Management of Acute Coronary Syndromes in Patients in Rural Australia: The MORACS Randomized Clinical Trial

Centralised Management System and Hot Transfer for ST-Elevation Myocardial Infarction in Western NSW: Closing the Gap in Current Models of Rural ST-Elevation Myocardial Infarction Care

BACKGROUND

Rural vs metropolitan ST-elevation myocardial infarction (STEMI) patients experience delayed access to percutaneous coronary intervention (PCI). Existing New South Wales (NSW) Statewide Cardiac Reperfusion Strategy protocols provide thrombolysis and ambulance diversion for patients within 90 minutes of a PCI centre in regional and rural NSW. Rural patients presenting to non-PCI hospitals and those more than 90 minutes from PCI are not routinely, urgently, diverted under existing protocols.

METHOD

Western NSW Local Health District, covering 250,000 km2 and a population of 278,759, implemented a centralised management system (CMS) in 2019, in partnership with NSW Ambulance, utilising existing STEMI thrombolysis protocols and extending "drip and ship" protocols for "hot transfer" of all patients to the 24/7 PCI centre, by direct ambulance diversion up to 120 minutes by road, or via multi-stage transfer by road or air, or via interhospital transfer. Data for 2 years post-CMS was compared to historical controls. Time from first clinical contact (FCC) to reperfusion, FCC to PCI centre, major adverse clinical events and percentage of patients undergoing angiography within 24 hours were compared in "medium" (90-120 minutes) and "long" (>120 minutes) transfer zones, not covered by existing protocols.

RESULTS

Outcomes were recorded for 274 patients before and 348 after CMS implementation (17% medium and 31% long transfer zones). Medium and long transfer zones had greater proportions of smokers and Indigenous patients than short transfer zones. There was significantly lower ambulance utilisation in the long (38%) compared with the short transfer zone (55%, p<0.001). In the long transfer zone, there were significant improvements in FCC to reperfusion (40 vs 48 minutes, p<0.05), FCC to PCI centre (296 vs 344 minutes, p<0.01), and angiography in 24 hours (77% vs 58%, p<0.01), with no significant differences in major adverse clinical events.

CONCLUSIONS

A rural STEMI CMS, with "hot transfer", can deliver patients from a vast geographical area directly to a rural PCI centre. Patients furthest away, with the greatest risk profile, benefit the most. Extension of this program and development of 24/7 PCI in NSW rural cardiac hubs stands to improve timely, definitive treatment, including access to angiography within 24 hours.

How Close Are We to Patient-Side Troponin Testing?

Laboratory-based high-sensitivity cardiac troponin testing has been the pillar for emergency stratification of suspected acute coronary syndrome for well over a decade. Point-of-care troponin assays achieving the requisite analytical sensitivity have recently been developed and could accelerate such assessment. This review summarises the latest assays and describes their potential diverse clinical utility in the emergency department, community healthcare, pre-hospital, and other hospital settings. It outlines the current clinical data but also highlights the evidence gap, particularly the need for clinical trials using whole blood, that must be addressed for safe and successful implementation of point-of-care troponin analysis into daily practice. Additionally, how point-of-care troponin testing can be coupled with advances in biosensor technology, cardiovascular screening, and triage algorithms is discussed.

Rural-Urban Differences in Outcomes of Acute Cardiac Admissions in a Large Health Service

Background

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality and residing in a rural and remote region is associated with an increased risk. The impact of rurality on CVD outcomes needs to be fully elucidated.

Objectives

The purpose of this study was to assess the difference in mortality, readmission within 30 days, total readmissions, survival, and total emergency department (ED) presentations following an index CVD admission among patients from rural or remote areas as compared to metropolitan areas.

Methods

This retrospective observational study included all index hospitalizations with heart failure (HF), atrial fibrillation (AF), or acute coronary syndrome (ACS) within the Hunter New England region of Australia, between January 1, 2008, and December 31, 2021.

Results

There were 27,995 ACS admissions, 15,586 HF admissions, and 16,935 AF admissions. Patients from a rural or remote area presenting with CVD presentations had increased 30-day readmission (OR: 1.19; P < 0.001), an increased number of readmissions (incident rate ratio: 1.19; P < 0.001), and more ED presentations (incident rate ratio: 1.39; P < 0.001) as compared to patients from metropolitan areas. This was consistent across patients presenting with ACS, HF, and AF. There was no difference in mortality (HR: 1.01; P = 0.515). However, in the ACS subgroup, there was increased mortality in the rural and remote population (HR: 1.05; P = 0.015).

