The Challenges Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors. The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations, and people with known CVD have increased morbidity and mortality from coronavirus disease 2019 (COVID-19). In addition, COVID-19 is associated with serious cardiac manifestations, potentially placing additional demand on limited regional services at a time of diminished visiting metropolitan support with restricted travel. Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity. Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic.
A systematic, integrated national approach is needed to implement 2006 Australian guidelines for management of acute coronary syndromes (ACS). Clinical outcomes can be improved by closing the current gaps between evidence and practice.
In 2007, the National Heart Foundation of Australia, the Cardiac Society of Australia and New Zealand, and the Australasian College for Emergency Medicine held a national forum to identify current gaps in ACS management and priority strategies to improve outcomes. Consensus recommendations were based on evidence and expert opinion.
Prompt reperfusion for patients with ST‐segment‐elevation myocardial infarction should be ensured by establishing protocols for single‐call activation of primary percutaneous coronary intervention, or, where unavailable, enabling health care workers to initiate thrombolysis.
Accuracy of risk stratification of non‐ST‐segment‐elevation ACS (NSTEACS) should be improved using clinical pathways that integrate ambulance, medical and nursing care.
Rates of early invasive management for patients with high‐risk NSTEACS should be increased using efficient systems for transfer to revascularisation facilities.
All patients with an ACS should be referred to rehabilitation and secondary prevention programs, including alternative models of care where appropriate.
Equal access to recommended care for all Australians with an ACS — including those in rural, remote and Aboriginal and Torres Strait Islander communities — should be achieved by improving workforce capacity in under‐resourced regions and ensuring access to third‐generation fibrinolytic agents, defibrillation, timely essential pathology tests and invasive revascularisation facilities.
National standards for data collection and clinical outcomes should be established, and performance should be monitored.
From a study of 526 patients having automatic ECG analysis, criteria were established which diagnosed acute evolving Q wave myocardial infarction with 71% sensitivity and 98% specificity. Specificity was 100% when patients with known previous Q wave infarction were excluded. In pre-hospital practice the high sensitivity and specificity were maintained. This method appears appropriate, when other criteria are met, for paramedic-initiated pre-hospital thrombolysis with remote supervision of a cardiologist by telephone.
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