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Editorial

Outcomes of Cardiac Surgery inAboriginal Australians: What are

the Problems and What’sto be Done?

Malcolm McDonalda,b,∗ and Bart Curriea,ba Menzies School of Health Research, P.O. Box 41096, Charles Darwin University,

Casuarina NT 0811, Australiab Northern Territory Clinical School, Royal Darwin Hospital, Flinders University,

Darwin NT, Australia

Cardiac disease is an unremitting catastrophe for Abo-riginal Australians, both in terms of excess morbid-

ity and premature mortality.1 The enormous burden ofischaemic heart disease is actually increasing and ratesof rheumatic heart disease remain among the highest re-ported anywhere.2 This is in stark contrast to trends innon-AboriginalAustralians andminority Indigenouspeo-ples of Canada, the US and New Zealand where morbid-ity and mortality differentials between Indigenous andnon-Indigenous populations are converging.3,4 Aborigi-nal Australians have poor outcomes at every point alongthe way, ranging from failure of basic preventative mea-sures and primary care at the community level through tocardiac surgery and post-surgery rehabilitation.

The two papers highlighting outcomes of cardiacsurgery in Aboriginal people in the last 5 years haveboth been published in this journal. In 1999, Carapetisand co-workers5 reported a retrospective case series ofpeople having valve replacement surgery for rheumaticheart disease who were from the Top End of the NorthernTerritory, although nearly all of the surgery was done inAdelaide. Of the 81 patients in the study, 70 were Aborig-inal and most had surgery for advanced disease. Medianfollow-up was for 4.6 years. Data were subjected to actu-arial analysis and at 1, 5 and 10 years, complication-freesurvival rates were 81, 52 and 44%, respectively. Impairedleft ventricular function at the point of surgerywas amajordeterminant of poor outcome. Rates of thromboembolicand bleeding complication were also high, reflecting thedifficulties monitoring anticoagulant therapy in manyAboriginal communities. Of the 29 late deaths (>30 dayspost-surgery), 27 were as a consequence of rheumaticheart disease.

The more recent paper by Kejriwal et al.6 is also a retro-spective cases series and included all open heart surgeryon Aboriginal people in Western Australia over a 6-year

∗ Corresponding author. Tel.: +61-8-8922-8197.E-mail address:malcolm@menzies.edu.au (M. McDonald).

period. Forty-five patients had coronary artery surgery,10 had valve procedures, presumably for rheumatic heartdisease in most cases (although it is not stated), and twowho had both. About 20% were lost to follow-up and themean follow-up period for the remainder was 3.1 years.Of the patients who had coronary artery surgery, 80%were taking aspirin therapy as prescribed at the time offollow-up and a similar percentage an anti-lipid agent;this is as compared with 94 and 89%, respectively in asimilar study of non-Aboriginal patients having surgery inthe same hospital. About a quarter of Aboriginal patientshad recurrent angina and a third of those with valvesurgery had been readmitted to hospital within a monthof discharge because of complications of anticoagulanttherapy. There were two late deaths.

Considering the extraordinary prevalence rates ofcoronary artery disease and rheumatic heart disease,it is remarkable how little published information isavailable about cardiac interventions and outcomes inAboriginal and Torres Strait Islander people. Indicationsfrom these two studies suggest that there is much roomfor improvement.

The excess mortality from cardiac disease in Aboriginalpeople is multifactorial and related to specific issues ofpoverty, cultural concepts of disease, population mobility,educational disadvantage, mistrust of health services,high rates of cigarette smoking and epidemic diabetesmellitus.7,8 In addition, people living in non-urban com-munities, Aboriginal and non-Aboriginal, often have tocope with great distances and difficulties with communi-cation, harsh environments, paucity of basic local healthresources, lack of tertiary institution support and a highturnover of clinic staff often with little continuity of care.Within this context the term ‘poor compliance’, oft-usedbyhealth professionals and administrators, would best be re-placed by ‘poor service’ in the majority of circumstances.9

At the heart of the problem forAboriginal people is failureof commitment at government levelwith long-termunder-spending on indigenous health and essential services.10

© 2004 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society ofAustralia and New Zealand. Published by Elsevier Inc. All rights reserved.

1443-9506/04/$30.00doi:10.1016/j.hlc.2004.03.012

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130 McDonald and Currie Heart Lung and CirculationOutcomes of Cardiac Surgery in Aboriginal Australians: What are the Problems and What’s to be Done? 2004;13:129–131

Given the barriers for Aboriginal people, rural and ur-ban, in accessing the whole range of health services it islikely that a substantial proportion of people with sig-nificant and treatable cardiac disease never get as far asbasic cardiac assessment, let alone investigation and in-tervention. Considerable time delay for presentation ofAboriginal people with acute coronary events has beendocumented in the Northern Territory.11 Specific data onaccess to cardiac surgery are not readily available; how-ever, barriers to accessing renal transplantation have beendocumented,12 as has a generally lower rate of therapeu-tic interventions.13 It is probable that availability of cardiacsurgery is similarly affected. It is also probable that Abo-riginal people who eventually do come to cardiac surgeryhave more advanced disease than non-Aboriginals and agreater burden of co-morbidities, including diabetes mel-litus and renal impairment.

