In this issue of the Journal Ellis et al1,2 report a repeat, 5 years later, of their original 2002 study3,4 in which they examined the treatment of acute coronary syndromes (ACS) both nationally, and by comparison of hospitals with and without facilities for invasive cardiac examination and treatment. They found that little had changed over the period 2002-7.While the use of coronary angiography and percutaneous balloon angioplasty had increased in New Zealand, neither was used as frequently as in Australia, Europe or the USA. Patients treated in non-intervention hospitals had equal access to invasive procedures, but access was delayed for those in the smaller hospitals. Most important, prescription of most state of the art drugs for secondary prevention was widely followed both in 2002 and 2007. The exception, due to funding restrictions, was clopidogrel.Ellis et al are to be congratulated for their pioneering efforts in bringing the audit process to bear on the most numerous and important group of medical patients admitted as emergencies to New Zealand hospitals; also on their recognition of the principle that audits should be compared over time and that individual performances should be compared so that those who do badly can learn from those who do well.In this respect, clinicians in the smaller hospitals performed as well as their colleagues in the larger hospitals by referring patients for coronary angiography, albeit with inevitably increased delay. The authors suggest that this delay might be reduced by adoption of a formalised "hub and spoke" approach whereby patients from smaller hospitals are referred to the five major hospitals which are fully equipped for invasive investigation and treatment..There are, however, caveats to interpretation of the study by Ellis et al. First, international comparisons of the use of invasive study and revascularisation do not necessarily imply that New Zealand hospitals should strive to achieve the highest rates. Although invasive revascularisation can be lifesaving, is the treatment of choice for acute ST elevation myocardial infarction, and is efficacious for relief of angina, it does not prevent reinfarction,5 because sites of vulnerable atherosclerotic plaques do not correspond with the sites of critical stenoses as defined by angiography.6Decisions to revascularise based on angiographic appearances rather than on real clinical need do not result in benefits to patients,7 nor does opening of a chronically occluded infarct-related artery.8 Anecdotal evidence suggests that revascularisation can be overused, particularly in parts of the USA. Moreover, coronary atherosclerosis can regress with secondary prevention, particularly with statins.9The second caveat applies, in the opinion of this reviewer, not only to the study by Ellis et al , but also to most if not all other audits of ACS. We pointed out some years ago10that, although defibrillation prevented four times as many deaths as thrombolytic treatment in ACS, it had been undervalued in the literature because it was not "evidence based"; it had never been subjected to clinical trial.Evidence for the greater efficacy of defibrillation came from two UK audits during the 1990s,11,12 which also showed that numbers of deaths prevented by defibrillation were critically dependent on delay from onset of symptoms to coming under care, and that 30-40% of successful defibrillations were performed outside hospital by ambulance personnel. If this evidence is accepted, audits of ACS should include success of defibrillation and should also examine delay in coming under care and the vitally important pre-hospital phase of ACS. A pilot study of delay has recently been reported from Middlemore Hospital in Auckland.13What should be the future of audit of ACS in NZ? Because the structure of the British National Health Service (NHS) is in many ways most comparable with the NZ Health Service, the British (England and Wales) National Audit of Myocardial Ischaemia (MINAP),14 although surprisingly not referred to by the authors, probably offers the best guide. MINAP, involving 210 hospitals, has been operating continuously for 10 years, has recorded data on more than 700,000 episodes of ACS, and has been associated with remarkable improvements in delivery of treatment, at first in reductions in delay to thrombolytic treatment, and more recently in the organization of the "hub and spoke" principle to primary angioplasty (PPCI).It is anticipated that in 2010 the majority of patients with ST elevation MI will be treated by PPCI. Classification of individual hospitals by their performance in treatment of ACS is recorded and is in the public domain. Similarly, information on performance of individual cardiac surgeons is available to the public,15 and it is planned to extend this to performance of invasive cardiologists. This culture of transparency is now an integral part of the NHS. Should a similar culture be adopted in New Zealand?What MINAP does not do, is to document the characteristics of the victims and the circumstances of death of the great majority of fatalities from ACS which happen outside hospital. Surprisingly, there are few or no data on this since the international MONICA study of 25 years ago16 and our own UK Heart Attack Study (UKHAS) of 15 years ago11,17 which showed that 74% of fatal events in people under 75 years of age happened outside hospital.The good news, according to official figures, is that mortality from coronary heart disease has fallen by more than 50% in the UK over the last 15 years.18 We are currently planning a repeat of UKHAS, which we hope will cast light on the mechanisms by which this has happened.

