Costs and healthcare use of patients with chronic kidney disease in the Northern Territory, Australia.

BACKGROUND: The burden of chronic kidney disease (CKD) is high in the Northern Territory (NT), Australia. This study aims to describe the healthcare use and associated costs of people at risk of CKD (e.g. acute kidney injury, diabetes, hypertension, and cardiovascular disease) or living with CKD in the NT, from a healthcare funder perspective. METHODS: We included a retrospective cohort of patients at risk of, or living with CKD, on 1 January 2017. Patients on kidney replacement therapy were excluded from the study. Data from the Territory Kidney Care database, encompassing patients from public hospitals and primary health care services across the NT was used to conduct costing. Annual healthcare costs, including hospital, primary health care, medication, and investigation costs were described over a one-year follow-up period. Factors associated with high total annual healthcare costs were identified with a cost prediction model. RESULTS: Among 37,398 patients included in this study, 23,419 had a risk factor for CKD while 13,979 had CKD (stages 1 to 5, not on kidney replacement therapy). The overall mean (± SD) age was 45 years (± 17), and a large proportion of the study cohort were First Nations people (68%). Common comorbidities in the overall cohort included diabetes (36%), hypertension (32%), and coronary artery disease (11%). Annual healthcare cost was lowest in those at risk of CKD (AUD$7,958 per person) and highest in those with CKD stage 5 (AUD$67,117 per person). Inpatient care contributed to the majority (76%) of all healthcare costs. Predictors of increased total annual healthcare cost included more advanced stages of CKD, and the presence of comorbidities. In CKD stage 5, the additional cost per person per year was + $53,634 (95%CI 32,769 to 89,482, p < 0.001) compared to people in the at risk group without CKD. CONCLUSION: The total healthcare costs in advanced stages of CKD is high, even when patients are not on dialysis. There remains a need for effective primary prevention and early intervention strategies targeting CKD and related chronic conditions.

Developing an integrated clinical decision support system for the early identification and management of kidney disease-building cross-sectoral partnerships.

BACKGROUND: The burden of chronic conditions is growing in Australia with people in remote areas experiencing high rates of disease, especially kidney disease. Health care in remote areas of the Northern Territory (NT) is complicated by a mobile population, high staff turnover, poor communication between health services and complex comorbid health conditions requiring multidisciplinary care. AIM: This paper aims to describe the collaborative process between research, government and non-government health services to develop an integrated clinical decision support system to improve patient care. METHODS: Building on established partnerships in the government and Aboriginal Community-Controlled Health Service (ACCHS) sectors, we developed a novel digital clinical decision support system for people at risk of developing kidney disease (due to hypertension, diabetes, cardiovascular disease) or with kidney disease. A cross-organisational and multidisciplinary Steering Committee has overseen the design, development and implementation stages. Further, the system's design and functionality were strongly informed by experts (Clinical Reference Group and Technical Working Group), health service providers, and end-user feedback through a formative evaluation. RESULTS: We established data sharing agreements with 11 ACCHS to link patient level data with 56 government primary health services and six hospitals. Electronic Health Record (EHR) data, based on agreed criteria, is automatically and securely transferred from 15 existing EHR platforms. Through clinician-determined algorithms, the system assists clinicians to diagnose, monitor and provide guideline-based care for individuals, as well as service-level risk stratification and alerts for clinically significant events. CONCLUSION: Disconnected health services and separate EHRs result in information gaps and a health and safety risk, particularly for patients who access multiple health services. However, barriers to clinical data sharing between health services still exist. In this first phase, we report how robust partnerships and effective governance processes can overcome these barriers to support clinical decision making and contribute to holistic care.

Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome: The TEXTMEDS Randomized Clinical Trial.

