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Cited by 38COVID-19 and healthcare impactsTelemedicine and Telehealth ImplementationHealthcare Systems and Challenges

Rural and Remote Cardiology During the COVID-19 Pandemic: Cardiac Society of Australia and New Zealand (CSANZ) Consensus Statement

Open access
Arnold, Ruth H., Tideman, Philip A., Devlin, Gerard P., Carroll, Gerard E., Elder, Alex, Lowe, Harry, Macdonald, Peter S., Bannon, Paul G. +8 more·2020·Heart, Lung and Circulation
DOI 10.1016/j.hlc.2020.05.001PMC PMC7203036
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Abstract

The challenges Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors. The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations, and people with known CVD have increased morbidity and mortality from coronavirus disease 2019 (COVID-19). In addition, COVID-19 is associated with serious cardiac manifestations, potentially placing additional demand on limited regional services at a time of diminished visiting metropolitan support with restricted travel. Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity. Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic. Main recommendations Health districts, cardiologists and government agencies need to minimise impacts on the already vulnerable cardiovascular health of regional and remote Australians and New Zealanders throughout the COVID-19 pandemic. Changes in management should include.

Integrity signals

Registry

Crossref · 10.1016/j.hlc.2020.05.001

Cites

21 of 21 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

9 of 22 cited sources checked · 1 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Rural and remote Australians and New Zealanders experience a higher rate of adverse outcomes from acute myocardial infarction.

    “Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors [3,4].”
    • Also stated in: § The Challenges · plain
      “Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [3] Kotwal, 2016, Long-term outcomes of patients with acute myocardial infarction presenting to regional and remote hospitals, Heart Lung Circ source

      The Mortality and Sensitivity Analyses sections (pages unavailable) report higher crude mortality for regional and remote NSW patients and higher adjusted mortality for those presenting with STEMI. They found no significant adjusted mortality difference for AMI patients overall, and the study did not examine New Zealanders. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
    • cites [4] Chew, 2013, Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study, Med J Aust source
  • Premisecitation

    ACE-2 dysfunction results in high rates of acute cardiac injury and left ventricular dysfunction seen in COVID-19.

    “This system usually protects against endothelial damage [9], hence ACE-2 dysfunction results in high rates of acute cardiac injury and left ventricular dysfunction seen in COVID-19 [6,7,10,11].”
    Quote in the paperNot a substantial claim2 of 4 sources checked
    • cites [6] Shi, 2020, Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China, JAMA Cardiol source

      The Discussion reports cardiac injury in 19.7% of hospitalized patients with COVID-19 and hypothesizes that ACE2 might mediate it. It does not establish ACE2 dysfunction as the cause, and says the study lacked echocardiography or MRI evidence to characterize myocardial injury, including left ventricular dysfunction. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [7] Wang, 2020, Clinical characteristics of 138 hospitalized patients with 2019 Novel Coronavirus-Infected pneumonia in Wuhan, China, JAMA source
    • cites [10] Arentz, 2020, Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State, JAMA source
    • cites [11] Guo, 2020, Cardiovascular implications of fatal outcomes of patients with Coronavirus Disease 2019 (COVID-19), JAMA Cardiol source

      The Discussion (Association of Myocardial Injury With Prognosis; page unavailable) reports myocardial injury in 27.8% of the studied patients and associates it with impaired cardiac function. But the paper does not establish left ventricular dysfunction specifically or show that ACE2 dysfunction causes either outcome; its Discussion says the mechanism of myocardial injury is not fully understood. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premisecitation

    The pathophysiology of COVID-19 is fundamentally linked to the vascular system due to viral infection and down-regulation of the ACE-2 system.

    “The pathophysiology of COVID-19 is fundamentally linked to the vascular system, due to viral infection and down-regulation of the angiotensin converting enzyme-2 (ACE-2) system [8].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [8] Wevers, 2010, Renin-angiotensin system in human coronavirus pathogenesis, Future Virol source

      The section ‘Role of the RAS in SARS-CoV & HCoV-NL63 infection’ (page unavailable) links SARS-CoV infection and ACE2 downregulation to lung injury and discusses possible cardiac effects. It does not address COVID-19 specifically or establish that its pathophysiology is fundamentally linked to the vascular system; the proposed cardiac mechanism is explicitly described as lacking direct evidence. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premisecitation

    The prevalence of cardiovascular disease is higher in regional and remote populations.

