Nadarajah Kangaharan

Safety and Efficacy of Warfarin Therapy in Remote Communities of the Top End of Northern Australia

BACKGROUND Warfarin remains a widely used anticoagulant but application in the remote context is not well documented. This study aimed to assess in more detail whether warfarin is being utilised effectively in Australias most isolated and remote areas. METHODS Retrospective cohort analysis of 2013 captured international normalised ratio (INR) results from people engaged in long term warfarin usage within a number of remote Northern Australian communities. Assessment of monitoring, effectiveness of dosing and complication rates was undertaken. RESULTS A cohort of 167 patients was established. On average, warfarin was utilised within therapeutic range 52% of the time. Monitoring frequency averaged 16 days. Major bleeding and thrombo-embolism occurred at rates of 5.8 and 4.1 per 100 patient years respectively. CONCLUSIONS Therapeutic utilisation of warfarin in this setting is close to accepted rates but has room for improvement. Monitoring was acceptable and complication rates were not disproportionately high. This study indicates that warfarin is being used with reasonable safety and efficacy in remote regions, but further research is needed.

Cardiac care for Indigenous Australians: practical considerations from a clinical perspective

Indigenous Australians have a much high burden of cardiovascular disease, which occurs at an earlier age than in the non-Indigenous population. Comorbidities such as diabetes are common. Early diagnosis of ischaemic heart disease may be difficult because of barriers such as distance to medical centres, communication problems and family and cultural responsibilities. Disparities in cardiac care between Indigenous and non-Indigenous populations are well documented, with examples including reduced angiography and revascularisation rates in Indigenous patients. Indigenous patients can have poor health literacy and need careful explanation of procedures, with the assistance of Aboriginal health workers, visual aids and family members. Acute rheumatic fever and chronic rheumatic heart disease remain ongoing health problems in Indigenous communities, especially in remote areas. Ambulatory care of Indigenous Australians with chronic cardiovascular disease is challenging. It requires well supported health care systems, including Aboriginal health workers and cardiac nurse coordinators to case-manage patients. A holistic approach to care, with attention directed towards both cardiac and non-cardiac comorbidities, is crucial for optimal management of cardiovascular disease in Indigenous Australians. Multidisciplinary care, involving an empowered and supported primary care team working together with specialists through outreach services or telehealth, is important for patients who are at high clinical risk and those living in remote areas. Indigenous Australians deserve the same level of evidence-based cardiovascular health care and access to care as non-Indigenous Australians.

Aboriginal and Torres Strait Islander Cardiovascular Health 2016: Is the Gap Closing?

In 2007, State and Federal Governments, together with a number of NGOs, made a commitment to close the life expectancy gap between Indigenous and non-Indigenous Australians within a generation by 2031[1]. Although there have been some improvements in health indicators since 2006, the life expectancy gap remains wide and at the current rate closure will not be achieved within this timeframe [2,3]. The Indigenous life expectancy is currently estimated to be 69 years for males and 74 years for females, a gap of 11 years for males and 9.5 years for females. Between 2005 and 2012 there was a small reduction in the gap of 0.8 years for males and 0.1 years for females. However, non-Indigenous life expectancy is increasing and it is estimated that Indigenous life expectancy will have to increase by almost 18 years for males and 16 years for females by 2031 to meet this target. Cardiovascular disease remains the major cause of premature death in Aboriginal and Torres Strait Islander (ATSI) people, with cardiovascular disease accounting for almost one third of the gap in life expectancy. The enormous burden of cardiovascular risk factors and cardiovascular disease in the Indigenous community has long been recognised as compared to non-Indigenous Australians. [3–5]. Although smoking rates have declined they remain high at 44% in comparison to non-Indigenous rates of !8%. Diabetes is far more common (overall 18% versus 5%, remote 28% versus 5%). Other risk factors which are significantly more common in Aboriginal and Torres Strait islanders are hypertension, obesity, chronic kidney disease and psychosocial stress. The prevalence of cardiovascular risk factors is highest in remote and very remote areas compared to Indigenous people who live in non-remote areas. The high burden of cardiovascular

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).

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.

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.

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 β-blocker was 68% and 87%, respectively. Forty-one (41) patients not on an ACEI/ARB and/or β-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 β-blocker due to hypotension. Fourteen (14) patients (34%) were not prescribed an ACEI/ARB and/or β-blocker had no identifiable contraindications. CONCLUSIONS Indigenous patients are over-represented at a younger age demonstrating the alarming rate of disease burden in NTs young Indigenous population. Generally, ACEI/ARBs were underutilised compared to β-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.

TEXT messages to improve MEDication adherence and Secondary prevention (TEXTMEDS) after acute coronary syndrome: a randomised clinical trial protocol

Background Identifying simple, low-cost and scalable means of supporting lifestyle change and medication adherence for patients following a cardiovascular (CV) event is important. Objective The TEXTMEDS (TEXT messages to improve MEDication adherence and Secondary prevention) study aims to investigate whether a cardiac education and support programme sent via mobile phone text message improves medication adherence and risk factor levels in patients following an acute coronary syndrome (ACS). Study design A single-blind, multicentre, randomised clinical trial of 1400 patients after an ACS with 12 months follow-up. The intervention group will receive multiple weekly text messages that provide information, motivation, support to adhere to medications, quit smoking (if relevant) and recommendations for healthy diet and exercise. The primary endpoint is the percentage of patients who are adherent to cardioprotective medications and the key secondary outcomes are mean systolic blood pressure (BP) and low-density lipoprotein cholesterol. Secondary outcomes will also include total cholesterol, mean diastolic BP, the percentage of participants who are adherent to each cardioprotective medication class, the percentage of participants who achieve target levels of CV risk factors, major vascular events, hospital readmissions and all-cause mortality. The study will be augmented by formal economic and process evaluations to assess acceptability, utility and cost-effectiveness. Summary The study will provide multicentre randomised trial evidence of the effects of a text message-based programme on cardioprotective medication adherence and levels of CV risk factors. Ethics and dissemination Primary ethics approval was received from Western Sydney Local Health District Human Research Ethics Committee (HREC2012/12/4.1 (3648) AU RED HREC/13/WMEAD/15). Results will be disseminated via peer-reviewed publications and presentations at international conferences. Trial registration number ACTRN12613000793718; Pre-results.

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 patients 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.