📋 Key Information Summary
- Cardiac catheterisation is an invasive diagnostic procedure enabling direct measurement of intracardiac pressures, oxygen saturations, cardiac output, and coronary angiography.
- Left heart catheterisation (coronary angiography) is the gold standard for defining coronary anatomy and is indicated for acute coronary syndromes (ACS), stable angina with high pre-test probability, and pre-operative assessment prior to valvular surgery.
- Right heart catheterisation (haemodynamic assessment) measures right-sided pressures, pulmonary artery wedge pressure, and cardiac output via thermodilution or Fick method — essential in heart failure workup, pulmonary hypertension classification, and pre-transplant evaluation.
- Radial artery access is the preferred first-line approach for coronary angiography (reduced bleeding, shorter stay) unless specific contraindications exist; femoral access is standard for right heart catheterisation.
- Major vascular complications occur in <1% of cases with radial access and 2–3% with femoral access; risk is minimised by ultrasound-guided puncture, ACT-guided anticoagulation, and vascular closure devices.
- All patients require pre-procedure assessment including renal function (eGFR), coagulation screen, FBC, and consideration of contrast allergy prophylaxis.
- Chronic kidney disease patients require pre-hydration with isotonic sodium chloride 1 mL/kg/h for ≥6 hours pre- and post-procedure to prevent contrast-induced acute kidney injury (CI-AKI).
- Antiplatelet and anticoagulation management must be planned: heparin 70–100 IU/kg (radial) or 50–70 IU/kg (femoral) for ACT 250–350 seconds; dual antiplatelet therapy (DAPT) is continued peri-procedure for stable patients.
- Standard monitoring includes continuous ECG, pulse oximetry, and invasive arterial pressure during the procedure.
- Haemodynamic data — including mean arterial pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure, and calculated cardiac index — guide diagnosis and management in heart failure and pulmonary hypertension.
- In Australia, cardiac catheterisation is performed in public and private catheterisation laboratories, typically managed by interventional cardiologists with procedural volumes ≥200 cases/year as per CPCA standards.
- Aboriginal and Torres Strait Islander patients experience higher rates of ischaemic heart disease, present later, and have reduced access to catheterisation services in remote regions — early referral is critical.
Introduction & Australian Epidemiology
Cardiac catheterisation is an invasive diagnostic and potentially therapeutic procedure that allows direct measurement of intracardiac pressures, oxygen saturations, cardiac output, and detailed visualisation of coronary anatomy. It encompasses both left heart catheterisation (coronary angiography ± left ventriculography) and right heart catheterisation (haemodynamic assessment), and remains the reference standard for the definitive evaluation of structural, valvular, and coronary artery disease.
In Australia, over 95,000 coronary angiography procedures are performed annually across public and private catheterisation laboratories, with approximately 40–45% of these proceeding to percutaneous coronary intervention (PCI) in the same sitting. The Cardiac Society of Australia and New Zealand (CSANZ) and the Conjoint Committee for the Recognition of Training in Cardiac Interventional Procedures (CPCA) oversee quality standards and procedural training requirements.
The shift toward radial artery access has been transformative: Australian data from the RIVAL and MATRIX trials have confirmed a significant reduction in major bleeding, vascular complications, and mortality with radial-first approaches. Current Australian practice sees >80% of elective coronary angiography performed via radial access, with femoral access reserved for specific anatomical or procedural indications.
Indications for cardiac catheterisation span the full spectrum of cardiovascular disease: acute coronary syndromes (ACS), stable ischaemic heart disease with high pre-test probability, heart failure with suspected coronary aetiology, valvular heart disease requiring haemodynamic assessment, pulmonary hypertension workup, and pre-operative evaluation prior to cardiac surgery or transcatheter interventions such as TAVI or MitraClip.
This guideline provides a comprehensive overview of left and right heart catheterisation techniques, indications, access strategies, haemodynamic interpretation, and complication management within the Australian clinical context, including consideration of access disparities affecting Aboriginal and Torres Strait Islander communities.
Left Heart Catheterisation (Coronary Angiography)
Left heart catheterisation involves cannulation of the left ventricle via retrograde arterial access, most commonly to perform coronary angiography (visualisation of the coronary arteries with iodinated contrast) and/or left ventriculography (assessment of LV systolic function and mitral regurgitation).