    “The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations.”
    • Also stated in: § Pre-Existing Cardiovascular Disease and COVID-19 · plain
      “Rural and regional populations are older, with higher rates of CVD [1].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] 2018

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Interpretationreasoning

    COVID-19 era disruption to protocols could result in greater morbidity and mortality due to delayed revascularisation.

    “COVID-19 era disruption to protocols could result in greater morbidity and mortality due to delayed revascularisation.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 21
  • May combine two claims. 7

  • Classified as probably not a substantial claim.

    Premisecitation

    CSANZ guidelines recommend full PPE for cardiac catheterisation procedures in STEMI, and in patients with suspected and confirmed COVID-19.

    “CSANZ guidelines recommend full PPE for cardiac catheterisation procedures in STEMI, and in patients with suspected and confirmed COVID-19.”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites [15] Zaman, 2020, Cardiovascular disease and COVID-19: Australian/New Zealand consensus statement, Med J Aust source
    • cites [16] Lo, 2020, CSANZ consensus guidelines for interventional cardiology services delivery during COVID-19 pandemic in Australia and New Zealand, Heart Lung Circ source

      The Practical Considerations section recommends level C PPE for catheterisation patients at high COVID-19 exposure risk, a category that includes suspected and confirmed cases. But it specifies level B PPE for low-risk patients, including those presenting with STEMI; it does not recommend full PPE for every STEMI catheterisation procedure. No page number is available in our copy. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
    • cites [21] Kirkpatrick, 2020, ASE Statement on Protection of Patients and Echocardiography Service Providers during the 2019 Novel Coronavirus Outbreak, J Am Coll Cardiol source

      The Background and How to Image? > Protection sections discuss PPE for echocardiography, including airborne precautions for TEE in suspected or confirmed COVID-19 cases. Searches for CSANZ, STEMI, and cardiac catheterisation found no passage addressing the attributed guideline recommendation; the copy therefore cannot verify it. The indexed passages provide no page numbers. (LLM, conf=0.76)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The rate of failed fibrinolysis in rural areas is approximately 30%, requiring rescue PCI.

    “The rate of failed fibrinolysis in rural areas is approximately 30% [18,19], requiring rescue PCI.”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [18] Elder, 2016, Early cardiologist input via LIFENET ECG transmission and pre-hospital thrombolysis achieves improved lysis times for STEMI in a rural setting, Heart Lung Circ source

      The Methods/Results passage (page not provided) reports that 65 of 104 thrombolysed STEMI patients in Western NSW successfully reperfused, implying about 38% did not—rather than approximately 30%. It does not say that those patients required rescue PCI, and its regional cohort does not establish a rate for rural areas generally. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [19] Khan, 2016, Pre-hospital thrombolysis in ST-segment elevation myocardial infarction: a regional Australian experience, Med J Aust source

  • May combine two claims.

    Premisecitation

    Early specialist input improves outcomes and delivers more cost-effective care closer to patients' homes.

    “Early specialist input improves outcomes and delivers more cost-effective care closer to patients' homes [18].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [18] Elder, 2016, Early cardiologist input via LIFENET ECG transmission and pre-hospital thrombolysis achieves improved lysis times for STEMI in a rural setting, Heart Lung Circ source

      The Results and Conclusion (page not available) report shorter treatment times with pre-hospital thrombolysis and suggest that early cardiologist input could further improve treatment times and reduce mortality in rural STEMI patients. The observed treatment-time trend specifically associated with early cardiologist input was not statistically significant. The paper does not establish improved patient outcomes or assess cost-effectiveness. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    System improvements could build greater long-term capacity, supporting existing regional centres and networks to provide a greater proportion of cardiac care locally on an ongoing basis.

    “System improvements could build greater long-term capacity, supporting existing regional centres and networks to provide a greater proportion of cardiac care locally on an ongoing basis.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: System improvements can build greater long-term capacity.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    Meeting these demands in regional and rural Australia and New Zealand will bring particular challenges.

