes for each type of cardiovascular calcifications were analyzed in univariable and multivariable regression models. Results Amongst 3604 AF patients, there were 2238 (62.1%), 308 (8.6%), 572 (15.9%) and 1048 (29.1%) patients with CAC, MAC, AVC and TAC respectively. Factors independently associated with these cardiovascular calcifications are listed in Table 1. During mean follow-up of 2.8±1.6 years, there were 97 (2.7%) all-cause deaths, and 158 (4.4%) major adverse cardiovascular events (MACE). Forest plots of unadjusted and adjusted hazards ratios of cardiovascular calcifications at predicting these outcomes are shown in Figure 1. Conclusion Cardiovascular calcifications especially CAC are prevalent in AF patients, and share common risk factors with cardiovascular events, except for female being protective for CAC and AVC but having higher risk of MAC and TAC. Although all cardiovascular calcifications were associated with death and MACE in unadjusted analyses, only CAC remained so for both outcomes in adjusted analyses. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): National Heart Foundation of New Zealand Table 1Figure 1