Technique
- Arterial access is obtained percutaneously using the Seldinger technique — radial (right preferred, left if needed) or femoral (common femoral artery, ideally at the femoral head under fluoroscopy or ultrasound guidance).
- A diagnostic catheter (e.g., Judkins Left, Judkins Right, or Amplatz) is advanced over a guidewire under fluoroscopic guidance into the aortic root.
- Selective cannulation of the left and right coronary ostia is performed with hand injection of non-ionic iodinated contrast (iopromide or iohexol), with cineangiographic recording at 15–25 frames/second.
- Left ventriculography (if indicated) uses a pigtail catheter advanced retrogradely across the aortic valve into the LV; contrast is injected at 12–15 mL/s to assess wall motion and ejection fraction.
- Haemodynamic pullback across the aortic valve can identify transvalvular gradients (aortic stenosis).
Views and Biplane Angiography
| Coronary Segment | Essential Views | Purpose |
|---|---|---|
| Left main (LM) | AP cranial, LAO cranial | Bifurcation assessment, ostial disease |
| LAD (proximal) | RAO caudal, LAO cranial | Diagonal/mid-LAD lesions |
| LAD (distal) | LAO caudal (spider view) | Distal LAD and D1/D2 bifurcation |
| Circumflex / OM | LAO caudal (cranberry view) | OM origin, proximal Cx |
| RCA (proximal–mid) | LAO, AP | RCA body and PDA |
| RCA (distal) | RAO | Crux, PDA, PLV |
Contrast Agents Used in Australia
Iopromide
Ultravist® · Low-osmolar non-ionic
Concentration
300 or 370 mgI/mL
Use
Standard coronary angiography
PBS status
✔ PBS General Benefit
Iohexol
Omnipaque® · Low-osmolar non-ionic
Concentration
300 or 350 mgI/mL
Use
Coronary angiography, peripheral angiography
PBS status
✔ PBS General Benefit
Anticoagulation During Left Heart Catheterisation
Unfractionated Heparin
Heparin sodium · Anticoagulant
Adult dose (radial)
70–100 IU/kg IV bolus at sheath insertion
Adult dose (femoral)
50–70 IU/kg IV bolus
Target ACT
250–350 seconds (diagnostic); ≥300 s if PCI
Paediatric dose
75–100 IU/kg IV bolus (refer to paediatric cardiology)
Renal adjustment
None required — hepatic metabolism
PBS status
✔ PBS General Benefit
Spasm Prophylaxis (Radial Access)
Glyceryl Trinitrate
GTN · Nitrate vasodilator
Adult dose
200–500 µg IA via sheath at radial access
Route
Intra-arterial via radial sheath
Contraindication
SBP <90 mmHg, severe aortic stenosis, PDE5 inhibitor within 24–48 h
PBS status
✔ PBS General Benefit
Verapamil
Isoptin® · Calcium channel blocker
Adult dose
2.5–5 mg IA via radial sheath (with or without GTN)
Route
Intra-arterial
Contraindication
Heart failure (LVEF <30%), AV block, concurrent β-blocker use
PBS status
✔ PBS General Benefit
Right Heart Catheterisation (Haemodynamic Assessment)
Right heart catheterisation (RHC) involves placement of a balloon-tipped, flow-directed catheter (typically a Swan–Ganz catheter) via central venous access into the pulmonary artery to obtain direct intracardiac pressure measurements, mixed venous oxygen saturation, and thermodilution or Fick cardiac output.
Indications
- Heart failure: Differentiation of cardiac vs. non-cardiac causes of dyspnoea; assessment of filling pressures to guide therapy; evaluation for advanced therapies (LVAD, transplantation).
- Pulmonary hypertension: Confirm diagnosis (mPAP ≥20 mmHg at rest), classify aetiology (pre-capillary vs. post-capillary), and assess vasoreactivity (acute vasodilator challenge with inhaled nitric oxide or IV epoprostenol).
- Valvular heart disease: Severity grading of aortic stenosis (Gorlin formula) and mitral stenosis (pressure half-time, Gorlin).
