Although mortality rates associated with cardiovascular disease (CVD) have decreased significantly in high-income countries in recent decades, substantial challenges related to CVD treatment and outcomes persist in rural areas.1 Higher rates of mortality from coronary heart disease have been observed in rural vs urban areas, and the distance between a patient’s home and the nearest metropolitan center was found to be positively correlated with the risk for CVD-related hospitalization and death.1,2

The authors of a narrative review published in the International Journal of Environmental Research and Public Health examined the factors that may have an impact on these issues, with a specific focus on acute coronary syndrome (ACS).1 “In general, the burden of CVD is felt more by lower socioeconomic groups, Indigenous people, people from diverse cultural backgrounds, and those living in rural and remote communities,” they noted. “However, it is worth highlighting that rurality, gender, and race interact in a complex manner, reflecting impacts on both incidence of disease and access to care for those who have a cardiac illness.”

Care may be delayed because of distance, travel limitations, and weather conditions, but other potential challenges remain for individuals residing in rural areas. These include a lack of access to a specialist to advise rural providers, inadequate resources for rapid assessment, and limited access to facilities with the capacity for highly specialized interventions. For example, centers that provide catheterization and cardiac rehabilitation are unavailable or inaccessible to many rural patients, further increasing the risk for poor outcomes.1

In a matched-cohort study, the outcomes in patients with acute myocardial infarction (including ST-elevation myocardial infarction [STEMI] and non-STEMI) who were transferred to metropolitan hospitals with revascularization capabilities were assessed.3 Patients who were vs patients who were not transferred from the presenting facility had lower mortality (1-year mortality: 7.5% vs 12.6%, respectively; hazard ratio [HR], 0.58; 95% CI, 0.52-0.64).  “Transferred patients are more likely to receive evidence-based therapies such as antiplatelet and antithrombotic agents, are more likely to be cared for under a cardiology service, and are more likely to undergo prognostically significant evaluations such as stress testing or assessment of left ventricular function,” noted the study authors.3


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Other issues affecting many rural patients with CVD include higher rates of comorbidities that may complicate the diagnosis of acute CVD, as well as sex differences in the epidemiology and presentation of CVD.1 Some studies indicate that women have a more conservative management of ACS compared with men, possibly due in part to etiologic differences. Type 2 myocardial infarction is more prevalent in women and more difficult to diagnose compared with type 1 myocardial infarction.1 “Rural clinicians and hospitals need to be aware of the evolving understanding of gender differences in CVD that are relevant for prevention as well as management,” noted the authors of the narrative review. 

High rates of workforce shortages and turnover have also been noted in rural healthcare systems. Telehealth and mobile health have increased access to specialty consultation in these areas, but reimbursement gaps and other barriers continue to limit the use of these technologies.1 

In an effort to further examine the management of ACS in rural areas, Cardiology Advisor interviewed 2 experts: Nicholas M. Mohr, MD, MS, associate professor of emergency medicine and anesthesia critical care at the University of Iowa Carver College of Medicine in Iowa City, who coauthored a 2018 case study on the topic,4 and Bill Houser, MD, FACC, an electrophysiologist at The Ohio State University Wexner Medical Center in Columbus and director of the cardiac catheterization lab at Mary Rutan Hospital in Bellefontaine, Ohio.

Cardiology Advisor: What are some of the key challenges involved in managing ACS in rural areas? 

Dr Mohr: ACS can be challenging to manage in facilities without cardiac catheterization capabilities. For patients with myocardial infarction, transfer to a center with percutaneous coronary intervention (PCI) capabilities is critical to provide revascularization therapy. These transfers require a system of care to rapidly recognize the need for intervention, rapidly activate the cardiac catheterization laboratory in another facility, and arrange rapid transfer, particularly for patients with STEMI. In facilities that do not have rapid access to a PCI-capable facility, intravenous thrombolytics are still recommended for the treatment of STEMI.

Dr Houser: The first challenge is proper identification of ACS. Public health education does not seem to differ much between rural and urban areas. Recognition of sex-based differences in symptoms seems to be a priority and has been more emphasized since the Women’s Health Initiative began in the 1990s.5

Education of first responders has been increasingly emphasized to quickly identify ACS – and specifically STEMI – to minimize time to reperfusion therapy. Historically, local education opportunities in rural areas were more limited than in urban areas. This has been less of an issue in the digital age, as educational opportunities are much more available to anyone regardless of geography; however, live conferences are less available locally.

Electrocardiograms (ECGs) are now performed at the scene by first responders to quickly identify STEMI vs other forms of ACS such as NSTEMI and unstable angina. These ECGs can be transmitted locally to the emergency department (ED) or remotely to a PCI-capable center, and STEMI alerts can be called for catheterization laboratory and air transport to be mobilized. The door-to-balloon time is critical, as “Time is myocardium.”