BACKGROUND: TEXTMEDS (Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome) examined the effects of text message-delivered cardiac education and support on medication adherence after an acute coronary syndrome. METHODS: TEXTMEDS was a single-blind, multicenter, randomized controlled trial of patients after acute coronary syndrome. The control group received usual care (secondary prevention as determined by the treating clinician); the intervention group also received multiple motivational and supportive weekly text messages on medications and healthy lifestyle with the opportunity for 2-way communication (text or telephone). The primary end point of self-reported medication adherence was the percentage of patients who were adherent, defined as >80% adherence to each of up to 5 indicated cardioprotective medications, at both 6 and 12 months. RESULTS: A total of 1424 patients (mean age, 58 years [SD, 11]; 79% male) were randomized from 18 Australian public teaching hospitals. There was no significant difference in the primary end point of self-reported medication adherence between the intervention and control groups (relative risk, 0.93 [95% CI, 0.84-1.03]; P=0.15). There was no difference between intervention and control groups at 12 months in adherence to individual medications (aspirin, 96% vs 96%; ß-blocker, 84% vs 84%; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 77% vs 80%; statin, 95% vs 95%; second antiplatelet, 84% vs 84% [all P>0.05]), systolic blood pressure (130 vs 129 mm Hg; P=0.26), low-density lipoprotein cholesterol (2.0 vs 1.9 mmol/L; P=0.34), smoking (P=0.59), or exercising regularly (71% vs 68%; P=0.52). There were small differences in lifestyle risk factors in favor of intervention on body mass index <25 kg/m2 (21% vs 18%; P=0.01), eating ≥5 servings per day of vegetables (9% vs 5%; P=0.03), and eating ≥2 servings per day of fruit (44% vs 39%; P=0.01). CONCLUSIONS: A text message-based program had no effect on medical adherence but small effects on lifestyle risk factors. REGISTRATION: URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364448; Unique identifier: ANZCTR ACTRN12613000793718.

Pulmonary hypertension in remote and disadvantaged population: overcoming unique challenges for improved outcomes.

Pulmonary hypertension (PH) is a common and debilitating medical condition with high mortality. PH research has traditionally focused on pulmonary arterial hypertension and its management in expert PH centres. Other forms of PH such as PH associated with cardiac or respiratory disease are more common, less well-understood and associated with higher mortality. Epidemiology of PH in disadvantaged, remote and rural regions, remains largely undocumented. In this review, we discuss the unique challenges in identifying PH in rural and disadvantaged populations using the Top End region of the Northern Territory of Australia as an example. We propose a simple diagnostic approach, ideally suited to regions where resource allocation is scarce, using clinical skills, echocardiography, and an escalation algorithm. The brief history, epidemiology and current literature on PH are summarised to inform the busy clinicians. We highlight two case examples from the Top End to illustrate the challenges and potential solutions.

Inpatient cardiac care for acute coronary syndromes in the Top End of Australia.

BACKGROUND: Disparities in cardiovascular outcomes between Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians persist. This has previously been attributed to a combination of differences in burden of cardiovascular disease risk factors, and inpatient access to guideline-recommended care. AIMS: To assess differences in inpatient access to guideline-recommended acute coronary syndrome (GR-ACS) treatment between Aboriginal and Torres Strait Islander and non-indigenous patients admitted to Royal Darwin Hospital (RDH) with index ACS event. METHODS: This retrospective study included index ACS admissions (n = 288) to RDH between January 2016 and June 2017. Outcomes included rates of coronary angiography, percutaneous coronary intervention (PCI), surgical revascularisation, GR-ACS medications prescribed on discharge and short-term outcomes (30-day mortality and ACS readmissions; 12-month all cardiac-related readmissions). RESULTS: Two hundred and eighty-eight patients, including 109 (37.85%) Aboriginal and Torres Strait Islander patients, were included. Compared with non-indigenous patients, they were younger (median age 48 years vs 60 years; P < 0.01), with a greater burden of comorbidities, including diabetes (39% vs 19%; P < 0.01), smoking (68% vs 35%; P < 0.01) and chronic kidney disease (29% vs 5%; P < 0.01). There were no differences in rates of coronary angiography (98% vs 96%; P = 0.24) or PCI (47% vs 57%; P = 0.12), although there was a trend towards surgical revascularisation in Aboriginal and Torres Strait Islander patients (16% vs 8%; P = 0.047). There were no differences in 30-day mortality (1.8% vs 1.7%; P = 0.72), 12-month ACS readmissions (7% vs 4%; P = 0.20) or 12-month cardiac-related readmissions (7% vs 13%; P = 0.11). CONCLUSIONS: Aboriginal and Torres Strait Islander patients received similar inpatient ACS care and secondary prevention medication at discharge, with similar short-term mortality outcomes as non-indigenous patients. While encouraging, these outcomes may not persist long term. Further outcomes research is required, with differences compelling consideration of other primary and secondary prevention contributors.