In this issue of the Journal Ellis et al1,2 report a repeat, 5 years later, of their original 2002 study3,4 in which they examined the treatment of acute coronary syndromes (ACS) both nationally, and by comparison of hospitals with and without facilities for invasive cardiac examination and treatment. They found that little had changed over the period 2002-7.While the use of coronary angiography and percutaneous balloon angioplasty had increased in New Zealand, neither was used as frequently as in Australia, Europe or the USA. Patients treated in non-intervention hospitals had equal access to invasive procedures, but access was delayed for those in the smaller hospitals. Most important, prescription of most state of the art drugs for secondary prevention was widely followed both in 2002 and 2007. The exception, due to funding restrictions, was clopidogrel.Ellis et al are to be congratulated for their pioneering efforts in bringing the audit process to bear on the most numerous and important group of medical patients admitted as emergencies to New Zealand hospitals; also on their recognition of the principle that audits should be compared over time and that individual performances should be compared so that those who do badly can learn from those who do well.In this respect, clinicians in the smaller hospitals performed as well as their colleagues in the larger hospitals by referring patients for coronary angiography, albeit with inevitably increased delay. The authors suggest that this delay might be reduced by adoption of a formalised "hub and spoke" approach whereby patients from smaller hospitals are referred to the five major hospitals which are fully equipped for invasive investigation and treatment..There are, however, caveats to interpretation of the study by Ellis et al. First, international comparisons of the use of invasive study and revascularisation do not necessarily imply that New Zealand hospitals should strive to achieve the highest rates. Although invasive revascularisation can be lifesaving, is the treatment of choice for acute ST elevation myocardial infarction, and is efficacious for relief of angina, it does not prevent reinfarction,5 because sites of vulnerable atherosclerotic plaques do not correspond with the sites of critical stenoses as defined by angiography.6Decisions to revascularise based on angiographic appearances rather than on real clinical need do not result in benefits to patients,7 nor does opening of a chronically occluded infarct-related artery.8 Anecdotal evidence suggests that revascularisation can be overused, particularly in parts of the USA. Moreover, coronary atherosclerosis can regress with secondary prevention, particularly with statins.9The second caveat applies, in the opinion of this reviewer, not only to the study by Ellis et al , but also to most if not all other audits of ACS. We pointed out some years ago10that, although defibrillation prevented four times as many deaths as thrombolytic treatment in ACS, it had been undervalued in the literature because it was not "evidence based"; it had never been subjected to clinical trial.Evidence for the greater efficacy of defibrillation came from two UK audits during the 1990s,11,12 which also showed that numbers of deaths prevented by defibrillation were critically dependent on delay from onset of symptoms to coming under care, and that 30-40% of successful defibrillations were performed outside hospital by ambulance personnel. If this evidence is accepted, audits of ACS should include success of defibrillation and should also examine delay in coming under care and the vitally important pre-hospital phase of ACS. A pilot study of delay has recently been reported from Middlemore Hospital in Auckland.13What should be the future of audit of ACS in NZ? Because the structure of the British National Health Service (NHS) is in many ways most comparable with the NZ Health Service, the British (England and Wales) National Audit of Myocardial Ischaemia (MINAP),14 although surprisingly not referred to by the authors, probably offers the best guide. MINAP, involving 210 hospitals, has been operating continuously for 10 years, has recorded data on more than 700,000 episodes of ACS, and has been associated with remarkable improvements in delivery of treatment, at first in reductions in delay to thrombolytic treatment, and more recently in the organization of the "hub and spoke" principle to primary angioplasty (PPCI).It is anticipated that in 2010 the majority of patients with ST elevation MI will be treated by PPCI. Classification of individual hospitals by their performance in treatment of ACS is recorded and is in the public domain. Similarly, information on performance of individual cardiac surgeons is available to the public,15 and it is planned to extend this to performance of invasive cardiologists. This culture of transparency is now an integral part of the NHS. Should a similar culture be adopted in New Zealand?What MINAP does not do, is to document the characteristics of the victims and the circumstances of death of the great majority of fatalities from ACS which happen outside hospital. Surprisingly, there are few or no data on this since the international MONICA study of 25 years ago16 and our own UK Heart Attack Study (UKHAS) of 15 years ago11,17 which showed that 74% of fatal events in people under 75 years of age happened outside hospital.The good news, according to official figures, is that mortality from coronary heart disease has fallen by more than 50% in the UK over the last 15 years.18 We are currently planning a repeat of UKHAS, which we hope will cast light on the mechanisms by which this has happened.