Major surgery is a daunting prospect for Aboriginalpeople, especially when undertaken in a far-off city and ina strange environment, away from the support of relativesand surrounded by a sea of perhaps well-meaning, butunfamiliar, faces. Cultural and language differences canmake the simplest of daily activities and tasks humiliating,confronting and confusing. Despite careful explanation,the consent process is fraught with difficulties; providinginformation is a long way from ensuring understanding.In addition, non-Aboriginal health professionals may notappreciate beliefs their Aboriginal patients have aboutsurgery14 or even take the trouble to find out. Many ofthese people also come from communities with highlevels of unemployment and despair where depressionmay add another layer of complexity of to poor health,although prevalence data are notably lacking. It is in-creasingly clear, however, that depression has an impacton the outcome of cardiac surgery15,16 and may well be asignificant factor here. Equally intriguing is the potentiallink between poor diet, including intake of omega-3 fattyacids, depression and cardiovascular mortality;17 lowintake of omega-3 fatty acids is common in Aboriginalpeople predominantly living on community store-baseddiets18 whereas ‘bush tucker’ is usually a good source.

In the post-operative period, patients and clinic staffface a series of obstacles to effective secondary prevention,including rehabilitation and management of medication,especially if the patient is discharged from hospital with acomplicated pharmaceutical regimen.9 Access to certainmedication is difficult in some communities, particularlythose without a medical practitioner on site. Likewise,communications between tertiary medical centres andremote Aboriginal communities are often problematic19

with management plans that are unrealistic or just lostin transit. Cardiac rehabilitation services for the majorityof Aboriginal people living outside urban and regionalcentres are greatly restricted or non-existent.20

Anticoagulant treatment poses special problems. In areview of anticoagulation21 in people with metallic valvu-lar prostheses in the Top End of the Northern Territory,Aboriginal patients (n = 33) had had a mean of only 3.4months per year with an INR between 2.0 and 4.0 as com-pared with 6.6 months for non-Aboriginal patients (n =

15). Several corrective strategies have been suggested,including routine addition of aspirin to warfarin in or-der to reduce the risks of thromboembolism. It remainsto be seen whether introduction of on-site facilities forINR monitoring in selected remote communities will im-prove the stability of anticoagulation for these patients.Although valve repair and porcine valve prostheses arealternatives that avoid the requirement for anticoagula-tion, it is possible that outcomesmaybe inferior, especiallywhen there is recurrent rheumatic fever.22

Sowhat is theway forward?Firstweneedadvocacy.1 TheNational Heart Foundation of Australia has already raisedthe profile of Aboriginal heart disease and given practicalsupport throughspecific research scholarships andgrants.The Cardiac Society of Australia andNew Zealand has re-cently formedan IndigenousWorkingGroupand theAus-tralasian Society of Cardiac and Thoracic Surgeons will beable to make a contribution. There is increased awarenessthrough activities of the NHMRC, the colleges and othernon-government organisations. Initiatives have also beentaken by the National Heart, Stroke and Vascular HealthStrategies Group. Should these bodies get together andmake a coordinated approach to policy-makers in gov-ernment and other funding agencies the impact wouldbe undeniable. But is it unrealistic to expect that we willever see a collective push from these and other expertgroups?

Wealsoneedmore information.Practical researchques-tions can be prioritised and addressed through prospec-tive multi-centre studies. How can we improve access toprimary care for people with cardiac disease?What medi-cal treatment regimenswork best for established coronaryartery disease in Aboriginal people? Should we be opt-ing for earlier surgical intervention? What does surgerymean on a personal level for Aboriginal people? Howcan the consent process be improved? How can targetedpre-operative measures reduce operative complications?Should surgeons be using mechanical or tissue valves forrheumatic heart disease? Are the benefits from not havingto use anticoagulants really outweighed bymore rapid de-terioration of tissue valves in this population? And whatis the role of new techniques in valvular reconstructionsurgery?What is the bestway to deliver cardiac rehabilita-tion and related services? How can secondary preventionbe optimised in remote communities?

Unless these issues are tackled with determination atthe local and at the national level, it is unlikely that sig-nificant progress will be made in the foreseeable future.A response to the call for action requires broad collabo-rative effort with Aboriginal Australians playing a pivotalrole in setting the agenda, charting theway and ultimatelyin delivering the services.23

“Aboriginal health is not heroic. It will not win votes, and isnot necessarily abouthaving the latest technologywithbellsand whistles. It is about compassion. It is about justice. It isabout priorities. And, it is about not forgetting people. . .”

Prof Lowitja O’Donoghue. Plenary speech to the 13thAnnual ScientificMeeting of the SouthAustralianCardiacRehabilitation Association, 2003.

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Heart Lung and Circulation McDonald and Currie 1312004;13:129–131 Outcomes of Cardiac Surgery in Aboriginal Australians: What are the Problems and What’s to be Done?

Malcolm McDonald is funded by a Postgraduate Biomedical Re-search Scholarship from the National Heart Foundation of Aus-tralian. Bart Currie is supported by grants from the NationalHealth and Medical Research Council and National Heart Foun-dation of Australia. Otherwise the authors have no conflict of in-terest.

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23. Murray RB, Bell K, Couzos S, Grant M, Wronski I. Aborig-inal health and policy process. In: Couzos S, Murray RB,editors. Aboriginal primary health care: an evidence-based ap-proach. 2nd ed. Melbourne: Oxford University Press; 2003.p. 37.