Australian Atherosclerosis Society Position Statement on Lipoprotein(a): Clinical and Implementation Recommendations.

This position statement provides guidance to cardiologists and related specialists on the management of adult patients with elevated lipoprotein(a) [Lp(a)]. Elevated Lp(a) is an independent and causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and calcific aortic valve disease (CAVD). While circulating Lp(a) levels are largely determined by ancestry, they are also influenced by ethnicity, hormones, renal function, and acute inflammatory events, such that measurement should be done after accounting for these factors. Further, circulating Lp(a) concentrations should be estimated using an apo(a)-isoform independent assay that employs appropriate calibrators and reports the results in molar units (nmol/L). Selective screening strategies of high-risk patients are recommended, but universal screening of the population is currently not advised. Testing for elevated Lp(a) is recommended in all patients with premature ASCVD and those considered to be at intermediate-to-high risk of ASCVD. Elevated Lp(a) should be employed to assess and stratify risk and to enable a decision on initiation or intensification of preventative treatments, such as cholesterol lowering therapy. In adult patients with elevated Lp(a) at intermediate-to-high risk of ASCVD, absolute risk should be reduced by addressing all modifiable behavioural, lifestyle, psychosocial and clinical risk factors, including maximising cholesterol-lowering with statin and ezetimibe and, where appropriate, PCSK9 inhibitors. Apheresis should be considered in patients with progressive ASCVD. New ribonucleic acid (RNA)-based therapies which directly lower Lp(a) are undergoing clinical trials.

Barriers to and Facilitators of Implementing Guidelines for Detecting Familial Hypercholesterolaemia in Australia.

BACKGROUND: Familial hypercholesterolaemia (FH) is a genetic condition that is a preventable cause of premature cardiovascular morbidity and mortality. High-level evidence and clinical practice guidelines support preventative care for people with FH. However, it is estimated that less than 10% of people at risk of FH have been detected using any approach across Australian health settings. The aim of this study was to identify the implementation barriers to and facilitators of the detection of FH in Australia. METHODS: Four, 2-hour virtual focus groups were facilitated by implementation scientists and a clinicians as part of the 2021 Australasian FH Summit. Template analysis was used to identify themes. RESULTS: There were 28 workshop attendees across four groups (n=6-8 each), yielding 13 barriers and 10 facilitators across three themes: (1) patient related, (2) provider related, and (3) system related. A "lack of care pathways" and "upskilling clinicians in identifying and diagnosing FH" were the most interconnected barriers and facilitators for the detection of FH. CONCLUSIONS: The relationships between barriers and facilitators across the patient, provider, and system themes indicates that a comprehensive implementation strategy is needed to address these different levels. Future research is underway to develop a model for implementing the Australian FH guidelines into practice.

Comparison of clinical manifestation among Australian Indigenous and non-indigenous patients presenting with pleural effusion.

