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Context: Prompt reperfusion therapy in acute ST-segment elevation myocardial infarction (STEMI) improves outcomes and is therefore a key part of the management of affected patients. Primary percutaneous coronary intervention (PPCI) is preferred over thrombolysis; however, when PPCI is not available within an acceptable time frame, thrombolysis should be administered without delay. When thrombolysis is contraindicated, this can lead to delays in achieving coronary artery reperfusion, and making therapeutic decisions is more challenging. Issues: A 57-year-old woman with hereditary haemorrhagic telangiectasia (HHT) presented with chest pain to local medical services on a Scottish island. Initial assessment including 12-lead ECG was performed without delay and led to a diagnosis of infero-lateral STEMI. Initial treatment was with antiplatelets, nitrate and opiate analgesia. Immediate reperfusion therapy with thrombolysis was considered; however, this was contraindicated due to the diagnosis of HHT. Following discussion with the regional centre she was treated with heparin and urgently transferred to the nearest catheterisation laboratory for PPCI. Unfortunately delays in transfer were caused by inclement weather conditions, which precluded the use of an air ambulance. The patient reached a cardiac catheterisation laboratory by road. A total occlusion of a distal branch of the circumflex artery was found to be the culprit lesion and despite wiring and ballooning good blood flow was not restored. However, she made a good recovery and was discharged home on secondary prevention therapy, which was modified to take into account her increased bleeding risk associated with her pre-existing HHT. Lessons learned: In this case, the patient presented early to medical services following the onset of symptoms and was immediately assessed, resulting in a prompt accurate diagnosis at first medical contact. Despite this, the presence of HHT, and the particularities of living in a remote area compounded by unfavourable weather conditions, resulted in a delay in definitive treatment that would have been available to a similar patient presenting in an urban setting. In remote regions where reperfusion therapy for acute STEMI relies more often on thrombolysis, an increased awareness of the issues around the contraindication of thrombolysis, together with early discussion with a regional cardiology service leads to the most efficient way of establishing the best treatment plan for individual patients. Despite this, rural patients may remain at a disadvantage. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to examine whether general practitioner (GP) practice locations in remote and rural areas affected the pattern of direct access echocardiography referral and to assess any variations in echocardiographic findings. Methods: All referrals made by all GP practices in the Scottish Highlands over a 36-month period were analysed. Referral patterns were examined according to distance and rurality based on the Scottish Government's Urban-Rural Classification. Reasons for referral and cardiac abnormality detection rates were also examined. Results: In total, 1188 referrals were made from 49 different GP practices; range of referral rates was 0.3-20.1 per 1000 population with a mean of 6.5 referrals per 1000 population. Referral rates were not significantly different between urban and rural practices after correction for population size. There was no correlation between the referral rates and the distance from the centre (r2=0.004, p=0.65). The most common reason for referral was the presence of new murmur (46%). The most common presenting symptom was breathlessness (44%). Overall, 28% of studies had significant abnormal findings requiring direct input from a cardiologist. There was no clear relationship between referral rates and cardiac abnormality detection rates (r2=0.07, p=0.37). The average cardiac abnormality detection rate was 56%, (range 52-60%), with no variation based on rurality (p=0.891). Conclusions: In this cohort, rurality and distance were not barriers to an equitable direct access echocardiography service. Cardiac abnormality detection rates are consistent with that of other studies. [ABSTRACT FROM AUTHOR]

