Issue 29 / 5 August 2013

ONE Sunday last month, colourful Sydney-based barrister and social commentator Charles Waterstreet began his regular column for the Sydney Morning Herald with the casual revelation, “By the time you read this, with a bit of luck, I will have joined tens of thousands of Australians who have a mesh stent placed in the coronary artery in their heart”.

That this brush with coronary artery disease rated only a passing mention seems a far cry from the days, just a few decades ago, when men in their middle-aged years were admitted to coronary care with “heart attacks”, and doctors did their best to deliver supportive management while watching as the electrocardiographic changes of dying myocardium evolved to their full and crippling potential.

The improvements in our knowledge and skills directed at cardiovascular disease — encompassing public health successes, drug regimens for primary and secondary prevention, and interventional therapy — are among the major medical advances of the 20th and 21st centuries.

Yet in an era when we know so much about how to manage cardiovascular disease, it is vexing that many patients who would benefit from a given therapy miss out.

The SNAPSHOT ACS study, published in the latest MJA, conducted over a 2-week period to examine the management and outcomes of patients with acute coronary syndrome in 286 hospitals in Australia and New Zealand, shows that we are not always good at providing guideline-recommended care and, more importantly, points to potentially remediable reasons.

According to an MJA editorial, while some variations in care can be explained by access barriers to interventional facilities, others, such as non-prescription of recommended drugs, failure to refer for rehabilitation and a lack of support for changes in diet and exercise, indicate that not everyone is yet onboard the best-practice cardiology train.

The third article in the MJA cardiology series uses two clinical scenarios to highlight this contemporary challenge in cardiovascular disease management.

To bring doctors’ clinical practice in line with best practice, Australia’s quality use of medicines watchdog, NPS MedicineWise, uses prescriber feedback, academic detailing, case studies, audits and printed educational materials. The results of an interrupted time-series analysis examining prescribing and service use for Department of Veterans’ Affairs patients between 2002 and 2010 indicate that four important management strategies (warfarin for atrial fibrillation, aspirin for secondary stroke prevention, echocardiograms to confirm heart failure, and spirinolactone for heart failure) are leading to small improvements with potentially big benefits when applied to large numbers of patients.

Parts of Australia present special challenges to sophisticated care provision and — as outlined in a rural health care contribution to our pre-election series — probably always will. In remote Central Australia, clinicians are acutely aware that when managing patients with coronary artery disease, the nearest angiography facilities are 1500 km away. Here, careful patient selection for investigation of suspected coronary artery disease is vital.

Researchers report that exercise electrocardiography testing is still useful in regional and remote settings — particularly if the result is negative.

Another study examines the utility of auscultatory screening for rheumatic heart disease among schoolchildren in the Northern Territory. This disease of poverty barely exists in most industrialised countries, but Indigenous Australians have among the highest rates in the world. The poor accuracy of the stethoscope for making the vital diagnosis should cause a rethink of current screening programs.

Our own struggles and progress — past and present — with cardiovascular disease are both a burden and an opportunity for Australia, says MJA editor-in-chief Professor Stephen Leeder.

We should be generous with our success by providing support to less developed countries where cardiovascular disease is taking over as the major killer.

Who knows; maybe some of the knowledge gleaned from the real-world Australia can be usefully applied to the rest of the world.

Dr Ruth Armstrong is senior deputy editor of the MJA.

This article is reproduced from the MJA.

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