    “Meeting these demands in regional and rural Australia and New Zealand will bring particular challenges.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationnone given

    Enhanced systems of telehealth and video support 24/7, including relevant enhancements of technical infrastructure and models of multi-disciplinary care, could allow uniform standards of inpatient cardiac assessment and mitigate the impact of the COVID-19 pandemic in regional and rural Australia and New Zealand.

    “Enhanced systems of telehealth and video support 24/7, including relevant enhancements of technical infrastructure and models of multi-disciplinary care could allow uniform standards of inpatient cardiac assessment and mitigate the impact of the COVID-19 pandemic in regional and rural Australia and New Zealand.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Enhanced systems of telehealth and video support can be implemented.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    Infection or prolonged self-isolation due to exposure of even a single regional interventional cardiologist and/or cardiac catheter nursing staff member could easily incapacitate an entire regional roster and service.

    “Infection or prolonged self-isolation due to exposure of even a single regional interventional cardiologist and/or cardiac catheter nursing staff member, could easily incapacitate an entire regional roster and service.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    COVID-19 will place a significant demand on cardiovascular services.

    “COVID-19 will place a significant demand on cardiovascular services.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Deployment of cardiovascular nurses to COVID-19 pandemic roles in the ED and ICU is more likely to compromise patient care in regional settings.

    “Deployment of cardiovascular nurses to COVID-19 pandemic roles in the ED and ICU is more likely to compromise patient care in regional settings, where fewer nursing staff are skilled in critical care.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Fewer nursing staff in regional settings are skilled in critical care.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    This is likely to affect the availability of tenecteplase, which is imported from Europe in limited supply.

    “This is likely to affect the availability of tenecteplase, which is imported from Europe in limited supply.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Tenecteplase is imported from Europe in limited supply.

  • Classified as probably not a substantial claim.

    Premisecitation

    The burden of cardiovascular disease in Australia and New Zealand is higher in Indigenous people.

    “In addition, the burden of CVD in both Australia and New Zealand is higher in Indigenous people [2]; many of whom live in remote rural settings.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [2] New Zealand Ministry of Health

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    Monitoring of impacts by centralised acute cardiac telehealth services in each rural health district could ensure rational and equitable use of limited resources throughout the pandemic and beyond.

    “Monitoring of impacts, by centralised acute cardiac telehealth services in each rural health district, allowing discussion and prioritisation of patients, could ensure rational and equitable use of limited resources throughout the pandemic and beyond.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Centralised acute cardiac telehealth services can monitor impacts in each rural health district.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    The availability of rapid-turnaround onsite polymerase chain reaction testing for COVID-19 in major regional hubs may reduce the number of staff undergoing prolonged quarantine while awaiting COVID-19 results.

    “The availability of rapid-turnaround onsite polymerase chain reaction testing for COVID-19 in major regional hubs may reduce the number of staff undergoing prolonged quarantine while awaiting COVID-19 results in patients, contact or themselves.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Rapid-turnaround onsite PCR testing for COVID-19 is available in major regional hubs.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    It would also allow appropriate planning for local patient care and transfers to tertiary hospitals.

    “It would also allow appropriate planning for local patient care and transfers to tertiary hospitals.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    These factors could result in a higher rate of severe COVID-19 disease, increased burden on limited resources, and further inequity between populations defined by geography or ethnicity.

    “These factors could result in a higher rate of severe disease in the event of COVID-19 infection placing an increased burden on already limited resources and driving further inequity between populations defined by geography or ethnicity.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Identification of patients with device malfunction or approaching battery end-of-life is a potentially life-threatening issue, particularly if the pandemic-related decline of services continues for several months.

    “Identification of patients with device malfunction or approaching battery end-of-life is a potentially life-threatening issue, particularly if the pandemic-related decline of services continues for several months.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The pandemic-related decline of services may continue for several months.

  • May combine two claims.

    Premisecitation

    Low tissue ACE-2 levels are found in the elderly and may be linked to increased COVID-19 severity.

    “Low tissue ACE-2 levels are found in the elderly and may be linked to increased COVID-19 severity [[12], [13], [14]].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [[12], [13], [14]]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    There is a greater percentage of Māori, Aboriginal, Torres Strait Islander and older people living in rural/regional areas.

