Cardiovascular Disease In Australia Research Articles

Understanding of seasonal influenza immunisation and its cardiovascular benefits among cardiology patients

Abstract Background Seasonal influenza immunisation reduces the risk of cardiovascular events. Patients with established cardiovascular disease (CVD) derive a greater benefit than those without yet up to 50% globally do not take up the immunisation. Purpose To describe the understanding and perceptions of seasonal influenza immuni2ation among patients CVD. Methods A cross sectional, voluntary and anonymous survey was administered to cardiology inpatients and outpatients attending a large health system in Australia during the 2022 influenza season, May 1st 2022 to August 31st 2022. Demographics, educational and employment status and prior immunisation behaviours were collected. Questions on perceptions and beliefs around seasonal influenza immunisation and influenza-related illness were presented with 5-point Likert scale (strongly disagree through to strongly agree). Results A total of 181 surveys were completed; median age was 64 (50.5% <65 years), 65.0% (115/177) of the population were inpatients, 82.2% (143/174) had completed high school or more; 35.0% (63/180) were female and 24.2% (43/178) spoke a language other than English at home. Over one third of respondents did not receive the seasonal influenza immunisation in the prior year (63/181, 34.5%). Only half (97/179, 54.2%) of patients agreed that their heart condition placed them at higher risk of complications and serious illness if they contracted influenza. While 73.3% (132/180) agreed that immunisation would help prevent risk of serious illness, only 26.8% (48/179) agreed that it would help to prevent myocardial infarction. Nearly a quarter of patients (24.0%, 43/179) were concerned about side effects while 1 in 10 (12.8%, 23/179) patients raised cost as a barrier despite being free-of-charge to all patients with CVD in Australia. If asked to receive the seasonal influenza immunisation, 86% (154/179) patients would agree if their cardiologist recommended it. Conclusions Despite guideline recommendations, most cardiology patients are uninformed of the cardiovascular benefits of seasonal influenza immunisation with many unaware they are at higher risk of influenza-related, preventable illness. The vast majority of patients would accept the immunisation if recommended by their cardiologist highlighting their important role in improving uptake among this high-risk group.

Association of ultra-processed foods with cardiovascular disease and hypertension in australian women

Abstract Background Ultra-processed food (UPF) intake has increased in the past few decades, yet knowledge around the long-term effects on cardiovascular disease (CVD) risk is limited. Moreover, the magnitude of the impact of UPF intake on CVD in Australia has not been established. Objective To investigate the association of UPF intake with incident CVD and hypertension in a population-based cohort of middle-aged women. Methods Women aged 46-55 years were prospectively recruited into the Australian Longitudinal Study on Women’s Health and followed for 15 years. UPFs were defined according to the NOVA classification, and the contribution of these foods to total dietary intake was estimated. Outcomes were incident CVD (self-reported heart disease/stroke) and/or hypertension. Logistic regression models assessed the association between UFP intake and endpoints with adjustment made for confounders. Results A total 10,006 women (mean age 52.5±1.5) with an average UPF intake of 26.6% of total food dietary intake (mean 347.8 g/d) were included. Over 15 years of follow-up, 1,038 incident CVD and 4,204 hypertension cases occurred. Higher UPF intake was associated with higher risk of CVD (ptrend=0.05) and hypertension (ptrend=0.02). The highest intake of UPF (mean 42% of total food intake) versus the lowest UPF intake (mean 14.2% of total food intake) was associated with incident CVD [odds ratio (OR) 1.35, 95% confidence interval (CI) 1.03-1.78; p=0.03)] and hypertension [OR 1.33, 95% CI 1.06-1.66; p=0.01]. Conclusion In middle-aged women, a higher intake of ultra-processed food was associated with increased CVD risk and hypertension. These findings lend support to minimising UPF intake as a component of a heart-healthy diet.

Genetic counselling – a key first step in genetic testing for people at risk of inherited cardiovascular disease in Australia

Genetic counselling – a key first step in genetic testing for people at risk of inherited cardiovascular disease in Australia

Cardiovascular Disease in Australia, and the Impact of the Rurality

Cardiovascular Disease in Australia, and the Impact of the Rurality

Corrigendum to: Evolution of non-fatal burden estimates for cardiovascular disease in Australia: a comparison of national and state-wide methodology of burden of disease.

