In Australia, many deaths and significant cardiac disability result from delayed response to symptoms of heart attack. Although delays due to transport and initiation of reperfusion therapy in hospital may contribute to late treatment, the major component of delay is the time patients take in deciding to seek help. A critical examination of campaigns to shorten patient delay concludes that they were based on a factual, short‐term, non‐targeted approach that included education and mass media strategies. They achieved equivocal results. One randomised controlled trial has been conducted. Although this showed an improved understanding of heart attack symptoms, it did not shorten pre‐hospital delays. The implications of these findings are that future campaigns to shorten patient delay are likely to be more effective if they address the psychosocial and behavioural blocks to action, are ongoing rather than short term, and focus on people at highest risk, including those with known or high risk of coronary heart disease, those in rural locations, and Indigenous Australians. The National Heart Foundation of Australia proposes a comprehensive strategy to incorporate this approach into its future campaigns to reduce patient delay for suspected heart attack.

Objective: To determine the feasibility, safety and effectiveness of a structured clinical pathway for stratification and management of patients presenting with chest pain and classified as having intermediate risk of adverse cardiac outcomes in the subsequent six months. Design: Prospective clinical audit. Participants and setting: 630 consecutive patients who presented to the emergency department of a metropolitan tertiary care hospital between January 2000 and June 2001 with chest pain and intermediate‐risk features. Intervention: Use of the Accelerated Chest Pain Assessment Protocol (ACPAP), as advocated by the Management of unstable angina guidelines — 2000 from the National Heart Foundation and the Cardiac Society of Australia and New Zealand. Main outcome measure: Adverse cardiac events during six‐month follow‐up. Results: 409 patients (65%) were reclassified as low risk and discharged at a mean of 14 hours after assessment in the chest pain unit. None had missed myocardial infarctions, while three (1%) had cardiac events at six months (all elective revascularisation procedures, with no readmissions with acute coronary syndromes). Another 110 patients (17%) were reclassified as high risk, and 21 (19%) of these had cardiac events (mainly revascularisations) by six months. Patients who were unable to exercise or had non‐diagnostic exercise stress test results (equivocal risk) had an intermediate cardiac event rate (8%). Conclusions: This study validates use of ACPAP. The protocol eliminated missed myocardial infarction; allowed early, safe discharge of low‐risk patients; and led to early identification and management of high‐risk patients.

We describe rapidly fatal cardiomyopathy in a young man. He had for twelve months ingested large amounts of ascorbic acid and was admitted with severe heart failure having been symptomatic for two months. He died after eight days. Idiopathic haemochromatosis was diagnosed at autopsy. The clinical and laboratory features are discussed and the possible implications of ascorbic acid ingestion are explored.

New approaches are needed to reduce patient-related delay after the onset of symptoms suggesting possible myocardial infarction.

Background-Little information exists regarding mid-term and long-term patency of radial artery grafts. Methods and Results-We performed restudy coronary angiography at 5.2Ϯ0.4 years after surgery on 50 asymptomatic patients who had undergone coronary artery bypass graft surgery, using at least 1 radial artery graft, to determine both graft patency and presence of narrowing. We examined preoperative clinical or angiographic variables that might predict graft occlusion. Radial artery graft patency was 89%, with 91% of grafts free of narrowing. Preoperative New York Heart Association anginal class Յ2, target vessel proximal stenosis Յ70%, and small target vessel supply territory were predictive of graft occlusion. Conclusion-At