BACKGROUND: There is sparse evidence in the literature in relation to the nature and causes of pleural effusion among Australian Indigenous population. AIM: To investigate the clinical and demographic characteristics of adult indigenous patients presenting with pleural effusion in the Northern Territory of Australia. METHODS: In this retrospective study, indigenous and non-indigenous adults diagnosed to have pleural effusion over a 2-year study period were included for comparative analysis. RESULTS: Of the 314 patients, 205 (65%) were non-indigenous and 52% were male. In comparison with non-indigenous patients, the indigenous patients were younger (50 years (interquartile range (IQR) 39-60) vs 63 years (IQR 52-72); P < 0.001), female (61% vs 41%; P = 0.001), had a higher prevalence of renal and cardiovascular disease and tended to have exudative effusion (93% vs 76%; P = 0.032). Infections were judged to be the most common cause of effusion in both groups, more so among the indigenous cohort. Effusion secondary to renal disease was higher (13% vs 1%; P < 0.001) among Australian Indigenous patients, but in contrast, malignant effusions were higher (13% vs 4%; P = 0.004) among non-indigenous patients. Length of hospital stay was longer for indigenous patients (P = 0.001), and a greater proportion received renal dialysis (13% vs 1%; P < 0.001). Intensive care unit admission rates were higher with infective aetiology of pleural effusion (82% vs 53% indigenous and 44% vs 39% non-indigenous respectively). Re-presentations to hospital were higher among indigenous patients (46% vs 33%; P = 0.046) and were associated with renal and cardiac disease and malignancy in non-indigenous patients. CONCLUSION: There are significant differences in the way pleural effusion manifests among Australian Indigenous patients. Understanding these differences might facilitate approaches to management and to implementation of strategies to reduce morbidity and mortality in this population.

Obstructive Sleep Apnoea and Cardiac Disease Among Aboriginal Patients in the Northern Territory of Australia.

BACKGROUND: There is paucity of information on obstructive sleep apnoea (OSA) and cardiac diseases among Aboriginal Australian patients. This study evaluates the association of various cardiac disease profiles among Aboriginal patients undergoing a diagnostic polysomnography (PSG). METHOD: In this 5-year retrospective study demographics, clinical characteristics, medical and cardiac -conditions were analysed. RESULTS: There were total of 340 eligible patients included in the study. The median age was 47 (38-57) years, 51% were males and obesity was noted in 78%. In the overall study participants, cardiac diseases were present in 46%: coronary artery disease (CAD) in 27%, pulmonary hypertension (PH) 19% and atrial fibrillation (AF) 14%. Diabetes and hypertension were noted in 42 and 41% of patients. Overall, 73/340 (21.5%) had two, 69/340 (20.3%) three, 55/340 (16.2%) four, 40/340 (11.8%) five and 10/340 (2.9%) had six comorbidities. In the overall study participants, 297/340 (87%) had OSA (Apnoea-Hypopnoea Index [AHI]>5/hour). Co-occurrence of OSA and cardiac diseases was found in 140/297 (47%), CAD being the commonest (27%). Patients with OSA had a higher number of comorbidities compared to patients without sleep apnoea. Hospital admissions frequency showed a median 2 (IQR: 0-4) times readmission rates since the diagnosis of OSA overall compliance with CPAP therapy was observed in 63 (43%). CONCLUSION: Our study demonstrated that a significant proportion of Aboriginal patients with OSA have co-existing cardiac diseases, with CAD being the commonest. Patients with OSA had a higher number of comorbidities compared to patients without sleep apnoea. Furthermore, hospital admission frequency increased among OSA patients with multiple comorbidities.

Top End Pulmonary Hypertension Study: Understanding Epidemiology, Therapeutic Gaps and Prognosis in Remote Australian Setting.

INTRODUCTION: The Top End of Australia has a high proportion of Indigenous people with a high burden of chronic cardiac and pulmonary diseases likely to contribute to pulmonary hypertension (PH). The epidemiology of PH has not been previously studied in this region. METHODS: Patients with PH were identified from the Northern Territory echocardiography database from January 2010 to December 2015 and followed to the end of 2019 or death. Pulmonary hypertension was defined as a tricuspid regurgitation velocity ≥2.75 m/s measured by Doppler echocardiography. The aetiology of PH, as categorised by published guidelines, was determined by reviewing electronic health records. RESULTS: 1,764 patients were identified comprising 49% males and 45% Indigenous people. The prevalence of PH was 955 per 100,000 population (with corresponding prevalence of 1,587 for Indigenous people). Hypertension, atrial fibrillation, diabetes and respiratory disease were present in 85%, 45%, 41% and 39%, respectively. Left heart disease was the leading cause for PH (58%), the majority suffering from valvular disease (predominantly rheumatic). Pulmonary arterial hypertension (PAH), respiratory disease related PH, chronic thromboembolic PH (CTEPH) and unclear multifactorial PH represented 4%, 16%, 2% and 3%, respectively. Underlying causes were not identifiable in 17% of the patients. Only 31% of potentially eligible patients were on PAH-specific therapy. At census, there was 40% mortality, with major predictors being age, estimated pulmonary artery systolic pressure (ePASP) and Indigenous ethnicity. CONCLUSION: Pulmonary hypertension is prevalent in Northern Australia, with a high frequency of modifiable risk factors and other treatable conditions. Whether earlier diagnosis, interpretation and intervention improve outcomes merits further assessment.

