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The article presents remote cardiac rehabilitation services and the digital divide: implications for elderly populations during the COVID19 pandemic. Topics discussed include Cardiac rehabilitation (CR) is a complex intervention offered to patients diagnosed with CVD; and these outpatient programmes aim to reduce the risk of a recurrent event and, whilst significant variations exist.

Background: Guidelines recommend referral to cardiac rehabilitation (CR) for cardiac event prevention and risk factor management, but poor attendance persists. Following the development of standardised data and uniform capture, CR services have contributed to three audits in South Australia, Australia. We aimed to determine if CR attendance impacts on cardiovascular readmission, morbidity and mortality.Methods: In a retrospective cohort study, CR databases were linked to hospital administrative datasets to compare the characteristics and outcomes of CR patients between 2013 and 2015. Inverse probability weighting methods were used to measure associations between CR attendance versus non-attendance and cardiovascular readmission and the composite of death, new/re-myocardial infarction, atrial fibrillation, heart failure and stroke within 12-months.Results: Of 49,909 eligible separations, 15,089/49,909 (30.2%) were referred to CR with an attendance rate of 4,286/15,089 (28.4%). Referred/declined patients were older (median: 67.3 vs 65.3 years, p < 0.001), more likely to be female (32.3% vs 26.5%, p < 0.001) with more heart failure (17.1% vs 10.9%, p < 0.001) and arrhythmia (6.1% vs 2.1%, p < 0.001) admissions and higher socio-economic disadvantage (median Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD): 950.1 vs 960.4, p < 0.001). Referred/attended patients had lower cardiovascular readmission, (referred/attended vs not referred: 15.6% vs 22.7% and referred/attended vs referred/declined: 15.6% vs 29.6%, p < 0.001). After clinical and social factors adjustment there was no difference in composite outcomes, but attendance was associated with reduced cardiovascular readmission (HR:0.68, 95% IQR: 0.58-0.81, p = 0.001).Conclusions: Audit can measure service effectiveness, identifying areas for improvement. This study highlights patient eligibility, system and program considerations for future CR services. [ABSTRACT FROM AUTHOR]

Objective. Effective translation of evidence to practice may depend on systems of care characteristics within the health service. The present study evaluated associations between hospital expertise and infrastructure capacity and acute coronary syndrome (ACS) care as part of the SNAPSHOT ACS registry. Methods. A survey collected hospital systems and process data and our analysis developed a score to assess hospital infrastructure and expertise capacity. Patient-level data from a registry of 4387 suspected ACS patients enrolled over a 2-wee Results. Of 375 participating hospitals, 348 (92.8%) were included in the analysis. Higher expertise was associated with increased coronary angiograms (440/1329; 33.1%), 580/1656 (35.0%) and 609/1402 (43.4%) for low, intermediate and high expertise capacity respectively; P < 0.001) and the prescription of guideline therapies observed a tendency for an association with (531/1329 (40.0%), 733/1656 (44.3%) and 603/1402 (43.0%) for low, intermediate and high expertise capacity respectively; P = 0.056), but not rehabilitation (474/1329 (35.7%), 603/1656 (36.4%) and 535/1402 (38.2%) for low, intermediate and high expertise capacity respectively; P = 0.377). Higher expertise capacity was associated with a lower incidence of major adverse events (152/1329 (11.4%), 142/1656 (8.6%) and 149/149 (10.6%) for low, intermediate and high expertise capacity respectively; P = 0.026), as well as adjusted mortality within 18 months (low vs intermediate expertise capacity: odds ratio (OR) 0.79, 95% confidence interval (CI) 0.58-1.08, P = 0.153; intermediate vs high expertise capacity: OR 0.64, 95% CI 0.48-0.86, P = 0.003). Conclusions. Both higher-level expertise in decision making and infrastructure capacity are associated with improved evidence translation and survival over 18 months of an ACS event and have clear healthcare design and policy implications. [ABSTRACT FROM AUTHOR]

