Background To describe the long-term mortality of a complete national cohort of acute coronary syndrome (ACS) patients enrolled in 2002, to compare this with a national age, sex and Maori ethnicity matched population, and to assess the influence of baseline factors on the 12-year mortality. Methods We reviewed 721 patients with a discharge diagnosis of an ACS who were enrolled in the first New Zealand ACS audit group cohort over 14 days in May 2002. We matched the cohort to the national mortality database using each patient's unique national identity number. Results Over a median follow-up of 12.7 years of 721 patients discharged with an ACS, overall mortality was 52%: ST-elevation myocardial infarction (STEMI) (58%), non-ST-elevation myocardial infarction (NSTEMI) (61%) and unstable angina pectoris (UAP) (42%) patients, p < 0.0001. In an age-adjusted survival model, males had a 29% increased mortality rate compared to females with a hazard ratio of 1.29 (95% CI 1.04, 1.61, p = 0.019). Over 12 years there were 339 (47%) deaths, compared to 284 (39%) deaths observed in the matched population. The standardised mortality ratio for patients admitted with an ACS in New Zealand is 1.3 (95% CI 1.2, 1.5) with eight patients per 100 not surviving to 12 years compared to this matched population. Conclusion The high mortality rate in this ACS cohort is a stark reminder of the prognostic implications of a presentation with an ACS. It emphasises the on-going need for optimal management of these patients throughout every stage of their initial treatment and subsequent on-going care.

This study aimed to describe blood pressure (BP) and hypertension (HT) in samples of high altitude populations of Nepal and to explore associations of systolic and diastolic BP with altitude. This was a cross-sectional survey of cardiovascular disease and associated risk factors among 521 people living at four different altitude levels, all above 2800 m, in the Mustang and Humla districts of Nepal. Data on BP was available for all 521 participants. Systolic and diastolic BP levels were highest at the altitude of 3620 m (the highest area surveyed) but did not consistently increase with altitude. Using the cut-point of ≥ 140/90 mmHg (systolic/diastolic), the prevalence of HT (or on anti-hypertensive medication) was 46.1%, 40.9% and 54.5%, respectively, at 2800, 3270 and 3620 m of Mustang district, and 29.1% at 2890 m of Humla district. In a multivariate model adjusting for potential confounders, there was strong evidence of a relationship between systolic BP and altitude; mean systolic BP increased by 15.6 mmHg (95% CI: 4.0–27.2), P = 0.009 for every 1000 m elevation. Although diastolic BP and the probability for HT or on anti-hypertensive medication also tended to increase with increasing altitude levels, there was no evidence of a relationship. In the present study three out of four communities living at higher altitude levels showed a greater prevalence of HT among those aged 30 years or older compared with the overall national data. These findings indicate a probable high risk of raised BP in high altitude populations in Nepal.

AIMS 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

This study aimed to describe lipid profiles and the distribution of glycated hemoglobin (HbA1c) in a sample of a high altitude population of Nepal and to explore associations between these metabolic risk variables and altitude. A cross-sectional survey of cardiovascular disease and associated risk factors was conducted among 521 people living at four different altitude levels, all above 2800 m, in the Mustang and Humla districts of Nepal. Urban participants (residents at 2800 m and 3620 m) had higher total cholesterol (TC) and triglyceride (TG) than rural participants. A high ratio of TC to high-density lipoprotein-cholesterol (HDL) (TC/HDL ≥ 5.0) was found in 23.7% (95% CI 19.6, 28.2) and high TG (≥1.7 mmol/L) in 43.3% (95% CI 38.4, 48.3) of participants overall. Mean HbA1c levels were similar at all altitude levels although urban participants had a higher prevalence of diabetes. Overall, 6.9% (95% CI 4.7, 9.8) of participants had diabetes or were on hypoglycaemic treatment. There was no clear association between lipid profiles or HbA1c and altitude in a multivariate analysis adjusted for possible confounding variables. Residential settings and associated lifestyle practices are more strongly associated with lipid profiles and HbA1c than altitude amongst high altitude residents in Nepal.

OBJECTIVE:The main objective of this study was to estimate the prevalence of coronary heart disease (CHD) of high-altitude populations in Nepal determined by an ECG recordings and a medical history. METHODS:We carried out a cross-sectional survey of cardiovascular disease and risk factors among people living at four different altitude levels, all above 2800 m, in the Mustang and Humla districts of Nepal. 12-lead ECGs were recorded on 485 participants. ECG recordings were categorised as definitely abnormal, borderline or normal. RESULTS:No participant had Q waves to suggest past Q-wave infarction. Overall, 5.6% (95% CI 3.7 to 8.0) of participants gave a self-report of CHD. The prevalence of abnormal (or borderline abnormal) ECG was 19.6% (95% CI 16.1 to 23.4). The main abnormalities were: right axis deviation in 5.4% (95% CI 3.5 to 7.7) and left ventricular hypertrophy by voltage criteria in 3.5% (95% CI 2.0 to 5.5). ECG abnormalities were mainly on the left side of the heart for Mustang participants (Tibetan origin) and on the right side for Humla participants (Indo-Aryans). There was a moderate association between the probability of abnormal (or borderline abnormal) ECG and altitude when adjusted for potential confounding variables in a multivariate logistic model; with an OR for association per 1000 m elevation of altitude of 2.83 (95% CI 1.07 to 7.45), p=0.03. CONCLUSIONS:Electrocardiographic evidence suggests that although high-altitude populations do not have a high prevalence of CHD, abnormal ECG findings increase by altitude and risk pattern varies by ethnicity.