    “There is a greater percentage of Māori, Aboriginal, Torres Strait Islander and older people living in these areas [1,2].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [1] 2018

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [2] New Zealand Ministry of Health

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    In larger regional hospitals without cardiac catheterisation facilities, access to echocardiography and cardiac computed tomography (CT), if available, may reduce the number of patients requiring transfer.

    “In larger regional hospitals without cardiac catheterisation facilities, access to echocardiography and cardiac computed tomography (CT), if available, may reduce the number of patients requiring transfer.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Echocardiography and cardiac CT are available in larger regional hospitals without cath facilities.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A broader role for ARBs in the treatment of COVID-19 is being trialled.

    “A broader role for ARBs in the treatment of COVID-19 is being trialled [12].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] Wang, 2020, Angiotensin converting enzyme 2: a double-edged sword, Circulation source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Many health care workers around the world have been exposed to, or have died from, COVID-19.

    “Many health care workers around the world have been exposed to, or have died from, COVID-19 [5].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [5] Wu, 2020, Characteristics of important lessons from Coronavirus Disease 2019(COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention, JAMA source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    As a result of the Australian government stopping elective surgery, most cardiac surgical units have had their operative lists reduced.

    “The Australian government has currently stopped elective surgery, other than Category A and urgent Category B patients. As a result, most cardiac surgical units have had their operative lists reduced.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The Australian government has currently stopped elective surgery, other than Category A and urgent Category B patients.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Increased community transmission of COVID-19, should it occur, will place huge strain on already fragile health care and emergency transport systems throughout Australia and New Zealand.

    “Increased community transmission of COVID-19, should it occur, will place huge strain on already fragile health care and emergency transport systems throughout Australia and New Zealand.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Redeployment of heart failure nurses may impact vulnerable patients at a time when avoidance of hospital admission is essential.

    “Redeployment of heart failure nurses may impact vulnerable patients at a time when avoidance of hospital admission is essential.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Avoidance of hospital admission is essential.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Uniform coverage would be particularly beneficial during the COVID-19 pandemic, when all resources will be stretched and appropriate utilisation essential.

    “Uniform coverage would be particularly beneficial during the COVID-19 pandemic, when all resources will be stretched and appropriate utilisation essential.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: All resources will be stretched during the COVID-19 pandemic.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    This could prevent or delay timely access of unstable rural acute coronary syndromes patients to PCI-capable facilities.

    “This could prevent or delay timely access of unstable rural acute coronary syndromes patients to PCI-capable facilities.”
    Quote in the paperSubstantial claim
26 of 26

  • The paper relies on this without support.

    One in four New Zealanders and 30% of Australians live in rural or regional locations.

    “One (1) in four New Zealanders and 30% of Australians live in rural or regional locations.”

  • The paper relies on this without support.

    The health care needs of rural and regional communities are greater than for metropolitan populations.

    “The health care needs of these communities are greater than for metropolitan populations and yet the number of doctors, particularly specialists, per capita is lower and access to cardiovascular services remains challenging in usual, non-pandemic circumstances.”

  • The paper relies on this without support.

    The number of doctors, particularly specialists, per capita is lower in rural and regional areas.

    “The health care needs of these communities are greater than for metropolitan populations and yet the number of doctors, particularly specialists, per capita is lower and access to cardiovascular services remains challenging in usual, non-pandemic circumstances.”

  • The paper relies on this without support.

    Access to cardiovascular services remains challenging in usual, non-pandemic circumstances.

    “The health care needs of these communities are greater than for metropolitan populations and yet the number of doctors, particularly specialists, per capita is lower and access to cardiovascular services remains challenging in usual, non-pandemic circumstances.”

  • The paper relies on this without support.

    Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays.

    “Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity.”

  • The paper relies on this without support.

    Cardiovascular resources are diverted to increasing ICU and ED capacity.

    “Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity.”

  • The paper relies on this without support.

    Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic.

    “Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic.”

  • The paper relies on this without support.

    Commonly used cardiovascular drugs, such as angiotensin receptor blockers (ARBs), increase ACE-2 levels.

    “Commonly used cardiovascular drugs, such as angiotensin receptor blockers (ARBs), increase ACE-2 levels.”