Atrial Fibrillation in Remote Indigenous and Non-Indigenous Individuals Hospitalised in Central Australia.

BACKGROUND: The epidemiology of atrial fibrillation (AF) amongst Indigenous populations remains poorly characterised. We studied hospitalisations for AF in Central Australia, the most populous Indigenous region in the country. METHODS: Patients with a diagnosis of AF admitted to Alice Springs Hospital, the only secondary health care facility and provider of cardiac care in remote Central Australia, were identified from 2006 to 2016. Age and gender-specific hospitalised AF prevalence, comorbidities, and CHA2DS2-VASc scores were ascertained. RESULTS: Of 57,056 admitted patients over the study period, 1,210 (2.1%; 46% Indigenous) had a diagnosis of AF. For Indigenous and non-Indigenous individuals <45 years, hospitalised AF prevalence per 10,000 population was 105 (CI 84-131) and 50 (CI 36-68) in males (ratio=2.10), and 98 (CI 77-123) and 12 (CI 6-23) in females (ratio=7.92), respectively. For Indigenous and non-Indigenous individuals ≥65 years, hospitalised AF prevalence per 10,000 was 1,577 (CI 1,194-2,026) and 2,326 (CI 2,047-2,623) in males (ratio=0.68), and 1,713 (CI 1,395-2,069) and 1,897 (1,623-2,195) in females (ratio=0.90). Indigenous individuals had higher rates of cardiometabolic comorbidities, particularly at younger ages. CHA2DS2-VASc scores were greater in Indigenous individuals, particularly those <45 years (2.5±1.5 versus 0.7±1.1, p<0.001). CONCLUSIONS: The prevalence of hospitalised AF amongst Indigenous people in remote Central Australia was significantly higher than in non-Indigenous individuals, particularly in younger age groups and females. Indigenous individuals with hospitalised AF also had a markedly greater prevalence of cardiometabolic comorbidities and elevated stroke risk. These data suggest that AF may be contributing to the gap in morbidity and mortality experienced by Indigenous Australians.

Management and Outcomes of Prosthetic Valve Thrombosis. An Australian Case Series From the Northern Territory.

BACKGROUND: Prosthetic valve thrombosis (PVT) is an uncommon but serious cause of morbidity and mortality after cardiac valve implantation. The most common cause leading to PVT is inadequate anticoagulation. Royal Darwin Hospital is a major referral centre for the Top End of Australia and is unique in having a high burden of rheumatic heart disease (RHD) requiring valve surgery, issues with adherence with oral anticoagulants, and the absence of onsite cardiothoracic facility. METHODS: We report clinical characteristics and outcomes of consecutive patients presenting with PVT to a single centre without on-site cardiothoracic surgery. RESULTS: Thirty-two (32) episodes involving 21 patients were retrospectively identified between 2000 and 2017. Our cohort had an average age of 37 years. Nineteen (19) patients were of Aboriginal or Torres Strait Islander descent. All valves were mechanical, except for one bioprosthetic mitral valve, with average time from implantation to initial PVT 5.1 years. The majority of patients were in New York Heart Association (NYHA) class III and IV (6%, and 66%, respectively). Anti-coagulation was sub-therapeutic in 88% of presentations. Eleven (11) (34%) presentations were recurrent PVT involving eight patients. Twenty-six (26) (82%) episodes were treated with thrombolytic therapy which achieved complete success in 65% and partial success in 19%. Five (5) patients received a second dose of the lytic agent. Of the four patients not responding to thrombolytic therapy, two died and two were urgently transferred to a facility with on-site cardiothoracic surgery. Five (5) out of 32 episodes resulted in death (16%) with overall mortality 24% for the cohort over the entire time period. Thrombolytic therapy was associated with five major bleeding episodes (16%) including two fatal bleeds. CONCLUSIONS: Prosthetic valve thrombosis is a rare but life-threatening complication of prosthetic valves, with the vast majority of patients found to be inadequately anticoagulated. Despite differences in thrombolytic agents these were successful in the majority of patients.