Objective Burden of disease studies measure the impact of disease at the population level;however, methods and data sources for estimates of prevalence vary. Using a selection of cardiovascular diseases, we aimed to describe the implications of using different disease models and linked administrative data on prevalence estimation within three Australian burden of disease studies. Methods Three different methods (A = 2011 Australian Burden of Disease Study; B = 2015 Australian Burden of Disease Study; C = 2015 Western Australian Burden of Disease Study), which used linked data, were used to compare prevalence estimates of stroke, aortic aneurysm, rheumatic valvular heart disease (VHD) and non-rheumatic VHD. We applied these methods to 2015 Western Australian data, and calculated crude overall and age-specific prevalence for each condition. Results Overall, Method C produced estimates of cardiovascular prevalence that were lower than the other methods, excluding non-rheumatic VHD. Prevalence of acute and chronic stroke was up to one-third higher in Method A and B compared to Method C. Aortic aneurysms had the largest change in prevalence, with Method A producing an eight-fold higher estimate compared to Method C, but Method B was 10-20% lower. Estimates of VHD varied dramatically, with an up to six-fold change in prevalence in Method C due to substantial changes to disease models and the use of linked data. Conclusions Prevalence estimates require the best available data sources, updated disease models and constant review to inform government policy and health reform. Availability of nation-wide linked data will markedly improve future burden estimates.

Are social isolation, lack of social support or loneliness risk factors for cardiovascular disease in Australia and New Zealand? A systematic review and meta-analysis.

An international systematic review concluded that individuals with poor social health (social isolation, lack of social support or loneliness) are 30% more likely to develop coronary heart disease (CHD) and stroke. Notably, the two included Australian papers reported no association between social health and CHD or stroke. We undertook a systematic review and meta-analysis to investigate the association between social isolation, lack of social support and loneliness and cardiovascular disease (CVD) incidence among people living in Australia and New Zealand. Four electronic databases were systematically searched for longitudinal studies published until June 2020. Two reviewers undertook title/abstract screen and one reviewer undertook full-text screen and data extraction. Quality was assessed using the Newcastle - Ottawa Quality Assessment Scale. Of the 725 unique records retrieved, five papers met our inclusion criteria. These papers reported data from three Australian longitudinal datasets, with a total of 2137 CHD and 590 stroke events recorded over follow-up periods ranging from 3 to 16years. Reports of two CHD and two stroke outcomes were suitable for meta-analysis. The included papers reported no association between social health and incidence of CVD in all fully adjusted models and most unadjusted models. Our systematic review is inconclusive as it identified only a few studies, which relied heavily on self-reported CVD. Further studies using medical diagnosis of CVD, and assessing the potential influence of residential remoteness, are needed to better understand the relationship between social health and CVD incidence in Australia and New Zealand.

Economic Burden of Dementia Caused by Cardiovascular Disease in Australia.

The established link between cardiovascular disease (CVD) and dementia may provide new insights into dementia prevention. It aims to quantify the burden of dementia attributable to people with CVD. A Markov microsimulation model was developed to simulate the lifetime cost and quality-adjusted life-years (QALYs) related to people with and without CVD in Australia. A de-novo systematic review was undertaken to identify all evidence around the association between CVD [i.e., stroke, myocardial infarction (MI), atrial fibrillation (AF), and heart failure (HF)] and the risk of developing dementia. Incremental costs and QALY losses were estimated for people by type of CVD compared to the general Australian population without CVD. Of the comprehensive literature search, 19 observational studies were included in the qualitative synthesis. Patients who had CVD incurred both higher healthcare costs over their lifetime (ranging from $73,131 for patients with AF to $127,396 for patients with HF) and fewer QALYs gains (from -1.099 for patients with MI to -5.163 for patients with stroke), compared to people who did not have CVD. The total incremental economic burden of dementia from patients aged 65 years and over with CVD was $6.45 billion (stroke), $11.89 billion (AF), $17.57 billion (MI), or $7.95 billion (HF) over their remaining life expectancy. The results highlighted the importance of CVD prevention to reduce the CVD burden and decrease the prevalence of dementia. Interventions that target patients with dementia risk factors like CVD may prove to be effective and cost-effective strategies.

P8 New Onset Cardiovascular Disease in Australia by Socioeconomic Groups: A Modelling Study

P8 New Onset Cardiovascular Disease in Australia by Socioeconomic Groups: A Modelling Study

Evolution of non-fatal burden estimates for cardiovascular disease in Australia: a comparison of national and state-wide methodology of burden of disease.