  • The paper relies on this without support.

    Increased availability of point of care pathology services improves diagnostic accuracy at the site of presentation.

    “Increased availability of point of care pathology services improves diagnostic accuracy at the site of presentation.”

  • The paper relies on this without support.

    Established systems such as the State Cardiac Reperfusion Strategy (SCRS) in New South Wales and the Integrated Cardiovascular Clinical Network (iCCnet) in South Australia provide 24/7 cardiologist support.

    “Established systems such as the State Cardiac Reperfusion Strategy (SCRS) in New South Wales (NSW), Australia, and the Integrated Cardiovascular Clinical Network (iCCnet) in South Australia (SA), Australia, provide 24/7 cardiologist support.”

  • The paper relies on this without support.

    Telehealth support structures and existing health infrastructure vary between states and health districts in their resource allocation, staffing and scope of service.

    “However, telehealth support structures and existing health infrastructure vary between states and health districts in their resource allocation, staffing and scope of service.”

  • The paper relies on this without support.

    Video-consultation in acute situations can significantly improve the comprehensiveness and accuracy of remote specialist assessment.

    “Video-consultation in acute situations can significantly improve the comprehensiveness and accuracy of remote specialist assessment.”

  • The paper relies on this without support.

    Many rural health districts have existing protocols to expedite immediate transfer of STEMI patients to regional PCI centres.

    “Many rural health districts have existing protocols to expedite immediate transfer of STEMI patients to regional PCI centres.”

  • The paper relies on this without support.

    Access to cardiology outpatient outreach services has rapidly declined since mid-March 2019.

    “Access to cardiology outpatient outreach services has rapidly declined since mid-March 2019.”

  • The paper relies on this without support.

    Regional airlines have severely curtailed their schedules.

    “Regional airlines have severely curtailed their schedules.”

  • The paper relies on this without support.

    Many specialists have had their ability to travel, especially interstate, restricted or terminated, related to metropolitan hospital pandemic plans.

    “Many specialists have had their ability to travel, especially interstate, restricted or terminated, related to metropolitan hospital pandemic plans.”

  • The paper relies on this without support.

    Telephone consultation to a patient in the home, whilst useful for short-term follow-up, has significant limitations in patient assessment.

    “Telephone consultation to a patient in the home, whilst useful for short-term follow-up, has significant limitations in patient assessment.”

  • The paper relies on this without support.

    Clinic-to-clinic video-consultations provide greater clinical capability than telephone consultations but require more time, staff and infrastructure to establish.

    “Clinic-to-clinic video-consultations provide greater clinical capability than telephone consultations but require more time, staff and infrastructure to establish.”

  • The paper relies on this without support.

    Assessment of patients presenting with increasing dyspnoea, via telehealth, can be difficult without access to investigations such as chest x-ray, echocardiography, NTproBNP and routine blood tests, prior to the consultation.

    “Assessment of patients presenting with increasing dyspnoea, via telehealth, can be difficult without access to investigations such as chest x-ray (CXR), echocardiography, N-terminal prohormone B-type natriuretic peptide (NTproBNP) and routine blood tests, prior to the consultation.”

  • The paper relies on this without support.

    Movement of medical staff between health services may carry a risk of COVID-19 transmission, but with appropriately applied rules of self-isolation for exposed or symptomatic staff, this risk can be minimised.

    “Movement of medical staff between health services may carry a risk of COVID-19 transmission, but with appropriately applied rules of self- isolation for exposed or symptomatic staff, this risk can be minimised.”

  • The paper relies on this without support.

    The average age of rural and regional cardiologists and cardiac nursing staff is higher than in metropolitan centres, placing more staff at higher personal risk due to COVID-19.

    “The average age of rural and regional cardiologists and cardiac nursing staff is higher than in metropolitan centres, placing more staff at higher personal risk due to COVID-19.”

  • The paper relies on this without support.

    Cardiac sonographers are a limited resource in regional and rural areas.

    “Cardiac sonographers are a limited resource in regional and rural areas.”

  • The paper relies on this without support.

    Remote patient monitoring requires access to the monitoring device and a mobile phone network.

    “Remote patient monitoring requires access to the monitoring device and a mobile phone network.”

