Heart attack in the bush: challenges of management

THE most successful tools are those that are simplest to use. There is no better example than the pre-hospital electrocardiogram (ECG) notification system, which requires the user to press a single button following a 12-lead ECG to transmit an ECG directly to the smartphone of an interventional cardiologist.

We know that the incidence of acute myocardial infarction in rural and regional areas is higher than that of metropolitan areas.  Providing equitable treatment requires the development of complex systems of care so rural and regional patients can receive timely reperfusion and access to guideline-directed secondary preventive treatments.

Rural and regional areas have benefited from the ability to transmit ECGs to tertiary services with a one-touch button, and point-of-care troponin testing has allowed earlier diagnosis and risk stratification. Pre-hospital thrombolysis has allowed earlier reperfusion for many rural and regional patients.

However, challenges remain, both in diagnosis and timely transfer to percutaneous coronary intervention (PCI)-capable centres as well as post-infarct management and availability of cardiac rehabilitation services.

Systems need continuous refinement, and while much focus initially was on early reperfusion post-diagnosis of an ST-segment myocardial infarction (STEMI), we have recently turned our attention to ensuring all measures are taken pre-diagnosis of STEMI to ensure rural and regional patients, many of whom are assessed in small hospitals with either GP visiting medical officer or nursing support, are triaged and assessed with a 12-lead ECG in a timely fashion.

In our recently published randomised Management Of Rural Acute Coronary Syndromes (MORACS) trial, the addition of an automatically triggered nurse-led diagnostic support service to usual care in 29 rural hospitals in the Hunter New England Health District led to a reduction in the number of missed infarcts and an improvement in the rate of timely reperfusion therapy.

The positive outcomes of this intervention have directly led to interim NSW Ministry of Health funding for a tele-ECG service to all rural hospitals in the district that do not have emergency staff specialist support. Scoping is underway to roll out the program statewide. This tele-ECG service is provided alongside the existing pre-hospital thrombolysis and pre-hospital activation for primary angioplasty services that have now been established for over a decade.

In rural and regional areas, clinicians both on-site and at tertiary referral centres encounter challenging management decisions post-STEMI diagnosis regarding transfer to a 24-hour PCI centre or transfer to a closer, but limited hours, PCI centre.

Most patients with STEMI in rural areas receive either pre-hospital thrombolysis from paramedics or in-hospital thrombolysis. Pre-hospital thrombolysis is preferable and can reduce the time from first medical contact to reperfusion by 50%. Transfer to a tertiary hospital is also desirable and appears to be associated with higher rates of angiography in lower mortality in a large New South Wales cohort, after adjusting for confounders.

Some rural hospitals may be hours by road from a PCI centre with limited availability, while a 24-hour tertiary service may be further away and require fixed wing or helicopter aeromedical retrieval. The majority of patients receiving thrombolysis in rural areas will reperfuse and may be able to be monitored at a smaller PCI hospital for their angiogram during the next available day. However, for those that don’t reperfuse, the symptom-to-balloon time can be lengthy, leading to larger infarcts and the sequelae of longer term issues that accompany them.

Despite it being where the greatest patient impact for angiography and PCI is made, having smaller PCI sites offer a 24-hour STEMI service is unattractive for the PCI operators with a roster where they might be one of only a few names. Recruiting more proceduralists is then dilutional for overall operator volume requirements, where annual PCI volumes may only be sufficient for one or two interventionalists.

Hospital staffing is another factor that can limit the establishment of a 24-hour PCI service in a regional town. The smaller pool of nursing and radiography staff to recruit from can lead to rosters with a large amount of off-site on-call for those that are recruited, while call-backs after hours may then result in staff shortages the following day, affecting the ability to do planned lists.

Therefore, given all of these issues, it is likely that the current situation of regional PCI sites with limited after-hours availability will continue.

Following admission and treatment, rural and regional patients with acute coronary syndromes (ACS) may also face barriers in accessing ongoing specialist care after discharge. These barriers include long wait lists in regional areas with specialists, long travel times, limited availability of echocardiography to reassess left ventricle function after ACS, and finally the ability to pay in areas without public clinics. Furthermore, cardiac rehabilitation services may require long travel times, if offered at all.

Looking forward, there are likely to be ongoing challenges with workforce issues in rural and regional areas, despite the many different attempts over a prolonged time period to increase specialists on the ground.

Our MORACS trial has shown that a simple and relatively in-expensive diagnostic support tool can have a profound impact on patient outcomes in rural and regional areas and provide support to overworked clinicians on the ground.

The challenge now is to identify and develop tools that may support the other important aspects of longer term ACS management, including meeting guideline-directed low-density lipoprotein (LDL) targets, medication review and adherence to therapy, and cardiac rehabilitation.

Dr Allan Davies is a Staff Specialist interventional cardiologist at John Hunter Hospital, Newcastle.

Professor Andrew Boyle is Professor of Cardiology at the University of Newcastle and is an interventional cardiologist at John Hunter Hospital, Newcastle.

Fiona Dee is Cardiac Liaison Officer and TeleECG coordinator at John Hunter Hospital, Newcastle and was the Principal Investigator and lead author of the recently published MORACS trial.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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