7th April 2017, Volume 130 Number 1453

John Elliott, Tom Kai Ming Wang, Greg Gamble, Michael Williams, Philip Matsis, Richard Troughton, Andrew Hamer, Gerry Devlin, Stewart Mann, Mark Richards, John French, Harvey White, Chris Ellis

Cardiovascular disease remains the leading cause of death globally at 31% in 2012.1 In New Zealand, cardiovascular disease accounted for 33% of all deaths in 2013.2 Diagnosis and management of…

Subscriber content

The full contents of this page is only available to subscribers.

To view this content please login or subscribe


The presentation with a ‘STEMI’ heart attack is a dangerous medical event. Even by 2012, approximately 7% of those who reach hospital die. The 2002 National heart attack and unstable angina audit was run by cardiologists and specialist physicians who wanted to record the low levels of service available. This audit shocked the Health Ministry into action, with subsequent audits from 2007 and 2012 demonstrating ongoing improvements in services available to manage patients, which the paper describes. However, the paper also describes the need for ongoing improvements from 2012, especially in the rapid access to a cardiac angiogram, with a stent or cardiac surgery for those who need this treatment. This should occur within 24 hours.



To audit the management of ST-segment elevation myocardial infarction (STEMI) patients admitted to a New Zealand Hospital over three 14-day periods to review their number, characteristics, management and outcome changes over a decade.


The acute coronary syndrome (ACS) audits were conducted over 14 days in May of 2002, 2007 and 2012 at New Zealand Hospitals admitting patients with a suspected or definite ACS. Longitudinal analyses of the STEMI subgroup are reported.


From 2002 to 2012, the largest change in management was the proportion of patients undergoing reperfusion by primary PCI from 3% to 15% and 41%; P<0.001, and the rates of second antiplatelet agent use in addition to aspirin from 14% to 62% and 98%; P<0.001. The use of proven secondary prevention medications at discharge also increased during the decade. There were also significant increases in cardiac investigations for patients, especially echocardiograms (35%, 62% and 70%, P<0.001) and invasive coronary angiograms (31%, 58% and 87%, P<0.001). Notably even in 2012, one in four patients presenting with STEMI did not receive any reperfusion therapy.


Substantial improvements have been seen in the management of STEMI patients in New Zealand over the last decade, in accordance with evidenced-based guideline recommendations. However, there appears to be considerable room to optimise management, particularly with the use of timely reperfusion therapy for more patients.

Author Information

John M Elliott, Cardiologist, Christchurch Hospital, Christchurch; Tom Kai Ming Wang, Cardiology Registrar, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland; Greg D Gamble, Statistician, University of Auckland, Auckland; Michael JA Williams, Cardiologist, Dunedin Hospital, Dunedin; Philip Matsis, Cardiologist, Wellington Hospital, Wellington; Richard Troughton, Cardiologist, Christchurch Hospital, Christchurch; Andrew Hamer, Cardiologist, Nelson Hospital, Nelson; Gerry Devlin, Cardiologist, Waikato Hospital, Hamilton; Stewart Mann, Cardiologist, Wellington Hospital, Wellington; Mark Richards, Cardiologist, Christchurch Hospital, Christchurch; John K French, Cardiologist, Liverpool Hospital, SW Sydney Clinical School (UNSW) Sydney, Australia; Harvey D White, Cardiologist, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland; Chris J Ellis, Cardiologist, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland. For the NZ Regional Cardiac Society ACS Audit Group.


The authors would like to thank the many investigators who assisted with the three National audits, and who are acknowledged in each of the three primary papers.


Dr Chris Ellis, Cardiologist, Green Lane Cardiovascular Service, Auckland City Hospital, Grafton, Auckland 1023.

Correspondence Email


Competing Interests

Dr Hamer reports affiliation with Capricor Inc and Amgen Inc outside the submitted work. A part of Dr Hamer's income was reimbursed to Nelson Marlborough District Health Board by the Ministry of Health for New Zealand Cardiac Network responsibilities during the time that this research was performed; Dr White reports grants and non-financial support from GlaxoSmithKline during the conduct of the study, grants from Sanofi Aventis, grants from Eli Lilly and Company, grants from National Institute of Health, grants from Merck Sharpe and Dohm, grants and personal fees from AstraZeneca, grants from Omthera Pharmaceuticals, grants from Pfizer New Zealand, grants from Intarcia Therapeutics Inc, grants from Elsai Inc and grants from DalGen Products and Services outside the submitted work.