- Cardiac tamponade: Equalisation of diastolic pressures across chambers.
- Constrictive pericarditis: Discordant ventricular filling with respiration, enhanced ventricular interdependence (Kussmaul sign).
- Shock: Differentiation of cardiogenic, distributive, and obstructive shock.
- Pre-operative: Assessment for cardiac surgery or transcatheter interventions.
Access Route
RHC is typically performed via right internal jugular vein (IJV) under ultrasound guidance. Alternative sites include femoral vein and left IJV. The right IJV is preferred because it provides a direct path to the right atrium and is associated with fewer complications.
Normal Haemodynamic Values
| Parameter | Normal Range | Unit |
|---|---|---|
| Right atrial pressure (RAP) | 2–8 | mmHg |
| Right ventricular systolic pressure | 15–30 | mmHg |
| Pulmonary artery systolic (PASP) | 15–30 | mmHg |
| Pulmonary artery diastolic (PADP) | 4–12 | mmHg |
| Mean pulmonary artery pressure (mPAP) | 9–18 | mmHg |
| Pulmonary capillary wedge pressure (PCWP) | 6–12 | mmHg |
| Left ventricular end-diastolic pressure (LVEDP) | 5–12 | mmHg |
| Cardiac index (CI) | 2.5–4.0 | L/min/m² |
| Stroke volume index (SVI) | 33–47 | mL/m² |
| Systemic vascular resistance (SVR) | 800–1200 | dyn·s·cm⁻⁵ |
| Pulmonary vascular resistance (PVR) | 20–130 | dyn·s·cm⁻⁵ |
Derived Haemodynamic Calculations
| Derived Parameter | Formula |
|---|---|
| Cardiac Output (CO) | Thermodilution: CO = (V × (Tb − Ti) × K) / ∫ΔTb dt |
| Fick Cardiac Output | CO = VO₂ / (CaO₂ − CvO₂) × 10 |
| Pulmonary vascular resistance (PVR) | PVR = 80 × (mPAP − PCWP) / CO |
| Systemic vascular resistance (SVR) | SVR = 80 × (MAP − RAP) / CO |
| Transpulmonary gradient (TPG) | TPG = mPAP − PCWP |
| Diastolic pressure gradient (DPG) | DPG = PADP − PCWP |
Fick vs Thermodilution: The thermodilution method is the standard in most Australian catheterisation laboratories. Fick method is preferred in the setting of severe tricuspid regurgitation (where thermodilution overestimates CO) or intracardiac shunts. Assumed VO₂ of 125 mL/min/m² is commonly used when direct measurement is not available.
Indications, Access & Complications
Indications for Cardiac Catheterisation
Emergency
Acute STEMI
Primary PCI within 90 minutes (PCI-capable centre) or 120 minutes (transfer). Door-to-balloon target <60 min per Australian STEMI guidelines.
Setting: Emergency catheterisation laboratory
Urgent
High-risk NSTE-ACS
GRACE score >140, dynamic ST changes, troponin rise, haemodynamic instability. Angiography within 24 hours.
Setting: Inpatient catheterisation within 24 hours
Early
Intermediate-risk NSTE-ACS
GRACE 109–140, diabetes, renal impairment, LVEF <40%, prior PCI/CABG. Angiography within 72 hours.
Setting: Inpatient catheterisation within 72 hours
Elective
Stable IHD / Pre-operative
High pre-test probability of CAD (Duke Clinical Score, CTCA inconclusive). Pre-valvular surgery assessment.
Setting: Elective admission, day-case if radial access
Access Site Comparison
| Feature | Radial Access | Femoral Access |
|---|---|---|
| Preferred for | Coronary angiography, diagnostic LHC | RHC, complex PCI, haemodynamic support |
| Bleeding risk | Low (~0.5%) | Higher (~2–3%) |
| Access site complication | Radial artery occlusion (1–5%, usually clinically silent) | Haematoma, pseudoaneurysm, AV fistula |
| Patient mobility | Immediate ambulation | 4–6 hours bed rest (closure device) / 6–8 hours (manual) |
| Contraindications | Negative Allen test, Raynaud's, prior radial harvest (CABG) | Severe PAD, aortic aneurysm, recent groin surgery |
| Closure | TR Band® or radial compression device | Manual pressure, Angioseal™, Perclose ProGlide™ |
Complications
Major complications (death, stroke, MI, emergency surgery) occur in <1% of diagnostic catheterisations and 1–2% of interventional procedures. Mortality for diagnostic angiography is approximately 0.1%.