Background The development of troponin assays with increased diagnostic sensitivity and greater analytic precision has improved the diagnosis of myocardial infarction in high risk patients. However for those patients at intermediate or low risk in whom a small troponin rise is detected, a cascade of clinical decisions and investigations could result; potentially having uncertain impact on recurrent ischemic events and increasing bleeding risk and resource utilization. Clinical equipoise remains as to the clinical utility of high sensitivity troponin. Methods We designed a pragmatic randomized clinical trial to evaluate the short and long term clinical impact and resource implications of high sensitivity 5th generation troponin T reporting compared with 4th generation troponin T reporting. Two thousand patients presenting with a suspected acute coronary syndrome were randomized and risk stratified in 5 metropolitan emergency departments in South Australia, Australia. Clinical events occurring after the first 24 h and within 30 days were assessed as the primary endpoint with subsequent events evaluated at 6 and 12 months. Conclusion The true translational benefits of innovations in diagnostic testing need to be evaluated in robust clinical trials as they can be costly to introduce and the adoption process often focuses on sensitivity and specificity at the expense of measuring improvements in clinical outcome. The results of this study will provide valuable information on contemporary patterns of troponin utilization on the heterogeneous population of chest pain patients presenting to emergency departments, while providing important information from the clinical practice setting for health administrators, government and policy makers. [ABSTRACT FROM AUTHOR]

Evolution of diagnostic testing modalities in cardiovascular medicine has been rapid. Technological advances in cardiac imaging have enabled the assessment of cardiac texture and function with unprecedented resolution, while the assessment of coronary artery disease by non-invasive means has matured to rival coronary angiography. Similarly, developments in the area of serum biomarkers have given further insights into the risk experienced by patients with coronary artery disease, acute coronary syndromes and heart failure. However, the rate of this innovation calls for a moment''s pause to refocus on the goals of the diagnostic and risk refinement process that is to deliver better care and improve clinical outcome. To date many studies in this area have fallen short of demonstrating such benefits and it is our responsibility as a clinical community to demand more of such innovation. [Copyright &y& Elsevier]

Background: Informed consent is a basic standard of care for all patients undergoing medical procedures, but recall of information has been shown to be poor. We sought to compare verbal, written and animated audiovisual information delivery, during consent for coronary angiography, by measuring improvement in recall. Method: A sample population of 99 cardiac patients at Flinders Medical Centre was randomised (1:1:1) to receive one of three information delivery methods. The information content was standardised by a risk proforma, which explained the procedure and defined 12 specific risks. Recall, satisfaction and anxiety were assessed by a questionnaire administered at three different time points: post-consent, post-procedure and at 30 days. Effect of delivery method on satisfaction and anxiety was rated on a self-reported scale from 1-5, with 5 representing very satisfied or very anxious. Groups were compared by non-parametric testing and a p-value of <0.05 was considered statistically significant. Results: Patients were a median age of 64 (i.q.r. 56, 72) years. Information delivery method had no effect on recall of risks at any time-point (p=0.2, 0.7, 0.5, respectively) and the average recall score across the population was 3-4 out of 12. There was no significant effect on median satisfaction scores: verbal; 5 (i.q.r.4, 5) versus written/audiovisual; 4 (i.q.r.4, 5) (p=ns), or on median anxiety scores: verbal; 3 (i.q.r.2, 4) versus written/audiovisual; 3 (i.q.r.2, 4) (p=ns). Conclusion: Despite careful design of an innovative audiovisual delivery technique aimed at optimising comprehension and aiding memory, recall of information was poor and informational aids showed no improvement. Modes of information delivery are not the key to patient assimilation of complex medical information. [ABSTRACT FROM AUTHOR]

Background: Nursing, allied health and technical personnel are increasingly being recognised as pivotal in the diagnosis and management of heart disease. This recognition is mirrored in research, scholarship and professional development activities. Documenting the evolution and progression of a group''s professional development is a useful strategy in informing future strategic initiatives. Aim: The purpose of this paper is to illustrate the development and participation of the Affiliates group within the Cardiac Society of Australia and New Zealand (CSANZ). Method: Data related to CSANZ membership, participation in the Annual Scientific Meeting as well as the number, type and ranking of abstracts were retrieved from CSANZ records for the period 1995–2003. These data were analysed using descriptive statistics. Results: Since the introduction of the Affiliate member status in 1988, membership has grown steadily, as has participation of members in the governance of the CSANZ. Mean abstract grades of Affiliate members are increasingly comparable with those of the FCSANZ, Ordinary and Associate members. Conclusions: Affiliate members are increasing their profile in the highly competitive environment of the Annual Scientific Meeting, demonstrating the critical role of nursing, allied health and technical professions in cardiovascular health and science. [Copyright &y& Elsevier]

