Clinical Outcomes and Economic Costs of Rural Patients Referred for Invasive Angiography: An Opportunity for Cost-Effective Non-Invasive Models of Care

Low‐level elevations in high‐sensitivity cardiac troponin predict obstructive coronary artery disease and revascularisation in rural patients with non‐ST‐elevation myocardial infarction referred for coronary angiography

“…Better identifying patients with nonobstructive CAD could improve resource utilisation, avoid the risk of procedural-related complications from ICA and reduce patient inconvenience. 12 Approximately one-quarter of patients in this study were Indigenous Australians, who may be particularly impacted by family, cultural and social disruptions from being relocated to metropolitan hospitals for ICA. In the current study, the rate of obstructive CAD was not significantly higher in Indigenous Australians despite their known higher cardiovascular risk.…”

“…The cohort for this analysis has been described previously. 12 In brief, this was a retrospective analysis of rural and remote patients who were transferred to one of three Western Australian metropolitan hospitals (Fiona Stanley Hospital, Royal Perth Hospital and Sir Charles Gairdner Hospital) for ICA in the year 2019. This was an exploratory analysis of patients with a documented diagnosis of NSTEMI.…”

Can CTCA provide health care equity for people in rural Australia with coronary artery disease?

“…The retrospective cohort analysis of rural‐to‐metropolitan transfers for invasive coronary angiography in Western Australia undertaken by Alexander and colleagues and reported in this issue of the MJA 5 further illustrates the health service and economic challenges that result from application of the available evidence. Of the 1017 people referred from rural and remote Western Australia to Perth for invasive coronary angiography in 2019, 61% did not require revascularisation and 36% had non‐obstructed coronary arteries (less than 50% stenosis).…”

“…Of the 1017 people referred from rural and remote Western Australia to Perth for invasive coronary angiography in 2019, 61% did not require revascularisation and 36% had non‐obstructed coronary arteries (less than 50% stenosis). Given the substantial economic and resource burden of patient transfers, it is not at all surprising that modelling the impact of providing computed tomography coronary angiography (CTCA) in rural centres as a first line investigation for people with suspected CAD indicated that it could mitigate these costs, both in terms of metropolitan hospital bed‐days (43%) and health costs (36%), which include a major transport component 5 . However, key insights from the analysis by Alexander and colleagues warrant further consideration.…”

“…Only a small proportion of people referred for invasive coronary angiography in Perth subsequently required revascularisation, particularly of those with moderate stenosis (50–69%: nine of 137 patients) or non‐obstructed coronary arteries (none of 365 patients) 5 . Given that the benefits associated with an early invasive strategy are only realised by the revascularisation of unstable coronary lesions causing type 1 myocardial infarction, the low angiography to revascularisation conversion rate highlights a significant challenge for the clinical selection of patients.…”