Clinical Utility of Stress Echocardiography in Remote Indigenous and Non-Indigenous Populations: A 10-Year Study in Central Australia.

BACKGROUND: Remote Central Australia has a large Indigenous population and a significant burden of cardiovascular disease. Stress echocardiography has been previously validated as a useful investigation for long-term prognostication. However, there are no prior studies assessing its utility in remote or Indigenous populations. METHOD: Consecutive individuals undergoing stress echocardiography in Central Australia between 2007 and 2017 were included. Stress echocardiography was performed and reported via standard protocols. Individuals were followed up for all-cause mortality. RESULTS: One-thousand and eight patients (1,008) (54% Indigenous Australian) were included. After a mean follow-up of 3.5±2.4 years, 54 (5%) patients were deceased. Overall, 797 (79%) patients had no abnormalities during rest or stress echocardiography, with no difference according to ethnicity (p>0.05). In patients with a normal test, annual mortality averaged 1.3% over 5 years of follow-up, with annual mortality significantly higher in Indigenous compared to non-Indigenous individuals (1.8% vs 0.6% respectively). In those with an abnormal test, annual mortality was 4.4% vs 1.3% in Indigenous and non-Indigenous individuals respectively. Increasing age, Indigenous ethnicity and cardiometabolic comorbidities were associated with mortality in univariate analyses (p<0.05 for all). In multivariate models, only chronic kidney disease remained predictive of mortality, with other associations (including Indigenous ethnicity) becoming attenuated. CONCLUSION: This is the first study to report on the use of stress echocardiography in a remote or Indigenous population. A normal stress echocardiogram in remote Indigenous individuals was able to identify a lower risk group of patients in this setting. Although Indigenous individuals with a normal test still had a higher annual rate of mortality compared to non-Indigenous individuals, this association appeared to be mediated by cardiometabolic comorbidities.

Adherence to Treatment Guidelines in Heart Failure Patients in the Top End Region of Northern Territory.

BACKGROUND: Heart failure (HF) is associated with significant morbidity and mortality and recurrent hospitalisations, particularly in the Indigenous Australians of the Northern Territory. In remote Northern Australia, the epidemiology is less clear but anecdotal evidence suggests it may be worse. In addition, some anecdotal evidence suggests that prognostic pharmacological therapy could also be underutilised. Minimal HF data exists in the remote and Indigenous settings, making this study unique. METHODS: A retrospective cohort review of pharmacological management of 99 patients from 1 January 2014 to 31 December 2014 was performed. RESULTS: Ninety-nine (99) patients were identified. 59.6% were non-Indigenous vs 40.4% Indigenous. The majority was male (69.7%). Indigenous patients were younger; median age was 51.4 (43.4-60.6) vs 70.5 (62.2-77.0), p<0.001. Major causes of HF were coronary artery disease (61%) and dilated cardiomyopathy (27%). Associated comorbidities included hypertension (52%), dyslipidaemia (38%), diabetes mellitus (40%) and atrial fibrillation (25%). The use of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) and ß-blocker was 68% and 87%, respectively. Forty-one (41) patients not on an ACEI/ARB and/or ß-blocker were identified. Seventeen (17) of those patients (42%) did not receive an ACEI/ARB because of renal failure. Four (4) patients (10%) did not take a ß-blocker due to hypotension. Fourteen (14) patients (34%) were not prescribed an ACEI/ARB and/or ß-blocker had no identifiable contraindications. CONCLUSIONS: Indigenous patients are over-represented at a younger age demonstrating the alarming rate of disease burden in NT's young Indigenous population. Generally, ACEI/ARBs were underutilised compared to ß-blockers with renal impairment being the primary contraindication. There is a need to develop processes to further improve the use of heart failure medications and setting up a HF database could be the first step in progress.