Conclusions

This study highlights the increased incidence of ED presentations and hospital readmissions, for those living in rural Australia, illustrating the disparity in health care provided, and the ongoing need for interventions that address poorer access to specialized health care in the early discharge phase of hospitalization.

Outcome disparities in acute coronary syndrome patients from rural versus urban settings: A narrative review of causes, and strategies to minimize them

Acute coronary syndrome (ACS) remains an important cause of morbidity and mortality worldwide. Critical elements of improving outcomes in ACS patients include timely access to acute care including prompt revascularization if indicated, and subsequent ongoing secondary prevention and risk factor modification, ideally with cardiovascular specialists. It is being increasingly realized that ACS patients from rural settings suffer from inferior outcomes compared to their urban counterparts due to factors such as delayed diagnosis, delayed access to acute care, and less accessibility to specialized follow up. This narrative review will examine the importance of timely access to care in ACS patients, particularly in ST-elevation myocardial infarction; how barriers in access to care affects outcomes in various rural populations; and strategies that have been shown to improve such access, and therefore hopefully achieve more equitable health outcomes compared to patients who live in urban settings.

Cardiovascular outcomes of cancer patients in rural Australia

Background

Cancer and heart disease are the two most common health conditions in the world, associated with high morbidity and mortality, with even worse outcomes in regional areas. Cardiovascular disease is the leading cause of death in cancer survivors. We aimed to evaluate the cardiovascular outcomes of patients receiving cancer treatment (CT) in a regional hospital.

Methods

This was an observational retrospective cohort study in a single rural hospital over a ten-year period (17th February 2010 to 19th March 2019). Outcomes of all patients receiving CT during this period were compared to those who were admitted to the hospital without a cancer diagnosis.

Results

268 patients received CT during the study period. High rates of cardiovascular risk factors: hypertension (52.2%), smoking (54.9%), and dyslipidaemia (38.4%) were observed in the CT group. Patients who had CT were more likely to be readmitted with ACS (5.9% vs. 2.8% p = 0.005) and AF (8.2% vs. 4.5% p = 0.006) when compared to the general admission cohort. There was a statistically significant difference observed for all cause cardiac readmission, with a higher rate observed in the CT group (17.1% vs. 13.2% p = 0.042). Patients undergoing CT had a higher rate of mortality (49.5% vs. 10.2%, p ≤ 0.001) and shorter time (days) from first admission to death (401.06 vs. 994.91, p ≤ 0.001) when compared to the general admission cohort, acknowledging this reduction in survival may be driven at least in part by the cancer itself.

Conclusion

There is an increased incidence of adverse cardiovascular outcomes, including higher readmission rate, higher mortality rate and shorter survival in people undergoing cancer treatment in rural environments. Rural cancer patients demonstrated a high burden of cardiovascular risk factors.

Death rates following emergency department chest pain assessment

OBJECTIVES

We sought to define the rate of unexpected death from acute coronary syndrome or arrhythmia in chest pain patients directly discharged from the ED.

METHODS

Retrospective audit of all chest pain patients at a tertiary ED for 7 years. Medical and post-mortem records of the deceased were reviewed with independent cardiologist adjudication to determine outcomes. Primary outcome measure was 28-day unexpected death secondary to acute coronary syndrome or arrhythmia.

RESULTS

During the study period, 25 924 patients presented with chest pain, 292 (1.1%, 95% confidence interval [CI] 0.99-1.01%) died within 28 days. Of these, 16 680(64%, 95% CI 63.88-64.12%) were discharged by ED, two (0.01%, 95% CI 0-0.011%) of this group died from the primary outcome.

CONCLUSION

Unexpected death is very uncommon after ED discharge of chest pain patients.

Treatment strategies of acute myocardial infarction: updates on revascularization, pharmacological therapy, and beyond

Owing to recent advances in early reperfusion strategies, pharmacological therapy, standardized care, and the identification of vulnerable patient subsets, the prognosis of acute myocardial infarction has improved. However, there is still considerable room for improvement. This review article summarizes the latest evidence concerning clinical diagnosis and treatment of acute myocardial infarction.