| Complication | Incidence | Management |
|---|---|---|
| Access site haematoma | 2–6% | Compression, observation. Surgical evacuation if expanding or haemodynamically significant. |
| Pseudoaneurysm | 0.5–2% | Ultrasound-guided thrombin injection (first-line). Surgical repair if failed. |
| Radial artery occlusion | 1–5% | Usually clinically silent. Patency haemostasis technique reduces risk. Anticoagulation if symptomatic. |
| Contrast-induced AKI | 2–5% (higher if CKD, DM) | Pre-hydration with 0.9% NaCl, minimise contrast volume (<3× eGFR mL). Avoid nephrotoxins 48 h peri-procedure. |
| Allergic reaction | 0.2–0.7% | Mild: antihistamine ± corticosteroid. Anaphylaxis: adrenaline IM, oxygen, IV fluids. |
| Stroke | 0.05–0.1% | Immediate neurological assessment. Stroke team activation. CT brain ± thrombolysis. |
| Coronary dissection / perforation | 0.1–0.3% | Prolonged balloon inflation, covered stent, pericardiocentesis, emergency cardiac surgery. |
| Ventricular fibrillation | 0.5–1% | Immediate defibrillation. Often transient with catheter manipulation. |
| Vasovagal reaction | 3–5% | Atropine 600 µg IV, IV fluid bolus, leg elevation. |
Pre-procedure Checklist
1
Consent & Review
Informed consent explaining risks, benefits, and alternatives. Review of CTCA/previous angiography, medication list, and allergy history.
2
Bloods
FBC, eGFR/creatinine, coagulation (INR/APTT), group & hold, troponin (if ACS). HbA1c if diabetic.
3
Medication Management
Continue aspirin and P2Y12 inhibitor. Withhold metformin 48 h pre-procedure if eGFR <45. Withhold DOACs 24–48 h pre-procedure. Warfarin: target INR <1.8 (or bridging per protocol).
4
Allergy Prophylaxis
If prior contrast reaction: prednisolone 50 mg PO at 13, 7, and 1 hour pre-procedure + promethazine 25 mg IV 1 hour pre-procedure. Use low-osmolar contrast.
5
Access Site Preparation
Radial: Allen/Barbeau test. Ultrasound mapping of radial artery. Femoral: bony landmark palpation, ultrasound-guided puncture preferred.
6
NPO & IV Access
Nil by mouth ≥4 hours (solids), 2 hours (clear fluids). Peripheral IV cannula in non-procedure arm. Ensure recent ECG and echo reviewed.
Interpretation of Results
Coronary Angiography Interpretation
Coronary lesions are assessed by visual estimation of diameter stenosis (%DS), location (segment numbering per CAD-RADS/SYNTAX), morphology (eccentric vs concentric, calcified, thrombotic, bifurcation), and flow characteristics.
| Stenosis Severity | % Diameter Stenosis | Clinical Significance |
|---|---|---|
| Normal | 0% | No atherosclerotic disease |
| Mild | 1–49% | Atherosclerosis present; unlikely flow-limiting; medical therapy |
| Moderate | 50–69% | Indeterminate; consider FFR/iFR to assess physiological significance |
| Severe | 70–89% | Likely flow-limiting; revascularisation usually indicated if symptomatic |
| Critical | 90–99% | Haemodynamically significant; high-grade obstruction |
| Occlusion (CTO) | 100% | Chronic total occlusion; antegrade or retrograde CTO-PCI techniques |
Fractional Flow Reserve (FFR) & Instantaneous Wave-Free Ratio (iFR)
Physiological lesion assessment is indicated for angiographically moderate (50–70%) stenoses to guide revascularisation decisions. FFR and iFR are available in Australian tertiary centres.
| Parameter | Normal | Significant | Grey Zone |
|---|---|---|---|
| FFR (hyperaemic) | ≥0.80 | <0.75 (definite ischaemia) | 0.75–0.80 |
| iFR (resting) | ≥0.89 | <0.85 (definite ischaemia) | 0.85–0.89 |
FAME and DEFINE-FLAIR trials: An iFR-guided strategy (defer if ≥0.89, treat if <0.85) is non-inferior to FFR-guided strategy for composite MACE at 1 year, with shorter procedure time and less patient discomfort (no adenosine required).