Objective Burden of disease studies measure the impact of disease at the population level;however, methods and data sources for estimates of prevalence vary. Using a selection of cardiovascular diseases, we aimed to describe the implications of using different disease models and linked administrative data on prevalence estimation within three Australian burden of disease studies. Methods Three different methods (A = 2011 Australian Burden of Disease Study; B = 2015 Australian Burden of Disease Study; C = 2015 Western Australian Burden of Disease Study), which used linked data, were used to compare prevalence estimates of stroke, aortic aneurysm, rheumatic valvular heart disease (VHD) and non-rheumatic VHD. We applied these methods to 2015 Western Australian data, and calculated crude overall and age-specific prevalence for each condition. Results Overall, Method C produced estimates of cardiovascular prevalence that were lower than the other methods, excluding non-rheumatic VHD. Prevalence of acute and chronic stroke was up to one-third higher in Method A and B compared to Method C. Aortic aneurysms had the largest change in prevalence, with Method A producing an eight-fold higher estimate compared to Method C, but Method B was 10-20% lower. Estimates of VHD varied dramatically, with an up to six-fold change in prevalence in Method C due to substantial changes to disease models and the use of linked data. Conclusions Prevalence estimates require the best available data sources, updated disease models and constant review to inform government policy and health reform. Availability of nation-wide linked data will markedly improve future burden estimates.

Gazing through time and beyond the health sector: Insights from a system dynamics model of cardiovascular disease in Australia.

To construct a whole-of-system model to inform strategies that reduce the burden of cardiovascular disease (CVD) in Australia. A system dynamics model was developed with a multidisciplinary modelling consortium. The model population comprised Australians aged 40 years and over, and the scope encompassed acute and chronic CVD as well as primary and secondary prevention. Health outcomes were CVD-related deaths and hospitalisations, and economic outcomes were the net benefit from both the healthcare system and societal perspectives. The eight strategies broadly included creating social and physical environments supportive of a healthy lifestyle, increasing the use of preventive treatments, and improving systems response to acute CVD events. The effects of strategies were estimated as relative differences to the business-as-usual between 2019-2039. Probabilistic sensitivity analysis produced uncertainty intervals of interquartile ranges (IQR). The greatest reduction in CVD-related deaths was seen in strategies that improve systems response to acute CVD events (8.9%, IQR: 7.7-10.2%), yet they resulted in an increase in CVD-related hospitalisations due to future recurrent admissions (1.6%, IQR: 0.1-2.3%). This flow-on effect highlighted the importance of addressing underlying CVD risks. On the other hand, strategies targeting the broad environment that supports a healthy lifestyle were effective in reducing both hospitalisations (7.1%; IQR: 5.0-9.5%) and deaths (8.1% reduction; IQR: 7.1-8.9%). They also produced an economic net benefit of AU$43.3 billion (IQR: 37.7-48.7) using a societal perspective, largely driven by productivity gains. Overall, strategic planning to reduce the burden of CVD should consider the varying effects of strategies over time and beyond the health sector.

1025Social interaction of middle-aged and older people with and without cardiovascular disease in Australia

Abstract Background Social interaction is important for social wellbeing and may be adversely affected in people with cardiovascular disease (CVD). Large-scale evidence on social interaction among older people with versus without CVD is limited. We quantified and compared social interaction in older people with and without CVD. Methods Survey data (2006-2009) from the 45 and Up Study were linked to hospitalisations data through CHeReL to ascertain CVD status. Four items from the Duke Social Support Index (social-visits/week, telephone-contacts/week, social-group-contact/week, and number of people to depend on) were examined, using generalised linear models to estimate prevalence ratios (PRs) of no social interaction in people with versus without CVD, adjusting for relevant factors, and separately according to CVD subtype and level of physical disability. Results There were 266,504 study participants, 21.4% had CVD. People with CVD were 8%, (95%CI: 5-11%), 7% (2-12%), 4% (3-5%) and 7% (3-11%) more likely than people without CVD to have no social-visits/week, telephone-contacts/week, social-group-meetings/week and people to depend on respectively. The magnitude but not direction of results varied by CVD subtype. People with CVD and severe physical functioning limitations were 30-80% more likely than those with neither of these to have no social interaction. Conclusions Levels of social interaction were slightly lower in people with versus without CVD, but they varied by social interaction items, CVD subtypes, population characteristics and physical disability. Key messages Management to improve quality of life for people living with CVD should consider the role of physical disability for social connectedness.