Echocardiography in Indigenous Populations and Resource Poor Settings.

The majority of global cardiovascular disease burden occurs in low- and middle-income countries (LMIC) and indigenous populations. Although common diseases, such as ischaemic heart disease, cause significant burden, there are also neglected diseases. Forgotten by many, these diseases-including rheumatic heart disease, endomyocardial fibrosis and Chagas cardiomyopathy-continue to take a tremendous toll on a large proportion of the world's population. Whilst the technology of echocardiography continues to evolve in many high-income countries, low resource countries are working out how to make this vital tool available and affordable for the most remote and poorest populations. This paper aims to highlight the neglected cardiovascular diseases and their echocardiographic features. It also highlights the latest research in relation to portable echocardiography, task shifting and disease screening. The authors make recommendations in relation to future directions, including making echocardiography an affordable and accessible tool for all.

Pulmonary Hypertension in Central Australia: A Community-Based Cohort Study.

BACKGROUND: The burden of pulmonary hypertension (PHT) in Central Australia has not been previously studied. Our aim is to characterise the prevalence, clinical classification, and long-term survival of individuals with PHT in Central Australia. METHODS: A community-based cohort study of all individuals diagnosed with PHT in Central Australia between 2005 and 2016 was undertaken. We estimated PHT prevalence using population data, describe clinical PHT classification, and characterised long-term survival using Kaplan-Meier approaches. RESULTS: A total of 183 patients were identified (mean age 52±16years, 63% female). Of these individuals, 149 (81.4%) were of Aboriginal and Torres Strait Islander (ATSI) descent. The prevalence per 100,000 of any PHT was significantly higher In ATSI (723 [95% CI 608-839] compared to non-ATSI individuals (126 [95% CI 84-168], p<0.001). Furthermore, ATSI individuals were diagnosed at younger ages compared to non-ATSI individuals (49±15 vs 64±16years, p<0.001). Median estimated pulmonary artery systolic pressure (ePASP) was higher in patients with pulmonary arterial hypertension (PAH) compared to other causes (62 [IQR 54-69] vs 50 [IQR 44-58] mmHg, p<0.01). The median survival rate from diagnosis was 9 years (IQR 7.2-13.2). Age and ePASP were significant predictors of mortality (HR 1.05 [95% CI 1.02-1.07] and HR 1.56 [95% 1.00-2.42] respectively). CONCLUSIONS: In this community based study, we found a high burden of PHT in Central Australia. The prevalence of PHT is greater in ATSI individuals and is diagnosed at younger ages compared to non-ATSI individuals. Together with other cardiovascular diseases, PHT may be in-part contributing to the gap in life expectancy between ATSI and non-ATSI individuals.

Differences in management and outcomes for men and women with ST-elevation myocardial infarction.