Introduction: Calcific aortic stenosis is the most common cardiac valve lesion and is becoming increasingly prevalent as life expectancy rises. There is evidence that patients in remote and rural areas with certain diseases have worse outcomes and present to specialist services later than their urban counterparts. It is not known whether patients with aortic stenosis follow a similar pattern. The aim of this study was to investigate whether increasing rurality was associated with later presentation to healthcare services at a more advanced stage of aortic stenosis. Methods: This was a retrospective cohort study. Using ICD-10 discharge codes and local databases, 605 patients with aortic stenosis who presented between 31 November 1999 and 1 December 2008 were identified. Aortic stenosis was defined as a pressure gradient across the aortic valve of 25 mmHg or more. Patients with prior aortic valve replacement were excluded. Clinical notes were reviewed for all patients. Gender, age and pressure gradient across the aortic valve at presentation and patient GPpractice location were recorded. Patients were then assigned a Clinical Peripherality Index score based on the postcode of their GP's practice to define rurality. Patient data were compared across the six defined levels of clinical peripherality by ANOVA. Results: Mean patient age was 73 ± 13 years, and 336 (54%) were male. The peak gradient across the valve was 41.1 ± 26.7 mmHg. There was no association between the level of clinical peripherality and the stage of aortic stenosis at presentation, age or gender (all p >0.05). Conclusions: There was no urban-rural gradient in the severity of aortic stenosis at presentation in this remote Scottish cohort. This suggests that patients with this condition in remote areas do not present later in their disease trajectory. [ABSTRACT FROM AUTHOR]

Introduction: An early invasive strategy with follow-on percutaneous coronary intervention (PCI) is recommended in the management of high risk acute coronary syndromes (ACS). This article aimed to assess the impact of a new PCI service in a remote population. Method: The study compared patient treatment pre- and post-introduction of the PCI service in a remote regional centre. Patients were identified using ICD discharge code during two 12 week periods ('pre' and 'post' introduction of the new PCI service). Further data was obtained from a catheter laboratory database, electronic patient management systems and clinical notes. Nonparametric statistical tests were used. Results: There were 182 patients in the pre-PCI group and 204 in the post-PCI group. There were no demographic differences between the groups. Patients admitted post service introduction who required active treatment were more likely to have PCI rather than an angiogram only (p=0.046). Furthermore, patients admitted after the introduction of the PCI service had a shorter period of time from admission to PCI (p=0.002), were less likely to be transferred to another hospital (p<0.001), and on average had a shorter hospital stay (p=0.017). Conclusion: A local PCI service in a remote regional centre increased efficiency in the management of patients with ACS with increased rates of PCI, shorter waiting times, reduced requirement for hospital transfer, and shorter length of stay. Nevertheless, many patients still required transfer to other centres. Therefore, maintaining links with other regional centres with clear patient pathways are necessary to provide optimal ACS care to all patients in a rural area. [ABSTRACT FROM AUTHOR]

Introduction: The treatment of patients with chronic heart failure (CHF) remains sub-optimal. Specialist CHF nurses are proven to improve care and reduce admission but developing such services, especially in remote areas, can be difficult. This study aimed: first, to assess the perceived acceptability and effectiveness of a new community based nurse-led heart failure service by general practitioners (GPs) in an area with a dispersed population; second, to assess the knowledge and learning needs of GPs; and third, to assess perceptions of the use of national guidelines and telehealth on heart failure management. Methods: The study was conducted in the Scottish Highlands, a large geographical area in the north of the UK which includes both rural and urban populations. The area has a total population of 240 000, approximately 60% of whom are within 1 hour travel time of the largest urban centre. A postal survey of all GPs (n = 260) and structured email survey of all CHF specialist nurses (n = 3) was performed. All responses were entered into a Microsoft Excel spreadsheet, summarised and subjected to thematic analysis. Differences between GPs in 'rural', 'urban' or both 'urban & rural' was investigated using an F-test for continuous variables and a three-sample test for equality of proportions for nominal data. Results: Questionnaires were returned from 83 GPs (32%) and all three CHF specialist nurses. In this sample there were only a few differences between GPs from 'rural', 'urban' and 'urban & rural'. There also appeared to be little difference in responses between those who had the experience of the CHF nurse service and those who had not. Overall, 32 GPs (39%) wished better, local access to echocardiography, while 63 (76%) wished access to testing for brain natriuretic peptide (BNP). Only 27 GPs (33%) referred all patients with CHF to hospital. A number of GPs stated that this was dependant on individual circumstances and the patient's ability to travel. The GPs were confident to initiate standard heart failure drugs although only 54 (65%) were confident in the initiation of beta-blockers. Most GPs (69%) had had experience of the CHF specialist nurse service and the responses were mixed. The GPs who had experienced the service appeared less confident that it would lead to reduced admission of patients to hospital (51% vs 77%, p = 0.046). Three main themes emerged from the nurse responses: service planning, communication and attitudinal changes after service embedment. Conclusions: This study demonstrates that a community based heart failure nurse service was not universally valued. Differences between urban and rural localities (communication) suggest that models of care derived from evidence based practice in urban areas may not be directly transferable to remote areas. Clearly, good communication among staff groups at all stages of implementation is important; however, despite best efforts and clinical trial evidence, specialist nurse services will not be welcomed by all doctors. Service providers and commissioners should be cognisant of the different roles of urban and rural GPs when designing such services. Among GPs there was a high degree of confidence with initiation and titration of drugs for heart failure with the exception of beta-blockers so clearly this is an area of ongoing educational need and support. Education and support should focus on ensuring that all doctors who care for patients with CHF have the skills and confidence to use medical therapies and specialist services as appropriate. [ABSTRACT FROM AUTHOR]

