Secondary prevention for acute coronary syndrome in rural South Australia: are drugs best? What about the rest?

Introduction: Acute coronary syndrome (ACS) is a major cause of morbidity and mortality worldwide. Current Australian clinical guidelines recommend all patients with ACS receive comprehensive secondary prevention services to address this burden. Optimal patient outcomes rely on the timely and effective implementation of proven therapies and for secondary prevention to be successful, pharmacological interventions must be combined with cardiovascular disease (CVD) risk factor identification and management. The ability to implement clinical guidelines is also reliant on available resources, yet many rural populations in Australia do not have access to structured secondary prevention services, and the level of support available to them in the form of unstructured services is unclear. Our aim was to examine the scope of secondary prevention in a 'significantly restricted' rural region of South Australia that does not have access to structured secondary prevention services.

Methods: A retrospective analysis of medical records was undertaken to identify documented evidence of assessment and intervention for medical, lifestyle and behavioural CVD risk factors in hospital and at follow up in general practice (GP) clinics. Eligible participants were patients admitted to hospital in the Riverland Region of South Australia with myocardial infarction over a 12 month period. Of 77 eligible participants, permission was received to access the medical records of 55 patients in the hospital setting, and 34 of these 55 patients in GP clinic follow up.

Results: Most patients received baseline assessment for previous AMI (98%), history of hypertension (82%), history of diabetes (78%), and smoking status (76%). Most poorly documented was history of dyslipidaemia (53%) and obesity/ overweight (2%). Prescribing rates for recommended ACS medications at the time of hospital discharge were aspirin (90%), beta blockers (55%), ACE inhibitors (42%), lipid lowering medication (66%) and clopidogrel (64%). Overall prescribing rates in the 12 month study period rose to 80% or higher for all recommended medications. There was no evidence of interventions for smoking and obesity/ overweight in the hospital setting and 45% of smokers in the GP clinic setting received quit advice. Measurement of biomedical risk factors (blood lipid analysis and blood glucose levels) was suboptimal, and there was no evidence of a written action plan for chest pain for any participants.

Conclusions: Unstructured services provided some of the recommended elements of secondary prevention. However, deficits in care exist that have the potential to negatively impact patient outcomes in this already disadvantaged population. Future research needs to focus on the extent to which this and other rural and remote health care services are working within current clinical guidelines for the management of ACS, and subsequent patient outcomes. Urgent consideration must also be given to the introduction and evaluation of a more structured and consistent approach in this and other rural and remote regions of Australia. The development of rehabilitation and prevention services that build on existing strengths and resources have the potential to widen access, enhance current services and ensure care is based on best practice guidelines. This in turn may reduce the burden of CVD and improve the overall health and quality of life for patients in rural and remote Australia.