Thrombolysis in Myocardial Infarction (TIMI) Flow Grading
| TIMI Grade | Description |
|---|---|
| TIMI 0 | No perfusion — no antegrade flow beyond the occlusion |
| TIMI 1 | Penetration without perfusion — contrast passes but does not opacify distal bed |
| TIMI 2 | Partial perfusion — contrast opacifies distal bed but fills more slowly than normal |
| TIMI 3 | Complete perfusion — normal filling and washout of contrast |
SYNTAX Score
The SYNTAX score quantifies coronary artery disease complexity based on lesion location, dominance, number of lesions, and morphological characteristics (total occlusion, bifurcation, calcification, thrombus, diffuse disease).
Low
SYNTAX 0–22
Low complexity. PCI or CABG equivalent outcomes in most patients. PCI generally favoured for simplicity.
Decision: PCI or CABG — patient preference and comorbidity-driven
Intermediate
SYNTAX 23–32
Intermediate complexity. Heart Team discussion recommended. CABG may offer advantage in diabetic patients and those with multivessel disease.
Decision: Heart Team discussion (cardiothoracic surgery + interventional cardiology)
High
SYNTAX ≥33
High complexity. CABG superior to PCI for MACE and repeat revascularisation (SYNTAX trial). PCI associated with significantly higher stent thrombosis and target vessel revascularisation rates.
Decision: CABG strongly preferred (Class I recommendation)
Interpretation of Right Heart Haemodynamic Data
| Haemodynamic Pattern | Key Findings | Diagnosis |
|---|---|---|
| Post-capillary PH | mPAP ≥20, PCWP >15, PVR <3 WU | Left heart disease (Group 2 PH) |
| Pre-capillary PH | mPAP ≥20, PCWP ≤15, PVR ≥3 WU | PAH, CTEPH, lung disease (Groups 1, 4, 5) |
| Combined pre- and post-capillary | mPAP ≥20, PCWP >15, PVR ≥3 WU | Combined PH (Group 2 with reactive component) |
| Constrictive pericarditis | Dip-and-plateau, LVEDP–RVEDP equalisation, discordant ventricular filling | Constrictive pericarditis (differentiate from restrictive cardiomyopathy) |
| Cardiac tamponade | Equal diastolic pressures (RA ≈ RV ≈ PA ≈ PCWP), pulsus paradoxus, RA waveform loss of Y descent | Pericardial effusion with tamponade physiology |
| Cardiogenic shock | CI <2.2, PCWP >18, SVR >1500 | Pump failure — consider MCS (IABP, Impella, ECMO) |
Shunt Assessment
Oxygen saturation step-up across cardiac chambers detects intracardiac shunts. A step-up of ≥7% at the atrial level suggests an atrial septal defect (ASD); ≥5% at the ventricular level suggests a ventricular septal defect (VSD). The Qp:Qs ratio (pulmonary-to-systemic flow ratio) quantifies shunt magnitude:
- Qp:Qs <1.5: haemodynamically insignificant
- Qp:Qs 1.5–2.0: moderate shunt — consider intervention if symptomatic
- Qp:Qs >2.0: large shunt — intervention usually indicated
Special Populations
Renal Impairment
Pre-hydration
0.9% NaCl 1 mL/kg/h for ≥6 hours pre- and post-procedure (or sodium bicarbonate protocol) if eGFR <45 mL/min/1.73 m². This is the single most effective measure to prevent CI-AKI.
Contrast volume
Limit total contrast volume to <3 × eGFR mL. Use iso-osmolar contrast (iodixanol) if eGFR <30.
Metformin
Withhold for 48 hours post-procedure if eGFR <45. Re-check creatinine before resuming.