Evidence-based guidelines recommend cardiac rehabilitation(CR) for secondary prevention of recurrent myocardial infarction(re-MI) and risk factor management, but poor referral and completion rates persist. Regular audit can measure the effectiveness of services. A 2011 audit of public CR services, by the South Australian Department of Health CR Clinical Network showed a 12% program attendance rate. Following development of standardised minimum data and uniform electronic data capture, 24 CR services have contributed within 3 audits. We aimed to link referral and attendance with administrative data to assess characteristics and outcomes of eligible patients. Methods: The CR patient database for 2013-2015 was linked to patients discharged alive with a primary cardiac-related diagnosis and/or interventional procedure, identified through public hospital administrative data. Outcomes were defined as readmission for cardiovascular causes and death captured through the Births Deaths and Marriages database. Patient categories were not referred, referred/declined and attended CR. Associations with cardiovascular readmission and composites of death, new/re-MI, heart failure, atrial fibrillation and stroke over the 12-month follow-up duration were reported using inverse probability weighted survival methods among those who attended and those referred/declined. Results: Of 49,909 eligible cardiac separations, referral rate was 15,089/49,909 (30.2%) and attendance 4,286/15,089 (28.4%). Those referred/declined were older (median: 67.3 vs 65.3 years, P< 0.001), more likely to be female (32.3% vs 26.5%, P< 0.001) with more heart failure (17.1% vs 10.9%, P< 0.001) and arrhythmia (6.1% v 2.1%, P< 0.001) admissions, ≥2 comorbidities (35.3% v 23.3%, P< 0.001), with higher socio-economic disadvantage (median IRSAD: 950.1 vs 960.4, p<0.001). Attending patients had lower cardiovascular readmission, (attended vs not referred: 27.3% vs 34.5% and attended vs referred/declined ; 27.3% vs 41.4%, P< 0.001). After clinical and social factors adjustment there was no difference in composite clinical outcomes to 12-months, but attendance was associated with reduced cardiovascular readmission (HR:0.68, 95% IQR: 0.58-0.81, P = 0.001). Conclusions: This analysis highlights the complexity of factors that influence referral, non-attendance and attendance to CR. Conducting clinical audit and reporting to services is vital for measuring program effectiveness and can be a mechanism for service improvement. [ABSTRACT FROM AUTHOR]

Lack of service data for cardiac rehabilitation limits understanding of program delivery, benchmarking and quality improvement. This study aimed to describe current practices, management, utilisation and engagement with quality indicators in Australian programs. Cardiac rehabilitation programs (n=396) were identified from national directories and networks. Program coordinators were surveyed on service data capture, management systems and adoption of published national quality indicators. Text responses were coded and classified. Logistic regression determined independent associates of the use of data for quality improvement. A total of 319 (81%) coordinators completed the survey. Annual patient enrolments/programs were >200 (31.0%), 51−200 (46%) and ≤50 (23%). Most (79%) programs used an electronic system, alongside paper (63%) and/or another electronic system (19%), with 21% completely paper. While 84% knew of the national quality indicators, only 52% used them. Supplementary to patient care, data were used for reports to managers (57%) and funders (41%), to improve quality (56%), support funding (43%) and research (31%). Using data for quality improvement was more likely when enrolments where >200 (Odds ratio [OR] 3.83, 95% Confidence Interval [CI] 1.76−8.34) and less likely in Victoria (OR 0.24 95%, CI 0.08−0.77), New South Wales (OR 0.25 95%, CI 0.08−0.76) and Western Australia (OR 0.16 95%, CI 0.05−0.57). The collection of service data for cardiac rehabilitation patient data and its justification is diverse, limiting our capacity to benchmark and drive clinical practice. The findings strengthen the case for a national low-burden approach to data capture for quality care. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID-19) pandemic has introduced a major disruption to the delivery of routine health care across the world. This provides challenges for the use of secondary prevention measures in patients with established atherosclerotic cardiovascular disease (CVD). The aim of this Position Statement is to review the implications for effective delivery of secondary prevention strategies during the COVID-19 pandemic.Challenges: The COVID-19 pandemic has introduced limitations for many patients to access standard health services such as visits to health care professionals, medications, imaging and blood tests as well as attendance at cardiac rehabilitation. In addition, the pandemic is having an impact on lifestyle habits and mental health. Taken together, this has the potential to adversely impact the ability of practitioners and patients to adhere to treatment guidelines for the prevention of recurrent cardiovascular events.Recommendations: Every effort should be made to deliver safe, ongoing access to health care professionals and the use of evidenced based therapies in individuals with CVD. An increase in use of a range of electronic health platforms has the potential to transform secondary prevention. Integrating research programs that evaluate the utility of these approaches may provide important insights into how to develop more optimal approaches to secondary prevention beyond the pandemic. [ABSTRACT FROM AUTHOR]