  1. World Health Organisation 2016. Cardiovascular diseases. http://www.who.int/mediacentre/factsheets/fs317/en/ (accessed 31/05/2016)
  2. New Zealand Ministry of Health 2015. Mortality 2013 online tables. http://www.health.govt.nz/publication/mortality-2013-online-tables (accessed 31/05/2016) 
  3. ST-Elevation Myocardial Infarction Guidelines Group and the New Zealand Branch of the Cardiac society of Australia and New Zealand. ST-elevation myocardial infarction: New Zealand management guidelines. NZ Med J. 2013; 126 (1387). URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2013/vol-126-no-1387/5953 
  4. Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012; 33:2569–2619.
  5. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013; 61(4):e78–e140.
  6. Ellis C, Gamble G, French J, et al. Management of patients admitted with an acute coronary syndrome in New Zealand: results of a comprehensive nationwide audit. NZ Med J. 2004; 117(1197): URL: http://www.nzma.org.nz/__data/assets/pdf_file/0003/17958/Vol-117-No-1197-09-July-2004.pdf
  7. Ellis C, Gamble G, Hamer A, et al. Patients admitted with an acute coronary syndrome in New Zealand in 2007: results of a second comprehensive nationwide audit and a comparison with the first audit from 2002. NZ Med J. 2010; 123(1319). URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2010/vol-123-no-1319/article-ellis
  8. Chew DP, French J, Briffa TG, et al: Acute Coronary Syndrome Care across Australia and New Zealand: the SNAPSHOT ACS study. MJA 2013; 199:1–7. doi: 10.5694/mja12.11854. 
  9. Ellis C, Gamble G, Devlin G, et al: The management of acute coronary syndrome patients across New Zealand in 2012: results of a third comprehensive nationwide audit and observations of current interventional care. N Z Med J. 2013; 126(1387):36–68. URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2013/vol-126-no-1387/5939
  10. Guidelines for an Accredited Institutional Ethics Committee to refer Studies to an Accredited Health and Disability Ethics Committee (“Referral Guidelines”) Guidelines of the HRC Ethics Committee Updated 2008 (http://www.hrc.govt.nz/assets/pdfs/FINAL%20Referral% 20Guidelines.pdf accessed 26 August 2010).
  11. Ranchord AM , Prasad S, Matsis P, Harding SA. Paramedic-administered prehospital thrombolysis is safe and reduces time to treatment. N Z Med J. 2009 Sep 11; 122(1302):47–53.
  12. Elliott J, Richards M. Heart attacks and unstable angina (acute coronary syndromes) have doubled in New Zealand since 1989: how do we best manage the epidemic? N Z Med J. 2005 Oct 7; 118(1223):U1674.
  13. White HD. Systems of Care: Hub and Spoke for both Primary PCI and Angioplasty Following Fibrinolysis. Circulation. 2008; 118(3); 219–222. 
  14. Ellis CJ, Hamer AW. Cardiovascular health in New Zealand: areas of concern and targets for improvement in 2008 and beyond. N Z Med J. 2008 Feb 15; 121(1269):5–10.
  15. White HD. Systems of Care: Need for Hub and Spoke systems of care for patients with myocardial infarction: A Call for Action. N Z Med J. 2010; 123(1309):7–10. 
  16. Ellis C, Hammett C, Ranasinghe I, et al. Bi-National Acute Coronary Syndromes (ACS) SNAPSHOT Audit Group. Comparison of the management and in-hospital outcomes of acute coronary syndrome patients in Australia and New Zealand: results from the binational SNAPSHOT acute coronary syndrome 2012 audit. Intern Med J. 2015 May;45(5):497-509. doi: 10.1111/imj.12739. 
  17. Kerr AJ, Williams MJA, Harding S, et al. The All New Zealand Acute Coronary Syndrome Quality Improvement Programme: Implementation, Methodology and Cohorts (ANZACS-QI 9) N Z Med J. 2016; 129(1439):23–36. URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no-1439-5-august-2016/6959
  18. Farshid A, Brieger D, Hyun K, et al. Characteristics and Clinical Course of STEMI Patients who Received no Reperfusion in the Australia and New Zealand SNAPSHOT ACS Registry. Heart Lung Circ. 2016 (25):132–129. 
  19. Buckley B, White S, Poppe K, Whalley G. (2013). The cardiac sonography workforce in New Zealand. Australas J Ultrasound Med 2013; Vol. 16(2). http://hdl.handle.net/10652/2594 
  20. Buckley BA, Poppe K, Farnworth MJ, Whalley GA. Regional differences in echocardiography provision in New Zealand: results from the 2013 SCANZ Workforce Survey. NZ Med J 2015; Vol. 128(1408):47–55. URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2015/vol-128-no-1408/6414
  21. Yusuf S, Zhao F, Mehta SR, et al. Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345:494–502. 
  22. White H, Ellis C. PHARMAC and lack of funding for clopidogrel. N Z Med J. 2006; 119(1228). URL: http://www.nzma.org.nz/__data/assets/pdf_file/0003/17859/Vol-119-No-1228-27-January-2006.pdf
  23. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009; 361:1045–57.


The downloadable PDF version of this article is only available to subscribers.

To view this content please login or subscribe