OBJECTIVE: To examine whether there are sex differences in the characteristics, management, and clinical outcomes of patients with an ST-elevation myocardial infarction (STEMI). Design, setting: Cohort study; analysis of data collected prospectively by the CONCORDANCE acute coronary syndrome registry from 41 Australian hospitals between February 2009 and May 2016. PARTICIPANTS: 2898 patients (2183 men, 715 women) with STEMI. MAIN OUTCOME MEASURES: Rates of revascularisation (percutaneous coronary intervention [PCI], thrombolysis, coronary artery bypass grafting [CABG]), adjusted for GRACE risk score quartile. SECONDARY OUTCOMES: timely vascularisation rates; major adverse cardiac event rates; clinical outcomes and preventive treatments at discharge. RESULTS: The mean age of women with STEMI at presentation was 66.6 years (SD, 14.5 years), of men, 60.5 years (SD, 12.5 years). The proportions of women with hypertension, diabetes, prior stroke, chronic kidney disease, chronic heart failure, or dementia were larger than those of men; fewer women had histories of previous coronary artery disease or myocardial infarction, or of prior PCI or CABG. Women were less likely to have undergone coronary angiography (odds ratio, adjusted for GRACE score quartile [aOR], 0.53; 95% CI, 0.41-0.69) or revascularisation (aOR, 0.42; 95% CI, 0.34-0.52); they were less likely to have received timely revascularisation (aOR, 0.72; 95% CI, 0.63-0.83) or primary PCI (aOR, 0.76; 95% CI, 0.61-0.95). Six months after admission, the rates of major adverse cardiovascular events (aOR, 2.68; 95% CI, 1.76-4.09) and mortality (aOR, 2.17; 95% CI, 1.24-3.80) were higher for women. At discharge, significantly fewer women than men received ß-blockers, statins, and referrals to cardiac rehabilitation. CONCLUSION: Women with STEMI are less likely to receive invasive management, revascularisation, or preventive medication at discharge. The reasons for these persistent differences in care require investigation.

Takotsubo Cardiomyopathy Associated With Work-Place Bullying.

Background: Takotsubo cardiomyopathy (TC) is a condition of transient left ventricular dysfunction precipitated by acute physical or emotional stress. The pathogenesis of TC is not well understood, but it is known to predominantly affect postmenopausal women in the context of physical or emotional triggers. Aims: To describe a case of TC with an association to a never previously described work place stressor of bullying. Case Report: A 48-year-old female lawyer developed acute chest pain after experiencing significant emotional distress at a workplace meeting. She had experienced 18 months of increasing work-related mental stress in a new managerial role. She was initially thought to have a non-ST-elevation myocardial infarction (NSTEMI) with widespread T wave inversion on electrocardiogram and elevated serial troponin. However, a diagnosis of TC was subsequently made given the characteristic apical ballooning morphology of the left ventricle found on echocardiogram, normal coronary arteries on angiography and a normal echocardiogram 3 weeks later. This case report describes TC in a younger demographic and a link with workplace bullying. Conclusions: Chronic workplace bullying has the potential for serious physical harm by precipitating Takotsubo cardiomyopathy.

Socioeconomic Equity in the Receipt of In-Hospital Care and Outcomes in Australian Acute Coronary Syndrome Patients: The CONCORDANCE Registry.

BACKGROUND: Socioeconomic status (SES) is a social determinant of both health and receipt of health care services, but its impact is under-studied in acute coronary syndrome (ACS). The aim of this study was to examine the influence of SES on in-hospital care, and clinical events for patients presenting with an ACS to public hospitals in Australia. METHODS: Data from 9064 ACS patient records were collected from 41 public hospitals nationwide from 2009 as part of the Cooperative National Registry of Acute Coronary Syndrome Care (CONCORDANCE) registry. For this analysis, we divided the cohort into four socioeconomic groups (based on postcode of usual residence) and compared the in-hospital care provided and clinical outcomes before and after adjustment for both patient clinical characteristics and hospital clustering. RESULTS: Patients were divided into four SES groups (from the most to the least disadvantaged: 2042 (23%) vs. 2104 (23%) vs. 1994 (22%) vs. 2968 (32%)). Following adjustments for patient characteristics, there were no differences in the odds of receiving coronary angiogram, revascularisation, prescription of recommended medication, or referral to cardiac rehabilitation across the SES groups (p=0.06, 0.69, 0.89 and 0.79, respectively). After adjustment for clinical characteristics, no associations were observed for in-hospital and cumulative death (p=0.62 and p=0.71, respectively). However, the most disadvantaged group were 37% more likely to have a major adverse cardiovascular event (MACE) than the least disadvantaged group (OR (95% CI): 1.37 (1.1, 1.71), p=0.02) driven by incidence of in-hospital heart failure. CONCLUSIONS: Although there may be gaps in the delivery of care, this delivery of care does not differ by patient's SES. It is an encouraging affirmation that all patients in Australian public hospitals receive equal in-hospital care, and the likelihood of death is comparable between the SES groups.