Management Of Rural Acute Coronary Syndromes (MORACS) – A randomized controlled trial of diagnostic support for patients in rural hospitals with acute coronary syndromes

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Abstract Background Rural and remote patients presenting with acute coronary syndrome (ACS) experience delays in diagnosis and reperfusion, contributing to higher mortality than those presenting to tertiary centres. Evidence supporting system-triggered diagnostic interventions across the full spectrum of ACS remains limited. Methods In a multicentre, cluster-randomized controlled trial, 29 rural emergency departments in New South Wales, Australia, were assigned to either a system-triggered diagnostic telemedical support from a tertiary centre (MORACS intervention) or usual care. Adult patients presenting with symptoms consistent with ACS were included in the study. The primary outcome was all-cause death. Secondary outcomes included 30-day and 1-year death, length of hospital stay and 30-day readmission rate. Results Between December 2018 and April 2020, ACS was confirmed in 587 of 7474 emergency department presentations consistent with possible ACS. Of these, 274 (47%) presented to MORACS intervention hospitals and 313 (53%) presented to control hospitals. Over a median follow-up of 62 months, all-cause death occurred in 54 patients (20%) in the intervention group and 85 patients (27%) in the control group, representing a 30% lower risk of death with the MORACS intervention (HR 0.70; 95% CI, 0.49–0.98; P = 0.036). The mortality benefit was consistent across both the ST-elevation ACS (STEACS) and non-ST elevation ACS (NSTEACS) subgroups. No significant differences were observed in length of stay or 30-day readmissions. Conclusions The MORACS intervention significantly reduced all-cause mortality among rural patients with ACS. These findings support the integration of system-triggered diagnostic telehealth support into rural emergency department settings to improve outcomes in ACS management. Registration ACTRN12619000533190 (anzctr.org.au) Clinical Perspective What is New? In this multicentre cluster-randomized controlled trial, system-triggered diagnostic telemedical support in rural emergency departments significantly reduced all-cause mortality in patients presenting with ACS. This larger cohort extends the findings of the initial MORACs study, demonstrating a mortality benefit of diagnostic telemedical support across the full spectrum of ACS presentations, including both STEACS and NSTEACS. What Are the Clinical Implications? Implementing system-triggered diagnostic telemedical support can help overcome barriers to timely diagnosis and reperfusion in geographically isolated hospitals. Broader implementation of such interventions may enhance equity in cardiac care delivery and reduce rural-urban disparities in ACS outcomes.

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