Cost-Effectiveness of Empagliflozin and Metformin Combination Versus Standard Care as First-Line Therapy in Patients With Type 2 Diabetes Mellitus

ObjectiveSodium-glucose cotransporter 2 inhibitors have been shown to reduce cardiovascular events but are currently not used as the first-line therapy. This study was conducted to evaluate the cost-effectiveness of first-line empagliflozin plus metformin versus metformin monotherapy among Australians with type 2 diabetes mellitus (T2DM) and existing cardiovascular disease (CVD). MethodsA Markov model with 1-year cycles and a 5-year time horizon was constructed to simulate the occurrence of recurrent cardiovascular events among Australians aged 50 to 84 years with T2DM and CVD. Efficacy results were derived from the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients-Removing Excess Glucose trial. Costs and utilities were drawn from published sources. The evaluation adopted both health care and societal perspectives, with the latter ascribing the Australian government’s “value of statistical life year” (A$213 000) to each year lived by a person. Future outcomes were discounted at 5% annually. Sensitivity analyses were conducted to enhance the robustness of conclusions. ResultsCompared with metformin monotherapy, first-line empagliflozin plus metformin reduced overall cardiovascular events by 0.82% and overall deaths by 7.72% over 5 years. There were 0.2 years of life saved per person and 0.16 quality-adjusted life years gained, at a net health care cost of A$4408. These equated to incremental cost-effectiveness ratios of A$22 076 per year of life saved and A$28 244 per quality-adjusted life year gained. The gains in the value of statistical life year equated to A$42 530 per person, meaning that from a societal perspective, the intervention was cost-saving. ConclusionFirst-line empagliflozin plus metformin may represent a cost-effective strategy for the management of T2DM and CVD in Australia.

National Heart Foundation of Australia: position statement on coronary artery calcium scoring for the primary prevention of cardiovascular disease in Australia.

IntroductionThis position statement considers the evolving evidence on the use of coronary artery calcium scoring (CAC) for defining cardiovascular risk in the context of Australian practice and provides advice to health professionals regarding the use of CAC scoring in primary prevention of cardiovascular disease in Australia.Main recommendations: CAC scoring could be considered for selected people with moderate absolute cardiovascular risk, as assessed by the National Vascular Disease Prevention Alliance (NVDPA) absolute cardiovascular risk algorithm, and for whom the findings are likely to influence the intensity of risk management. (GRADE evidence certainty: Low. GRADE recommendation strength: Conditional.)CAC scoring could be considered for selected people with low absolute cardiovascular risk, as assessed by the NVDPA absolute cardiovascular risk algorithm, and who have additional risk-enhancing factors that may result in the underestimation of risk. (GRADE evidence certainty: Low. GRADE recommendation strength: Conditional.)If CAC scoring is undertaken, a CAC score of 0 AU could reclassify a person to a low absolute cardiovascular risk status, with subsequent management to be informed by patient–clinician discussion and follow contemporary recommendations for low absolute cardiovascular risk. (GRADE evidence certainty: Very low. GRADE recommendation strength: Conditional.)If CAC scoring is undertaken, a CAC score > 99 AU or ≥ 75th percentile for age and sex could reclassify a person to a high absolute cardiovascular risk status, with subsequent management to be informed by patient–clinician discussion and follow contemporary recommendations for high absolute cardiovascular risk. (GRADE evidence certainty: Very low. GRADE recommendation strength: Conditional.) Changes in management as a result of this statementCAC scoring can have a role in reclassification of absolute cardiovascular risk for selected patients in Australia, in conjunction with traditional absolute risk assessment and as part of a shared decision‐making approach that considers the preferences and values of individual patients.

Future burden of cardiovascular disease in Australia: impact on health and economic outcomes between 2020 and 2029.

