Cardiology off the map: the impact of remoteness on secondary prevention after myocardial infarction

This editorial refers to ‘Use of secondary prevention medications in metropolitan and non-metropolitan areas: an analysis of 41925 myocardial infarctions in Australia’, by A.C. Livori et al., https://doi:10.1093/eurjpc/zwad360. The burden of cardiovascular diseases (CVDs) is considerable, and the prognosis of patients after a first cardiovascular event depends highly on the quality of management during the hospitalization phase, as well as the long-term implementation of treatments and measures to reduce the risk of recurrent events and mortality.1 The so-called secondary prevention of CVD has emerged as a cornerstone of risk management. It encompasses for multiple levels of actions including educational programmes for healthy diet, physical activity, and smoking cessation, as well as cardiovascular rehabilitation and pharmacotherapies. Regarding the latter, the European Society of Cardiology recommends the regular use of statins, antiplatelet drugs, angiotensin converting enzyme inhibitors, and beta-blockers to improve the long-term prognosis in patients who experienced myocardial infarction.1 One of the major challenges in preventive cardiology is in the quality of guidelines implementation. In Europe, the series of EUROASPIRE surveys highlighted a significant residual gap for optimal preventive management of patients with coronary artery disease.2,3 More globally, risk factors and cardiovascular care management are not similar among countries and ethnic groups, representing a barrier to the generalization of studies results in diverse populations. Among different hurdles, one of the major barriers for an adequate secondary prevention are the socio-demographic factors, including low education level and poor socio-economic status (SES).4 Communities with limited healthcare access, especially those at distance from medical centres, may face a triple challenge: the first can be related to a less favourable cardiovascular risk factor profile and a higher cardiovascular risk, in combination with looser medical attention.5–7 In a nationwide study in Denmark, almost 10% of the 120 000 victims of a first myocardial infarction did not visit any general physician within the year preceding the cardiac event, and the distance to the first general practitioner was a factor associated with the lack of medical visit.8 The second is related to the delay for management of acute coronary syndromes at its initial phase. In the STEMI Accelerator-2 project conducted in 12 metropolitan areas in the USA, cath lab activation within 20 min across a geographically diverse group of hospitals was associated with a doubling of primary percutaneous coronary intervention within the recommended guidelines timelines of 120 min.9 The third challenge is the implementation of cardiac rehabilitation10 and all the secondary cardiovascular prevention measures in the long term. Geographical remoteness may pose a multifaceted hurdle, not only because of physical distance but also limited healthcare facilities, scarcity of specialized medical practitioners, and logistical difficulties for reaching adequate infrastructures with medical expertise. From this perspective, the study published by Livori et al. in this issue of the Journal is of big interest: the authors analyzed the effect of remoteness on the implementation of pharmacotherapy for secondary prevention, by analyzing the data of 37 320 patients who experienced a myocardial infarction in the state of Victoria, Australia.11 As the 6th largest country worldwide, the pertinence of such study in Australia is undisputable. The authors assessed the medication use over 12 months according to the level of remoteness of the patients, based on a country-specific indicator, the Accessibility/Remoteness Index of Australia (ARIA).11 According to the authors, remoteness had no clinically significant impact for the 3-month post-discharge dispensing, although, similar to elsewhere,12 the rates of recommended therapies were suboptimal, with only 36% of the study population receiving the four recommended drug classes. Similar findings were reported for the 12-month medication use. The authors have emphasized that subsidizing the drugs for secondary prevention plays a crucial role in medications access despite geographic remoteness. It is however noteworthy that only 10% of the studied population was classified as ‘accessible’ to ‘moderately accessible’ areas according to the ARIA classification, and no area within the state of Victoria is classified as ‘remote’. This is not the first study on remoteness and cardiovascular prevention in Australia: in the Central Australian Heart Protection Study, the number of visits for secondary prevention appeared lower with greater distance, but multivariate analysis suggested that distance did not influence successful completion of visits.13 In another study, SES explained a substantial proportion of the association between the residence area and CVD mortality rates, but the remoteness effect remained significant beyond SES for a number of sub-populations.14 In another large sample of more than 1 million individuals with diabetes classified according to the ARIA remoteness indicator, the highest cardiovascular mortality was found in major urban and remote areas.15 Importantly, remote areas are often less confronted to air and noise pollution, which can somehow temper the poorer prognosis found in those areas. These results however can hardly be extrapolated to other world regions. Currently, even in the most remoted areas of high-income countries, access to the post-MI recommended therapeutic drug is eased by the presence of local healthcare facilities and services, medication subsidies and assistance programmes, in addition to education and awareness campaigns. Conversely, in secluded regions, the absence of these factors can affect the treatment availability and consequently the patient’s prognosis. Globally, the PURE study16 showed higher rates of patients without any secondary prevention therapy in low-income countries (80.2%) as compared to those living with a history of stroke or coronary artery disease in lower-middle- (69.3%), upper-middle- (45.1%), and high-income countries (11.2%). While the prescription rates were similar in urban and rural zones in the high-income countries, a gap in disfavour of rural habitants was progressively increasing with the level of country’s wealth. Looking more granularly, a study in the China Kadoorie Biobank Study, the rate of use of any therapy for secondary prevention was 33% lower in rural areas.17 In South-East Asia18 as well as in South America,19 the rates of use of evidence-based preventive drugs were lower in rural vs. urban patients with a history of coronary artery disease or stroke. Similarly, the rate of medication use for secondary prevention was significantly higher among urban patients in Turkey, as compared to rural counterparts.20 Addressing these challenges demands a multi-pronged approach. Telemedicine emerges as a solution to improve access to healthcare for remote communities. Distant patients monitoring, virtual consultations, and telehealth services present a promising method to ensure continuous access to medical guidance and support. In a retrospective study in Australia, telehealth cardiology was shown to have a favourable impact on adherence to secondary prevention medications and outcomes.21 In a multi-centre study in the USA, a multifaceted intervention with close collaboration of the pharmacist, the general physician, and the cardiologist, along with automatic refill reminders, improved substantially the medication adherence, blood pressure control, and attainment of LDL targets after myocardial infarction.22 A combination of these approached seem definitely useful to empower individuals in remote areas to adhere to their prescribed therapies, thereby mitigating the risk of further cardiac events.