The novel coronavirus disease of 2019 (COVID-19) pandemic significantly disrupted health care, especially outpatient services such as cardiac rehabilitation (CR). We investigated the impact of early COVID-19 waves on the delivery of Australian CR programs, comparing this time period with usual practice prior to the pandemic (2019) and current practice (2021) once the early waves had subsided. Specifically, we aimed to understand how the delivery of programs during COVID-19 compared to usual practice. An anonymous online cross-sectional survey of Australian CR program staff was conducted, comprising three sections: program and respondent characteristics, COVID-19 impact on program delivery, and barriers to, and enablers of, program delivery. Respondents were asked to consider three key timepoints: 1) Pre-COVID-19 (i.e. usual practice in 2019), 2) Early COVID-19 waves (March–December 2020), and 3) Currently, at time of survey completion post early COVID-19 waves (May–July 2021). Of the 314 Australian CR programs, 115 responses were received, of which 105 had complete data, representing a 33% response rate. All states and territories were represented. During early COVID-19 waves programs had periods of closure (40%) or reduced delivery (70%). The majority of programs reported decreased CR referrals (51.5%) and decreased participation (77.5%). The two core components of CR—exercise and education—were significantly impacted during early COVID-19 waves, affecting both the number and duration of sessions provided. Exercise session duration did not return to pre-pandemic levels (53.5 min compared to 57.7 min, p=0.02). The majority of respondents (77%) reported their CR program was inferior in quality to pre-pandemic and more organisational support was required across information technology, staffing, administration and staff emotional and social support. Australian CR programs underwent significant change during the early COVID-19 waves, consistent with international CR reports. Fewer patients were referred and attended CR and those who did attend received a lower dose of exercise and education. It will be important to continue to monitor the long-term impacts of the COVID-19 pandemic to ensure CR programs return to pre-pandemic functioning and continue to deliver services in line with best practice and evidence-based recommendations. [ABSTRACT FROM AUTHOR]

Background Patients with low and intermediate risk chest pain features comprise the greatest proportion presenting to emergency services for evaluation of suspected acute coronary syndromes (ACS). The efficient and timely identification of patients with these features remains a major challenge within clinical practice. Troponin assays are increasingly being used for the determination of risk among patients presenting with chest pain potentially facilitating more appropriate care. To date, no economic evaluation comparing high-sensitivity troponin T (hs-TnT) reporting to standard troponin T (c-TnT) reporting in the routine management of suspected ACS and based on longer-term clinical outcomes has been conducted. Methods and results An economic evaluation was conducted with 1937 participants randomized to either hs-TnT ( n = 973) or c-TnT ( n = 964) with 12 month follow-up. The primary outcome measure was the number of cumulative combined outcomes of all-cause mortality and new or recurrent ACS avoided. Mean per participant Australian Medicare costs were higher in the hs-TnT arm compared to the c-TnT arm (by $1285/patient). Mean total adverse clinical outcomes avoided were higher in the hs-TnT arm (by 0.0120/patient) resulting in an incremental cost-effectiveness ratio (ICER) of $108,552/adverse clinical outcome avoided. An ICER of $49,030/adverse clinical outcome avoided was obtained when the analysis was restricted to patients below the threshold of normal Troponin testing (actual c-TnT levels < 30 ng/L). Conclusions hs-TnT reporting leads to fewer adverse clinical events but at a high ICER. For the routine implementation of hs-TnT to be more cost-effective, substantial changes in clinical practice will be required. Clinical trial registration Australian New Zealand Clinical Trials Registry (ACTRN12614000189628). https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365726 [ABSTRACT FROM AUTHOR]