To estimate the health and economic burden of new and established cardiovascular disease from 2020 to 2029 in Australia. A two-stage multistate dynamic model was developed to predict the burden of the incident and prevalent cardiovascular disease, for Australians 40-90 years old from 2020 to 2029. The model captured morbidity, mortality, years of life lived, quality-adjusted life years, healthcare costs, and productivity losses. Cardiovascular risk for the primary prevention population was derived using Australian demographic data and the Pooled Cohort Equation. Risk for the secondary prevention population was derived from the REACH registry. Input data for costs and utilities were extracted from published sources. All outcomes were annually discounted by 5%. A number of sensitivity analyses were undertaken to test the robustness of the study. Between 2020 and 2029, the model estimates 377 754 fatal and 991 375 non-fatal cardiovascular events. By 2029, 1 061 756 Australians will have prevalent cardiovascular disease (CVD). The population accrued 8 815 271 [95% uncertainty interval (UI) 8 805 083-8 841 432] years of life lived with CVD and 5 876 975 (5 551 484-6 226 045) QALYs. The total healthcare costs of CVD were projected to exceed Australian dollars (AUD) 61.89 (61.79-88.66) billion, and productivity losses will account for AUD 78.75 (49.40-295.25) billion, driving the total cost to surpass AUD 140.65 (123.13-370.23) billion. Cardiovascular disease in Australia has substantial impacts in terms of morbidity, mortality, and lost revenue to the healthcare system and the society. Our modelling provides important information for decision making in relation to the future burden of cardiovascular disease.

Lifetime Costs of Hospitalised Cardiovascular Disease in Australia: An Incidence-Based Estimate

To estimate the incidence-based, lifetime costs of health care and productivity losses associated with cardiovascular disease (CVD) using hospital admission data from Queensland, Australia. Retrospective analysis of data on CVD health care use sourced from Queensland Hospital Admitted Patient Data Collection (QHAPDC), Emergency Department Data Collection (EDDC), Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS). Costs were estimated from the societal perspective. Study participants included patients who were first admitted to any Queensland hospital in 2010 for a CVD-related treatment. Subsequent admissions of these patients were followed until December 2015. The present value of incidence-based lifetime costs per patient were used to estimate the total costs for Australia. All costs were presented in Australian dollars at 2019 prices. The estimated lifetime health care cost of CVD was AUD$65,700 per person. Productivity loss cost was higher at AUD$75,200 per person, and total indirect lifetime costs were $140,900 per person. Scaling these costs up for the Australian population, the estimated incidence-based lifetime CVD costs for Australia were $60.5 billion ($28.2 billion in direct costs and $32.3 billion in indirect costs). Incidence-based lifetime indirect costs of CVD were higher than the direct costs. The life-time cost structure suggests that economic benefits of health care interventions for cardiovascular diseases from a societal perspective should be at least twice as large than that from a health service perspective.

Age-related Differences in the Receipt of Primary Healthcare Services in Managing Contemporary Patients with Cardiovascular Disease in Australia

Ensuring equity of access to primary healthcare services is a goal of the Australian health system. However, access to primary healthcare services for different cardiovascular disease (CVD) age groups appears to be variable.

How coronary artery catheterisation has influenced cardiovascular nursing – An historical Australian perspective

ABSTRACT Background Cardiovascular nursing has emerged as a vital specialty area in Australia with coronary artery disease having a significant impact on the health care system. Coronary catheterisation and interventions are currently the gold standard for the diagnosis and management of patients with coronary artery disease and has been conducted globally for the past 80 years. Aim This review details the events that led to the historical development of coronary artery catheterisation along with highlights and developments that occurred in Australia and how this has influenced the development of cardiovascular nursing in Australia and potential future directions for expansion. Method Historical methods using both primary and secondary sources were used. Initially secondary sources were accessed to create a timeline of potential archive locations to access. Primary sources of documentation in relation to nursing development in this area were scarce or otherwise included minimal information. Findings and discussion The history of coronary angiography extends to over five decades in Australia. It was first performed in Australia in 1962 by Dr Benness at St Vincent’s Hospital in Sydney. Since then as a result of continuing research, technological and medication-related advancements, there have been numerous changes in technique, materials used and indications for the procedure. These advances in technology have resulted in reduced complication rates, increased patient satisfaction and patient safety. Conclusion Developments started slowly and were clouded in ridicule for the pioneers in this area, these international developments have had a significant impact on the Australian population and evolution of treatment for cardiovascular disease in Australia. Associated advancements afforded developments in nursing practice and allowed nurses to work at extended scopes of practice and saw the new roles for nursing