Weather is a wild card in the whole process, and there are times that air transport is just not possible in STEMI. Close collaboration with a PCI-capable site is crucial in determining the appropriate medical therapy in these individualized cases. Thrombolytics are still used in rural areas in these cases at times.

In ACS that is not a STEMI, time is much less of an issue typically. It is not uncommon for these patients to be managed medically without invasive evaluation locally and without transfer to a tertiary care facility. The biggest challenge is keeping good [healthcare personnel] locally to ensure that the care is just as good as in tertiary care facilities with similar outcomes.

Rural catheterization laboratories without surgical backup that can provide 24-hour-capable PCI are a very attractive option.6 In the Cardiovascular Patient Outcomes and Research Team Primary PCI Registry study (CPORT; Clinicaltrials.gov identifier: NCT02201264), outcomes in these facilities were shown to be similar to those in hospitals with surgical backup.7 The greatest barriers are the cost of the hospitals providing the services and keeping adequate volumes of patients to maintain outcomes on par with higher-volume sites. Education and staffing the laboratories 24 hours a day with capably trained personnel are harder in a rural setting

Cardiology Advisor: How are these challenges currently being addressed?

Dr Mohr: Acute cardiac care requires systems of care, including transfer agreements, standard care protocols and pathways, and direct consultation. Historically, many of these direct consultations occurred by telephone, but increasingly telehealth is used for remote specialty consultations. In rural places where this is being done, telehealth providers can help with ECG interpretation and diagnosis, activating a catheterization laboratory, and even arranging interfacility transport.

Dr Houser: In our experience, most of these barriers have been best addressed through close collaboration with a tertiary care PCI-capable center. Having 1 number (STEMI alert) to call and streamline the process has made things much easier. Close collaboration with the local ED and ED physicians is essential. Availability to transmit an ECG 24 hours a day has been much easier in the digital age.

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Cardiology Advisor: What are remaining needs pertaining to this topic in terms of practical solutions, education, or research?

Dr Mohr: Acute cardiac care is an area where timely recognition and management improve clinical outcomes. In many facilities, these diagnoses are uncommon but important to make rapidly. Ongoing training and continuing education, standardization of care pathways, and collaborative relationships between centers can improve risk stratification and transfer of care.

Dr Houser: Remaining needs include investigation of STEMI metrics such as door-to-balloon time and times for air transport and continued efforts to improve these metrics.

Cardiology Advisor: What are additional relevant implications for clinicians?

Dr Mohr: The close collaboration between rural facilities and referral hospitals is important. Developing a standard approach for antiplatelet and anticoagulation therapy, thrombolytic therapy, and a transfer pathway is crucial, because it improves performance in a time-sensitive emergency. Using telehealth – telephone, video, and EcG transmission – to streamline communication between centers can also improve quality and timeliness of care when these patients arrive in rural facilities.

Dr Houser: In my experience, patients generally prefer their care to be provided locally, as long as it is the same quality they would receive elsewhere. Travel to a larger city is really an issue for some families, especially in elderly patients who may not drive or have anyone to transport them an hour or more away.

References

1. Thompson SC, Nedkoff L, Katzenellenbogen J, Hussain MA, Sanfilippo F. Challenges in managing acute cardiovascular diseases and follow up care in rural areas: a narrative review. Int J Environ Res Public Health. 2019;16(24):5126.

2. Kulshreshtha A, Goyal A, Dabhadkar K, Veledar E, Vaccarino V. Urban-rural differences in coronary heart disease mortality in the United States: 1999-2009. Public Health Rep. 2014;129(1):19-29.

3. Ranasinghe I, Barzi F, Brieger D, Gallagher M. Long-term mortality following interhospital transfer for acute myocardial infarction. Heart. 2015;101:1032-1040.

4. MacKinney AC, Mohr NM. Chest Pain in A Rural Hospital. Rockville, MD: US Department of Health and Human Services—Agency for Healthcare Research and Quality; 2018.

5. National Institutes of Health – National Heart, Lung, and Blood Institute. Women’s Health Initiative. https://www.nhlbi.nih.gov/science/womens-health-initiative-whi. Accessed January 22, 2020.

6. Dehmer GJ, Blankenship JC, Cilingiroglu M, et al. SCAI/ACC/AHA expert consensus document: 2014 update on percutaneous coronary intervention without on-site surgical backup. Circulation. 2014;129(24):2610-2626.

7. Aversano T, Lemmon CC, Liu L; Atlantic CPORT Investigators. Outcomes of PCI at hospitals with or without on-site cardiac surgery. N Engl J Med. 2012;366(19):1792-1802.