  • The paper relies on this without support.

    An estimated 25% of rural patients have remote monitoring facility.

    “An estimated 25% of rural patients have this facility.”

  • The paper relies on this without support.

    Remote monitoring checks diagnostic function but has no capacity to re-program devices to “work-around” malfunctions.

    “Remote monitoring checks diagnostic function but has no capacity to re-program devices to “work-around” malfunctions.”

  • The paper relies on this without support.

    Due to COVID-19 travel restrictions, device companies have already cancelled all rural clinics, leaving under-resourced local services searching for alternatives.

    “Due to COVID-19 travel restrictions, device companies have already cancelled all rural clinics, leaving under-resourced local services searching for alternatives.”

  • The paper relies on this without support.

    Pacemaker implantation in regional and rural Australia is highly variable and deficient in many areas.

    “Pacemaker implantation in regional and rural Australia is highly variable and deficient in many areas.”

  • The paper relies on this without support.

    The Australian government has currently stopped elective surgery, other than Category A and urgent Category B patients.

    “The Australian government has currently stopped elective surgery, other than Category A and urgent Category B patients.”

  • The paper relies on this without support.

    Patients will continue to require cardiac surgery.

    “Patients will however continue to require cardiac surgery.”

  • The paper relies on this without support.

    Some rural health districts have established models of video multi-disciplinary team (MDT) meetings, allowing cardiothoracic surgeons and cardiologists to discuss patients.

    “Some rural health districts have established models of video multi-disciplinary team (MDT) meetings, allowing cardiothoracic surgeons and cardiologists to discuss patients.”

  • The paper relies on this without support.

    Negotiations between the private and public sectors on resource utilisation during the pandemic are ongoing.

    “Negotiations between the private and public sectors on resource utilisation during the pandemic are ongoing.”

  • The paper relies on this without support.

    Bed availability in cardiac centres has already diminished, as administrators enact pandemic plans to expand ED and ICU services.

    “Bed availability in cardiac centres has already diminished, as administrators enact pandemic plans to expand ED and ICU services.”

  • The paper relies on this without support.

    Stringent patient assessment procedures, in place at all receiving hospitals, impose further delays.

    “Stringent patient assessment procedures, in place at all receiving hospitals, impose further delays.”

  • The paper relies on this without support.

    Transfers that normally occur across state boundaries may be subject to high level negotiations in the unprecedented era where states in Australia have closed borders.

    “Transfers that normally occur across state boundaries may be subject to high level negotiations in the unprecedented era where states in Australia have closed borders.”

  • The paper relies on this without support.

    Transport of COVID-19 patients between hospitals, either by regular ambulance or medical retrieval services, will incur additional unavailability required for decontaminating the vehicle after transport, which will add to the loss of operational capacity in smaller towns.

    “Transport of COVID-19 patients between hospitals, either by regular ambulance or medical retrieval services, will incur additional unavailability required for decontaminating the vehicle after transport, which will add to the loss of operational capacity in smaller towns.”

  • The paper relies on this without support.

    The pattern, speed and magnitude of COVID-19 spread cannot be accurately predicted.

    “The pattern, speed and magnitude of COVID-19 spread cannot be accurately predicted.”

  • The paper relies on this without support.

    Health care services in many countries have been overwhelmed.

    “Health care services in many countries have been overwhelmed.”

  • The paper relies on this without support.

    Currently, the largest number of cases in both countries are in metropolitan centres, but locally acquired cases have now been reported in regional areas.

    “Currently, the largest number of cases in both countries are in metropolitan centres, but locally acquired cases have now been reported in regional areas (see NSW COVID-19 case statistics by local health district (www.health.nsw.gov.au).”

  • The paper relies on this without support.

    Fewer nursing staff in regional settings are skilled in critical care.

    “where fewer nursing staff are skilled in critical care”

  • The paper relies on this without support.

    Avoidance of hospital admission is essential.

    “at a time when avoidance of hospital admission is essential”

  • The paper relies on this without support.

    The pandemic-related decline of services may continue for several months.

    “particularly if the pandemic-related decline of services continues for several months”

  • The paper relies on this without support.