Background: Studies of chronic diseases are associated with a financial burden on households. We aimed to determine if survivors of acute coronary syndrome (ACS) experience household economic burden and to quantify any potential burden by examining level of economic hardship and factors associated with hardship. Methods: Australian patients admitted to hospital with ACS during 2-week period in May 2012, enrolled in SNAPSHOT ACS audit and who were alive at 18 months after index admission were followed-up via telephone/paper survey. Regression models were used to explore factors related to out-of-pocket expenses and economic hardship. Results: Of 1833 eligible patients at baseline, 180 died within 18 months, and 702 patients completed the survey. Mean out-of-pocket expenditure (n = 614) in Australian dollars was A$258.06 (median: A$126.50) per month. The average spending for medical services was A$120.18 (SD: A$310.35) and medications was A$66.25 (SD: A$80.78). In total, 350 (51 %) of patients reported experiencing economic hardship, 78 (12 %) were unable to pay for medical services and 81 (12 %) could not pay for medication. Younger age (18-59 vs =80 years (OR): 1.89), no private health insurance (OR: 2.04), pensioner concession card (OR: 1.80), residing in more disadvantaged area (group 1 vs 5 (OR): 1.77), history of CVD (OR: 1.47) and higher out-of-pocket expenses (group 4 vs 1 (OR): 4.57) were more likely to experience hardship. Conclusion: Subgroups of ACS patients are experiencing considerable economic burden in Australia. These findings provide important considerations for future policy development in terms of the cost of recommended management for patients. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the proportion of patients hospitalised with acute coronary syndrome (ACS) in Australia and New Zealand who received optimal inpatient preventive care and to identify factors associated with preventive care. Methods: All patients hospitalised bi-nationally with ACS were identified between 14-27 May 2012. Optimal in-hospital preventive care was defined as having received lifestyle advice, referral to rehabilitation, and prescription of secondary prevention pharmacotherapies. Multilevel multivariable logistic regression was used to determine factors associated with receipt of optimal preventive care. Results: For the 2299 ACS survivors, mean (SD) age was 69 (13) years, 46% were referred to rehabilitation, 65% were discharged on sufficient preventive medications, and 27% received optimal preventive care. Diagnosis of ST elevation myocardial infarction (OR: 2.64 [95% CI: 1.88-3.71]; p<0.001) and non-ST elevation myocardial infarction (OR: 1.99 [95% CI: 1.52-2.61]; p<0.001) compared with a diagnosis of unstable angina, having a percutaneous coronary intervention (PCI) (OR: 4.71 [95% CI: 3.67-6.11]; p<0.001) or coronary bypass (OR: 2.10 [95% CI: 1.21-3.60]; p=0.011) during the admission or history of hypertension (OR:1.36 [95% CI: 1.06-1.75]; p=0.017) were associated with greater exposure to preventive care. Age over 70 years (OR:0.53 [95% CI: 0.35-0.79]; p=0.002) or admission to a private hospital (OR:0.59 [95% CI: 0.42-0.84]; p=0.003) were associated with lower exposure to preventive care. Conclusions: Only one-quarter of ACS patients received optimal secondary prevention in-hospital. Patients with UA, who did not have PCI, were over 70 years or were admitted to a private hospital, were less likely to receive optimal care. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) has been established as an independent predictor of long-term mortality after acute myocardial infarction. However, this is less well defined across the whole spectrum of acute coronary syndromes (ACSs). The Acute Coronary Syndrome Prospective Audit is a prospective multicenter registry with 12-month outcome data for 3,393 patients (755 with ST-segment elevation myocardial infarction, 1942 with high-risk non–ST-segment elevation ACS [NSTE-ACS], and 696 with intermediate-risk NSTE-ACS). A total of 149 patients (4.4%) had new-onset AF and 387 (11.4%) had previous AF. New-onset AF was more, and previous AF was less frequent in those with ST-segment elevation myocardial infarction than in those with high-risk NSTE-ACS or intermediate-risk NSTE-ACS (p <0.001). Compared to patients without arrhythmia, patients with new-onset AF and previous AF were significantly older and had more high-risk features at presentation (p <0.004). Patients with new-onset AF more often had left main coronary artery disease, resulting in a greater rate of surgical revascularization (p <0.001). Only new-onset AF resulted in adverse in-hospital outcomes (p <0.001). Only patients with previous AF had greater long-term mortality (hazard ratio 1.42, p <0.05). New-onset AF was only associated with a worse long-term composite outcome (hazard ratio 1.66, p = 0.004). However, the odds ratio for the composite outcome was greatest for patients with new-onset AF with intermediate-risk NSTE-ACS (odds ratio 3.9, p = 0.02) than for those with high-risk NSTE-ACS (odds ratio 2.0, p = 0.01) or ST-segment elevation myocardial infarction (odds ratio 1.4, p = 0.4). In conclusion, new-onset AF was associated with worse short-term outcomes and previous AF was associated with greater mortality even at long-term follow-up. The prognostic burden of new-onset AF differed with the type of ACS presentation. [Copyright &y& Elsevier]

Evolution of diagnostic testing modalities in cardiovascular medicine has been rapid. Technological advances in cardiac imaging have enabled the assessment of cardiac texture and function with unprecedented resolution, while the assessment of coronary artery disease by non-invasive means has matured to rival coronary angiography. Similarly, developments in the area of serum biomarkers have given further insights into the risk experienced by patients with coronary artery disease, acute coronary syndromes and heart failure. However, the rate of this innovation calls for a moment's pause to refocus on the goals of the diagnostic and risk refinement process that is to deliver better care and improve clinical outcome. To date many studies in this area have fallen short of demonstrating such benefits and it is our responsibility as a clinical community to demand more of such innovation. [ABSTRACT FROM AUTHOR]