Queensland Cardiovascular Data Linkage (QCard): A population-based cohort study

Queensland is Australia's hotspot for cardiovascular disease (CVD). Critically, beyond modifiable lifestyle risk factors; socio-demographic differences and environmental factors account for significant variations in healthcare use and outcomes among cardiac patients across the country. To better understand the impacts of these factors on the health of cardiac patients, there is a need for a comprehensive and robust longitudinal cohort study that can unpack the underlying dynamics. This paper describes the protocol for the Queensland Cardiovascular Linkage (QCard) Study. The QCard is a longitudinal linkage cohort study of cardiac patients who were first hospitalised with any cardiac condition in 2010, with follow up hospitalisations until December 2015. The primary aim of the QCard is to identify and characterise the nature and impact of socio-demographic inequality among those presenting for the first time with the most common form of CVD in Australia (heart disease) in Queensland from 2010 with minimum 5-years follow-up of subsequent healthcare utilisation and outcomes. A secondary aim is to undertake an exploration of the impact of environmental and specific health service factors on healthcare use and survival time in the same QCard cohort. Administrative public and private hospital inpatient, outpatient and emergency department data for all of Queensland will be linked with individual primary care data and pharmaceutical data. These data will also be linked to regional socio-demographic data and environmental data, as well as data that describes the features of each hospital in the region. The findings from the study will provide critical information for cardiac patients, clinicians and health policymakers. Such information ranges from identifying most vulnerable cardiac patients who may require targeted needs to providing estimates for cost-effective ways of evaluating healthcare interventions that seek to improve the health of cardiac patients.

Responsibility for evidence-based policy in cardiovascular disease in rural communities: implications for persistent rural health inequalities.

Objective The aim of this study was to understand, from the perspective of policy makers, who holds the responsibility for driving evidence-based policy to reduce the high burden of cardiovascular disease (CVD) in rural Australia. Methods Qualitative interviews were conducted with policy makers at the local, state and federal government levels in Australia (n=21). Analysis was conducted using the Conceptual Framework for Understanding Rural and Remote Health to understand perceptions of policy makers around who holds the key responsibility in driving evidence-based policy. Results At all levels of government, there were multiple examples of disconnect in the understanding of who is responsible for driving the generation of evidence-based policy to reduce CVD in rural areas. Policy makers suggested that the rural communities themselves, health services, health professionals, researchers and the health sector as a whole hold large responsibilities in driving evidence-based policy to address CVD in rural areas. Within government, there was also a noticeable disconnect, with local participants feeling it was the federal government that held this responsibility; however, federal government participants suggested this was largely a local government issue. Overall, there seemed to be a lack of responsibility for CVD policy, which is reflected in a lack of action in rural areas. Conclusion There was a lack of clarity about who is responsible for driving evidence-based policy generation to address the high burden of CVD in Australia, providing one possible explanation for the lack of policy action. Clarity among policy makers over shared roles and leadership for policy making must be addressed to overcome the current burden of CVD in rural communities. What is known about the topic? Rural health inequalities, such as the increased burden of CVD in rural Australia are persistent. Such health inequalities are unjust, with global theory suggesting political processes have facilitated, in part, the inequalities. With similar examples observed internationally in rural areas, little is known about the influence of the perspectives of policy makers regarding who is responsible for addressing health issues in rural areas, in the government context. What does this paper add? This paper provides empirical evidence, for all levels of government in Australia, that there is a lack of clarity in policy roles and responsibilities to address the unequal burden of CVD in rural Australia, at all levels of government. The paper provides evidence to support the urgent need for clarity within government around policy stakeholder roles. Without such clarity, it is unlikely that national-level progress in addressing rural health inequalities will be achieved in the near future. What are the implications for practitioners? Addressing ambiguity around who is responsible for the development of evidence-based policy to address the high burden of CVD in rural areas must be a high priority to ensure health disparities do not persist for future Australian generations. The results reported here are highly relevant to the Australian context, but also reflect similar findings internationally, namely that a lack of clarity among policy stakeholders appears to contribute to reduced action in addressing preventable health inequalities in disadvantaged populations. This paper provides evidence for policy makers and public health professionals to advocate for clear policy roles and direction in rural Australia.

548 Secondary Prevention of Cardiovascular Disease in Australia - an Update

548 Secondary Prevention of Cardiovascular Disease in Australia - an Update