Nephrotoxic agents
Withhold NSAIDs, aminoglycosides, and ACEi/ARB for 48 hours peri-procedure in moderate-to-severe CKD.
Pregnancy
Indications
Cardiac catheterisation in pregnancy is limited to life-threatening ACS or haemodynamic instability. Lead shielding over the abdomen, minimise fluoroscopy time, use radial access, and employ zero-PA-dose techniques.
Contrast
Iodinated contrast crosses the placenta but is not teratogenic at diagnostic doses. Avoid if possible; use smallest volume. Gadolinium is contraindicated (Category D).
Radiation
Keep fetal dose <1 mGy (diagnostic angiography typically 0.1–0.5 mGy). Involve medical physics if complex procedure anticipated.
Paediatric Patients
Setting
Performed by paediatric cardiologists in specialised centres (e.g., The Royal Children's Hospital Melbourne, Children's Hospital at Westmead, Queensland Children's Hospital). General anaesthesia is standard.
Indications
Congenital heart disease haemodynamic assessment, pre- and post-surgical evaluation, pulmonary hypertension workup, interventional procedures (ASD/VSD device closure, PDA occlusion, balloon valvuloplasty).
Access
Femoral vein/artery most common. Size-appropriate sheaths and catheters (3–6 Fr). Meticulous vascular management to avoid limb ischaemia in neonates.
Elderly (>75 years)
Access
Radial access strongly preferred — reduced bleeding risk critical in anticoagulated elderly patients. Ultrasound-guided puncture essential due to calcified arteries.
Complications
Higher risk of CI-AKI (age-related GFR decline), stroke (aortic arch atheroembolism), and bleeding. Pre-hydration mandatory. Minimise catheter exchanges in the aortic arch.
Anticoagulation
Consider dose reduction of heparin (50 IU/kg) in low-weight elderly patients. ACT-guided dosing is essential.
Immunocompromised Patients
Infection risk
Strict aseptic technique. Consider prophylactic antibiotics if neutrophils <0.5 × 10⁹/L. Radial access preferred (lower infection rate than femoral).
Transplant patients
Heart transplant recipients: routine surveillance angiography annually post-transplant for cardiac allograft vasculopathy (CAV). Coordinate with transplant team regarding immunosuppression and contrast dose.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
📚 References
- 1. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. Heart Lung Circ. 2016;25(9):895–951.
- 2. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377(9775):1409–1420.
- 3. Valgimigli M, Gagnor A, Calabró P, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial (MATRIX). Lancet. 2015;385(9986):2465–2476.
- 4. Tonino PAL, De Bruyne B, Pijls NHJ, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention (FAME). N Engl J Med. 2009;360(3):213–224.
- 5. Davies JE, Sen S, Dehbi H-M, et al. Use of the instantaneous wave-free ratio or fractional flow reserve in PCI (DEFINE-FLAIR). N Engl J Med. 2017;376(19):1824–1834.
- 6. Serruys PW, Morice M-C, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease (SYNTAX). N Engl J Med. 2009;360(10):961–972.
- 7. Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the ESC. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2022;43(38):3618–3731.
- 8. Nijjer SS, Sen S, Petraco R, Davies JE. Advances in coronary physiology. Circ J. 2015;79(6):1172–1184.
- 9. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework 2023 — summary report. Canberra: AIHW; 2023.
- 10. Brown A, O'Shea RL, Mott K, et al. Essential service standards for equitable national cardiovascular care for Aboriginal and Torres Strait Islander people. Heart Lung Circ. 2015;24(2):126–141.
- 11. Hallan SI, Orth SR. The concept of contrast-induced nephropathy — moving forward. Nephrol Dial Transplant. 2020;35(4):571–574.
- 12. Runciman WB, Coiera EW, Day RO, et al. Towards the safe and efficient use of medicines in Australia — the Australian Commission on Safety and Quality in Health Care. Med J Aust. 2013;198(10):511–513.
- 13. Tonelli M, Wiebe N, Culleton B, et al. Chronic kidney disease and mortality risk: a systematic review. J Am Soc Nephrol. 2006;17(7):2034–2047.
- 14. O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Circulation. 2013;127(4):e362–e425.
- 15. Collet J-P, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289–1367.