Arnold Ruth, Luscombe Georgina M, Gadeley Ryan, Edwards Sarah, Ryan Estelle, Faddy Steven, Larnach Gabrielle, Lowe Harry, Boyle Andrew, Hawke Catherine, Elder Alex, Adams Mark, Amos David
Cardiology Department, Orange Health Service, Western NSW Local Health District, Orange, NSW, Australia.
School of Rural Health, Faculty of Medicine and Health, The University of Sydney, Orange, NSW, Australia.
Heart Lung Circ. 2025 Feb;34(2):182-189. doi: 10.1016/j.hlc.2024.07.016. Epub 2024 Dec 10.
At a global level, regional variation in the management of ST-elevation myocardial infarction (STEMI) is influenced by patient demographics and geography. Rural patients with STEMI are disadvantaged in reaching timely care owing to distance and limited ambulance and healthcare resources. Optimising models of STEMI care is key to overcoming the excess rural vs metropolitan cardiovascular morbidity and mortality. In this descriptive study, we compare patient characteristics and STEMI management in three Local Health Districts (LHDs) across NSW: a rural LHD (Western NSW [WNSWLHD]), a regional LHD (Hunter New England), and a metropolitan site (Sydney LHD).
Data were collected from file audits conducted from 2019 to 2020 in a rural LHD with a single rural 24/7 cardiac catheter laboratory (WNSWLHD), a regional LHD with a part-time rural cardiac catheter laboratory, and a large regional 24/7 cardiac centre (Hunter New England LHD), and a metropolitan site (Sydney LHD), with two 24/7 cardiac centres. Patients with STEMI presenting in the three geographic regions were compared on demographics, differences in presentation, time to reperfusion treatment, time to percutaneous coronary intervention (PCI) centre, distances travelled, proportion of angiograms within 24 hours, and in-hospital mortality.
During 2020, there were 675 recorded STEMI across the three regions. The rural site in WNSWLHD had the highest rate of STEMI per capita, with patients more likely to identify as Indigenous, less likely to call an ambulance, and more likely to present to a non-PCI hospital and to receive thrombolysis. Only 14% of these rural patients received primary PCI (PPCI), with patients presenting a median of 153 km from the PCI centre, vs 69% PPCI in the regional and 89% in metropolitan LHD. Thrombolysis was the main reperfusion treatment in WNSWLHD (76%), and the proportion of patients receiving no treatment was the same in all LHDs at 10%. The percentage of patients receiving angiography within 24 hours in the rural site was 84%. There was no substantial difference in in-hospital mortality among the three LHDs.
We document large differences in the demographic profiles, use of ambulance, and access to PPCI in patients with STEMI across the three NSW centres. Current NSW health and ambulance protocols in a large, sparsely populated rural NSW LHD were able to deliver thrombolysis at the point of contact and facilitate "hot" transfer of patients with STEMI to a PCI centre. Long distances and transfer times mean that PPCI is a limited option in rural NSW, with scope for further improvement in models of care.
在全球范围内，ST段抬高型心肌梗死（STEMI）管理的地区差异受患者人口统计学特征和地理位置的影响。由于距离以及救护车和医疗资源有限，农村STEMI患者在获得及时治疗方面处于不利地位。优化STEMI护理模式是克服农村地区与大城市心血管发病率和死亡率过高问题的关键。在这项描述性研究中，我们比较了新南威尔士州三个地方卫生区（LHD）的患者特征和STEMI管理情况：一个农村LHD（新南威尔士州西部[WNSWLHD]）、一个地区LHD（亨特新英格兰）和一个大城市地区（悉尼LHD）。
数据收集自2019年至2020年对以下地区进行的档案审核：一个设有单一农村全天候心脏导管实验室的农村LHD（WNSWLHD）、一个设有兼职农村心脏导管实验室的地区LHD、一个大型地区全天候心脏中心（亨特新英格兰LHD）以及一个设有两个全天候心脏中心的大城市地区（悉尼LHD）。对在这三个地理区域就诊的STEMI患者的人口统计学特征、就诊差异、再灌注治疗时间、到达经皮冠状动脉介入治疗（PCI）中心的时间、行进距离、24小时内进行血管造影的比例以及住院死亡率进行了比较。
2020年期间，三个地区共记录了675例STEMI病例。WNSWLHD的农村地区人均STEMI发病率最高，患者中更多人自认为是原住民，呼叫救护车的可能性较小，更有可能前往非PCI医院并接受溶栓治疗。这些农村患者中只有14%接受了直接PCI（PPCI），患者就诊时距离PCI中心的中位数为153公里，而在地区LHD这一比例为69%，在大城市LHD为89%。溶栓是WNSWLHD的主要再灌注治疗方式（76%），所有LHD中未接受治疗的患者比例均为10%。农村地区24小时内接受血管造影的患者比例为84%。三个LHD的住院死亡率没有实质性差异。
我们记录了新南威尔士州三个中心STEMI患者在人口统计学特征、救护车使用情况以及获得PPCI的机会方面存在的巨大差异。新南威尔士州目前针对新南威尔士州一个幅员辽阔、人口稀少的农村LHD的卫生和救护车协议能够在接触点提供溶栓治疗，并促进STEMI患者“紧急”转运至PCI中心。距离远和转运时间长意味着PPCI在新南威尔士州农村地区是一种有限的选择，护理模式仍有进一步改进的空间。