    Rapid-turnaround onsite PCR testing for COVID-19 is available in major regional hubs.

    “The availability of rapid-turnaround onsite polymerase chain reaction testing for COVID-19 in major regional hubs”

  • The paper relies on this without support.

    Echocardiography and cardiac CT are available in larger regional hospitals without cath facilities.

    “access to echocardiography and cardiac computed tomography (CT), if available”

  • The paper relies on this without support.

    All resources will be stretched during the COVID-19 pandemic.

    “when all resources will be stretched”

  • The paper relies on this without support.

    Centralised acute cardiac telehealth services can monitor impacts in each rural health district.

    “Monitoring of impacts, by centralised acute cardiac telehealth services in each rural health district”

  • The paper relies on this without support.

    Tenecteplase is imported from Europe in limited supply.

    “which is imported from Europe in limited supply”

  • The paper relies on this without support.

    Enhanced systems of telehealth and video support can be implemented.

    “Enhanced systems of telehealth and video support 24/7”

  • The paper relies on this without support.

    System improvements can build greater long-term capacity.

    “System improvements could build greater long-term capacity”
48 of 48

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Outreach decline is dated before the pandemic

    Minor

    The paper places the decline in outreach cardiology access in mid-March 2019, although it says the virus was first detected in December 2019 and the pandemic was declared in March 2020. In context, the decline is attributed to pandemic-related travel restrictions.

1 of 1

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1 of the 22 references couldn’t be matched to a known paper.

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Authors
Arnold, R. H., Tideman, P. A., Devlin, G. P., Carroll, G. E., Elder, A., Lowe, H., Macdonald, P. S., Bannon, P. G., Juergens, C., McGuire, M., Mariani, J. A., Coffey, S., Faddy, S., Brown, A., Inglis, S., & Wang, W. Y. S.
Affiliations
  • SA Health (AU)
  • National Heart Foundation of New Zealand (NZ)
  • UNSW Sydney (AU)
  • The University of Sydney (AU)
  • Royal Prince Alfred Hospital (AU)
  • Liverpool Hospital (AU)
  • The Alfred Hospital (AU)
  • Southern District Health Board (NZ)
  • NSW Ambulance (AU)
  • South Australian Health and Medical Research Institute (AU)
  • University of Technology Sydney (AU)
  • The University of Queensland (AU)
Corresponding author
Arnold, Ruth H.
ORCID
Venue
Heart, Lung and Circulation
Publisher
Elsevier BV
Published
2020-07
Volume
29
Issue
7
Pages
e88-e93
ISSN
1443-9506 (ISSN-L)
DOI
10.1016/j.hlc.2020.05.001
PMC
PMC7203036
OpenAlex
W3023351326
Cited by
38
References
22
Citations by year
2026: 1 · 2025: 3 · 2024: 6 · 2023: 2 · 2022: 9 · 2021: 9 · 2020: 8
FWCI
2.53
Type
journal article
Language
en
Open access
Licence
Locations
  • Heart Lung and Circulation (publishedVersion)
  • PubMed Central (publishedVersion)
  • Monash University Research Portal (Monash University) (publishedVersion, other-oa)
  • PubMed (publishedVersion)
  • UNSWorks (University of New South Wales, Sydney, Australia) (submittedVersion, cc-by-nc-nd)
  • UTS ePRESS (University of Technology Sydney) (submittedVersion)
  • The Sydney eScholarship Repository (The University of Sydney) (submittedVersion)
Topics
  • Health Sciences › Medicine › Oncology › COVID-19 and healthcare impacts
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
  • Health Sciences › Health Professions › General Health Professions › Healthcare Systems and Challenges
Keywords
COVID-19 pandemic, acute myocardial infarction, cardiovascular disease, telemedicine, interhospital transfer, ambulance services, remote cardiac monitoring, regional health services, redeployment, Australia, New Zealand
MeSH terms
Betacoronavirus, COVID-19, SARS-CoV-2, Australia, Cardiology, Cardiovascular Diseases, Communicable Disease Control, Humans, Medically Underserved Area, New Zealand, Patient Care Management, Pneumonia, Viral, Societies, Medical, Telemedicine, Coronavirus Infections, Rural Health Services, Consensus, Pandemics

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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