Introduction: Thrombolysis for patients with an ST elevation myocardial infarction (STEMI) is most effective if given promptly. In remote areas, pre-hospital thrombolysis has been shown to be effective and reduce mortality. However, pre-hospital thrombolysis may offer advantages even in urban areas in terms of reduced 'call to needle' times. General practitioners' attitudes are crucial in the delivery of this service. Differences in perceptions between rural or remote and urban GPs have not been examined previously. The aim of this study was to investigate the attitudes and beliefs of GPs with a view to pre-empting potential barriers to service redesign. Methods: A questionnaire was sent by email and conventional post to all local GPs (n = 261) located in the study area (Highland Region in the North of Scotland). Data were entered into an Excel spreadsheet for statistical analysis. For the purposes of further analysis the data were divided into three groups: 'urban', 'rural' and 'undefined'. Data were analysed by either unpaired Student's t-test or χ² statistic as appropriate, with significance taken at the 5% level. Qualitative responses were grouped following thematic analysis. Results: There was a 49% (n = 127) response. More questionnaires were returned by conventional post than email (106 vs 21, p < 0.0001). There did not appear to be a relationship between confidence in giving pre-hospital thrombolysis and number of years worked as a GP. Rural GPs who had previously administered pre-hospital thrombolysis reported higher confidence compared with GPs who had never given pre-hospital thrombolysis (7.5 ± 1.7 vs 6.3 ± 2.0, p = 0.01). Responses to two open questions: 'What do you think are the main factors preventing delivery of pre-hospital thrombolysis?' and 'What more could be done to increase your own willingness to administer pre-hospital thrombolysis?' were classified into four areas: training, experience, organisational and equipment issues. Conclusions: Several potential barriers to improving the uptake of pre-hospital thrombolysis were highlighted and included training, experience, equipment and organisational factors. Rural GPs were more likely to be confident to give thrombolysis. To implement pre-hospital thrombolysis in areas closer to hospitals may require greater support and training of urban GPs, who reported lower confidence in ECG analysis. Many GPs, while under-confident, reported a desire for further training to improve skills. Other GPs clearly stated that they did not consider emergency treatment of myocardial infarction in terms of thrombolysis as part of their role and that the treatment of acute STEMI in the community should be performed by the ambulance service. This view was held by urban rather than rural GPs. In remote areas it is clear that lack of ambulance crews and poor communication between the ambulance service and GPs leads to instances of 'scoop and run' to hospital, even when the distances are considerable and local GPs have the ability and desire to administer pre-hospital thrombolysis. Clear local clinical care pathways are recommended. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Thrombolysis for Acute ST Elevation Myocardial Infarction: A Pilot Study Comparing Results from GP Led Small Rural Health Emergency Departments With Results From a Physician Led Sub-Regional Emergency Department," by R. Krones, P. Radford, C. Cunningham, D. Krones, and H. M. Haines, published in 2012 by the journal "Rural and Remote Health" at the web address www.rrh.org.au.

A letter to the editor is presented in response to the article "Identification of barriers to the implementation of evidence-based practice for pre-hospital thrombolysis," in the May 28, 2009.