Adherence to secondary prevention medications following acute coronary syndrome (ACS) is disappointingly low, standing around 40–75% by various estimates. This is an inefficient use of the resources devoted to their development and implementation, and also puts patients at higher risk of poor outcomes post-ACS. Numerous factors contribute to low adherence including poor motivation, forgetfulness, lack of education about medications, complicated polypharmacy of ACS regimens, (fear of) adverse side effects and limited practical support. Using technology to improve adherence in ACS is an emerging strategy and has the potential to address many of the above factors—computer-based education and mobile phone reminders are among the interventions trialled and appear to improve adherence in patients with ACS. As we move into an increasingly technological future, there is potential to use devices such as smartphones and tablets to encourage patient responsibility for medications. These handheld technologies have great scope for allowing patients to view online medical records, education modules and reminder systems, and although research specific to ACS is limited, they have shown initial promise in terms of uptake and improved adherence among similar patient populations. Given the overwhelming enthusiasm for handheld technologies, it would seem timely to further investigate their role in improving ACS medication adherence.

Objectives To compare the outcomes and safety of a rapid access chest pain clinic (RACPC) in Australia with those of a general cardiology clinic. Design Prospective comparison of the outcomes for patients attending an RACPC and those of historical controls. Setting Royal Hobart Hospital cardiology outpatient department. Participants 1914 patients referred for outpatient evaluation of new onset chest pain (1479 patients seen in the RACPC, 435 patients previously seen in the general cardiology clinic). Main outcome measures Service outcomes (review times, number of clinic reviews); adverse events (unplanned emergency department re‐attendances at 30 days and 12 months; major adverse cardiovascular events at 12 months, including unplanned revascularisation, acute coronary syndrome, stroke, cardiac death). Results Median time to review was shorter for RACPC than for usual care patients (12 days [IQR, 8–15 days] v 45 days [IQR, 27–89 days]). All patients seen in the RACPC received a diagnosis at the first clinic visit, but only 139 patients in the usual care group (32.0%). There were fewer unplanned emergency department re‐attendances for patients in the RACPC group at 30 days (1.6% v 4.4%) and 12 months (5.7% v 12.9%) than in the control group. Major adverse cardiovascular events were less frequent among patients evaluated in the RACPC (0.2% v 1.4%). Conclusions Patients were evaluated more efficiently in the RACPC than in a traditional cardiology clinic, and their subsequent rates of emergency department re‐attendances and adverse cardiovascular events were lower.

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Refractory angina (RA) is conventionally defined as a chronic condition (≥3 months in duration) characterised by angina in the setting of coronary artery disease (CAD), which cannot be controlled by a combination of optimal medical therapy, angioplasty or bypass surgery, and where reversible myocardial ischaemia has been clinically established to be the cause of the symptoms. 1 In clinical practice, patients diagnosed with RA are a heterogeneous group; common among them, however, is that they remain significantly limited by persistent debilitating chest discomfort despite optimised conventional therapy. In many cases, functional imaging may not demonstrate myocardial ischaemia. It is important to recognise that irrespective of aetiology, patients with refractory chest discomfort often attribute their symptoms to be cardiac in origin and believe that they may herald a life-threatening cardiac event. This predisposes to a progressive decline in their mental wellbeing and increasing anxiety whereby pain begets pain. Consequently, patients can develop persistent symptoms and pessimistic health beliefs, translating to negative behaviours and an impaired quality of life. In this regard, a shift in our approach of RA to that of managing a 'chronic chest pain syndrome' may help us not only to better appreciate the multifactorial aetiologies that are in operation in any given patient but also encourage the use of a holistic approach to manage these patients more effectively. Epidemiology Precise estimates of the prevalence and incidence of RA are not available; however, several sources suggest that this is a large and growing problem. 2,3 Variations in definition and clinical heterogeneity of patients labelled with a diagnosis of RA significantly complicate such endeavours. Data from the Canadian Community Health Survey (2000-2001) suggest that ~500,000 Canadians are living with unresolved angina. 4 The proportion of these patients with true RA is unknown. 5 In the US, it is estimated that between 600,000 and 1.8 million patients have RA, with approximately 75,000 new cases diagnosed each year. 5,6 In Europe, the annual incidence of RA is estimated at 30,000-50,000 new cases per year. 1,7 Specific figures for the UK are lacking and further work to define the burden of RA in the UK population is needed. However, if the results shown by Williams et al., who found that 6.7 % of patients undergoing angiography in a contemporary cohort had no revascularisation option, are applied to the 247,363 angiograms performed in England in 2014, it can be estimated that ~16,500 new cases of RA may occur in England per year. 3,8 Given improvements in CAD-related survival and increasing age of the population, together with an increasing appreciation from the contemporary Outcome of Percutaneous Coronary Intervention for Stent ThrombosIs Multicentre Study (OPTIMIST) registry that the long term prognosis of RA is not as bad as previously thought, the incidence and prevalence of RA is only set to rise. 5,6,9,10 Furthermore, it has also been r...

Radiomics, via the extraction of quantitative information from conventional radiologic images, can identify imperceptible imaging biomarkers that can advance the characterization of coronary plaques and the surrounding adipose tissue. Such an approach can unravel the underlying pathophysiology of atherosclerosis which has the potential to aid diagnostic, prognostic and, therapeutic decision making. Several studies have demonstrated that radiomic analysis can characterize coronary atherosclerotic plaques with a level of accuracy comparable, if not superior, to current conventional qualitative and quantitative image analysis. While there are many milestones still to be reached before radiomics can be integrated into current clinical practice, such techniques hold great promise for improving the imaging phenotyping of coronary artery disease.