Clinical characteristics of Aboriginal and Torres Strait Islander emergency department patients with suspected acute coronary syndrome.

OBJECTIVES: To describe the demographics, presentation characteristics, clinical features and cardiac outcomes for Aboriginal and Torres Strait Islander patients who present to a regional cardiac referral centre ED with suspected acute coronary syndrome (ACS). METHODS: This was a single-centre observational study conducted at a regional referral hospital in Far North Queensland, Australia from November 2017 to September 2018 and January 2019 to December 2019. Study participants were 278 Aboriginal and Torres Strait Islander people presenting to an ED and investigated for suspected ACS. The main outcome measure was the proportion of patients with ACS at index presentation and differences in characteristics between those with and without ACS. RESULTS: ACS at presentation was diagnosed in 38.1% of patients (n = 106). The mean age of patients with ACS was 53.5 years (SD 9.5) compared with 48.7 years (SD 12.1) in those without ACS (P = 0.001). Patients with ACS were more likely to be male (63.2% vs 39.0%, P < 0.001), smokers (70.6% vs 52.3%, P = 0.002), have diabetes (56.6% vs 38.4%, P = 0.003) and have renal impairment (24.5% vs 10.5%, P = 0.002). CONCLUSIONS: Aboriginal and Torres Strait Islander patients with suspected ACS have a high burden of traditional cardiac risk factors, regardless of whether they are eventually diagnosed with ACS. These patients may benefit from assessment for coronary artery disease regardless of age at presentation.

Emergency Department Assessment of Suspected Acute Coronary Syndrome Using the IMPACT Pathway in Aboriginal and Torres Strait Islander People.

OBJECTIVES: The Improved Assessment of Chest pain Trial (IMPACT) pathway is an accelerated strategy for the assessment of emergency patients presenting with suspected acute coronary syndrome (ACS). The objective of this study was to report outcomes for Aboriginal and Torres Strait Islander patients deemed low-, intermediate-, or high-risk according to this pathway. DESIGN: This was a prospective observational trial conducted between November 2017 and December 2019. SETTING: Regional hospital in Far North Queensland. PARTICIPANTS: Aboriginal and Torres Strait Islander people presenting to the Emergency Department with suspected ACS were asked to participate. Participants were stratified as low-, intermediate- or high-risk of ACS according to the IMPACT pathway. High-and intermediate risk patients were managed according to the IMPACT pathway. Management of low-risk patients included additional inpatient cardiac testing, which was not part of the original IMPACT pathway. MAIN OUTCOME MEASURES: The primary outcome was acute coronary syndrome within 30-days. Secondary outcomes included length of stay and prevalence of objective testing. RESULTS: A total of 155 participants were classified as either at low-risk (n=18 11.6%), intermediate-risk (n=87 56.1%), or high-risk (n=50 32.3%) of ACS. Thirty-day (30-day) ACS occurred in 29 (18.6%) patients, which included 26 (52.0%) high-risk patients and three (3.4%) intermediate-risk patients. No patients in the low-risk group were diagnosed with ACS during their index presentation or by 30-days. Median hospital length-of-stay was 11.9 hours (interquartile range [IQR] 5.3-20.2 hrs) for low- and 15.5 hours (IQR 5.9-29.2 hrs) for intermediate-risk patients. CONCLUSION: The IMPACT pathway, which has been associated with reduced LOS in other settings, could be safely implemented for patients of Aboriginal and Torres Strait Islander origin, classifying two-thirds as low- or intermediate risk. However, a clinically significant proportion of Aboriginal and Torres Strait Islander patients experience cardiac events, which supports the need to provide early objective testing for coronary artery disease.

The temporospatial epidemiology of rheumatic heart disease in Far North Queensland, tropical Australia 1997-2017; impact of socioeconomic status on disease burden, severity and access to care.

BACKGROUND: The incidence of rheumatic heart disease (RHD) among Indigenous Australians remains one of the highest in the world. Many studies have highlighted the relationship between the social determinants of health and RHD, but few have used registry data to link socioeconomic disadvantage to the delivery of patient care and long-term outcomes. METHODS: A retrospective study of individuals living with RHD in Far North Queensland (FNQ), Australia between 1997 and 2017. Patients were identified using the Queensland state RHD register. The Socio-Economic Indexes for Areas (SEIFA) Score-a measure of socioeconomic disadvantage-was correlated with RHD prevalence, disease severity and measures of RHD care. RESULTS: Of the 686 individuals, 622 (90.7%) were Indigenous Australians. RHD incidence increased in the region from 4.7/100,000/year in 1997 to 49.4/100,000/year in 2017 (p<0.001). In 2017, the prevalence of RHD was 12/1000 in the Indigenous population and 2/1000 in the non-Indigenous population (p<0.001). There was an inverse correlation between an area's SEIFA score and its RHD prevalence (rho = -0.77, p = 0.005). 249 (36.2%) individuals in the cohort had 593 RHD-related hospitalisations; the number of RHD-related hospitalisations increased during the study period (p<0.001). In 2017, 293 (42.7%) patients met criteria for secondary prophylaxis, but only 73 (24.9%) had good adherence. Overall, 119/686 (17.3%) required valve surgery; the number of individuals having surgery increased over the study period (p = 0.02). During the study 39/686 (5.7%) died. Non-Indigenous patients were more likely to die than Indigenous patients (9/64 (14%) versus 30/622 (5%), p = 0.002), but Indigenous patients died at a younger age (median (IQR): 52 (35-67) versus 73 (62-77) p = 0.013). RHD-related deaths occurred at a younger age in Indigenous individuals than non-Indigenous individuals (median (IQR) age: 29 (12-58) versus 77 (64-78), p = 0.007). CONCLUSIONS: The incidence of RHD, RHD-related hospitalisations and RHD-related surgery continues to rise in FNQ. Whilst this is partly explained by increased disease recognition and improved delivery of care, the burden of RHD remains unacceptably high and is disproportionately borne by the socioeconomically disadvantaged Indigenous population.

Heart of the tropics: delivering evidence-based care for acute coronary syndromes in northern Australia.

Acute coronary syndromes (ACS) are life-threatening medical emergencies that require urgent treatment, posing particular challenges for systems of health care in regional and remote parts of the world characterised by large distances and widely dispersed populations and healthcare facilities. Northern Australia is such an environment. The prevalence of cardiovascular risk factors, coronary artery disease and ACS (myocardial infarction and unstable angina) in northern Australia is amongst the highest in Australia. Despite the high burden of disease, appropriate healthcare services to address these important health challenges have been inadequate. The Australian Commission on Safety and Quality in Health Care has released a Clinical Care Standard for Acute Coronary Syndromes and the National Heart Foundation of Australia has developed an ACS Capabilities Framework, which together define minimum standards of care regardless of the patient's location. Strategies such as uniform state-wide ACS clinical pathways provide guidance on how evidence-based care can be provided in a range of geographical settings and to all populations, including Indigenous Australians. The continuing evolution of cardiac catheter laboratories in Townsville, Cairns, Mackay and Darwin has facilitated improved treatment for ACS in northern Australia, and has supported the development of region-wide, integrated, multidisciplinary pathways of care. Systems of care in ACS require consideration of the perspectives of the patient (from symptom onset to long-term secondary prevention of further events), the health system ('dissolving' traditional regional silos of care to enable a higher critical mass, greater cooperation, better communication and improved efficiency) and healthcare disciplines and services (including ambulance, retrieval, local health centres and local hospitals, tertiary centres, cardiac rehabilitation and general practice).