Parkinson's disease (PD) is a common neurodegenerative disorder caused by the loss of dopaminergic neurons in the substantia nigra. The pathophysiology of this disease is the formation of the Lewy body, mostly consisting of alpha-synuclein and dysfunctional mitochondria. There are two common PD-associated genes, Pink1 (encoding a mitochondrial ser/thr kinase) and Parkin (encoding cytosolic E3-ubiquitin ligase), involved in the mitochondrial quality control pathway. They assist in removing damaged mitochondria via selective autophagy (mitophagy) which if unchecked, results in the formation of protein aggregates in the cytoplasm. The role of Rab11, a small Ras-like GTPase associated with recycling endosomes, in PD is still unclear. In the present study, we used the PD model of Drosophila melanogaster and found that Rab11 has a crucial role in the regulation of mitochondrial quality control and endo-lysosomal pathways in association with Parkin and Pink1 and Rab11 acting downstream of Parkin. Additionally, overexpression of Rab11 in parkin mutant rescued the mitochondrial impairment, suggesting the therapeutic potential of Rab11 in PD pathogenesis.

Aryal, Nirmal, Mark Weatherall, Yadav Kumar Deo Bhatta, and Stewart Mann. Blood pressure and hypertension in adults permanently living at high altitude: a systematic review and meta-analysis. High Alt Med Biol. 17:185-193, 2016.-The objective of this study was to estimate the associations between altitude and mean blood pressure (BP) (or prevalence of hypertension [HT]) in adults who live permanently at high altitude. A literature search was conducted in December 2014 using PubMed, Scopus, and OvidSP (MedLine and EMBASE) databases to identify relevant observational studies. Inclusion criteria were reports of studies in populations permanently living at an altitude of ≥2400 m and in those 18 years or older. Meta-regression was used to estimate the association between average BP and HT and altitude. We identified 3375 articles and inclusion criteria were met for 21 reports, which included a total of 40,854 participants. Random-effects meta-regression estimated that for every 1000 m elevation the average systolic BP (SBP) (95% confidence interval [CI]) increased by 17 mmHg (0.2 to 33.8), p = 0.05 and diastolic BP (DBP) by 9.5 mmHg (0.6 to 18.4), p = 0.04 in participants with Tibetan origin. By contrast, in participants with non-Tibetan origin, average SBP decreased by 5.9 mmHg (-19.1 to 7.3), p = 0.38 and DBP by 4 mmHg (-13 to 5), p = 0.38. The odds ratios (95% CI) for the proportion of participants with HT per 1000 m increment in the altitude were 2.01 (0.37 to 11.02), p = 0.446 and 4.05 (0.07 to 244.69), p = 0.489 for Tibetan and non-Tibetan participants, respectively. Sensitivity analysis excluding two studies with older participants (≥60 years) reversed the direction of this effect in non-Tibetans with odds ratio (95% CI) of 0.10 (0.004 to 2.22) per 1000 m, p = 0.143. Overall, this review suggests weak association between BP and altitude in Tibetan origin populations.

Background: Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in New Zealand (NZ), accounting for 40% of all deaths, with Maori, Pacific Island and Indo-Asian populations experiencing greater CVD morbidity and mortality. In 2012, the NZ Ministry of Health implemented a program for primary health care to undertake Cardiovascular Disease Risk Assessment’ (CVDRA) in a group defined by age, sex and ethnicity. We wished to better understand factors influencing the uptake of CVDRA and any subsequent recommendations, Methods: We approached consecutive patients admitted to Wellington Hospital with a first presentation of an acute coronary syndrome. We then selected patients who consented to a semi-structured qualitative interview about their knowledge and experience of CVDRA. Interviews were digitally recorded, transcribed verbatim and analysed using grounded theory and thematic coding to identify key themes. Results: Six themes were identified: factors (motivators or barriers) influencing attendance of CVDRA and the uptake of subsequent recommendations; the importance of understanding the implications of the estimated cardiovascular risk; the relevance of the doctor-patient relationship and the necessity of effective discussion regarding CVDRA outcomes. A further widespread theme was the underestimation of personal risk of CVD. Conclusion: Our findings suggest that there is potential to improve the overall effectiveness of CVDRA and translate it into management. Identified motivators and barriers can be used to increase CVDRA attendance and the uptake of interventions. Allowing time for discussion regarding personal risk and the implications of risk scores would also offer potential to improve effectiveness of the process.

Background: In 2012 the New Zealand Ministry of Health made cardiovascular risk assessment (CVDRA) a health target aiming for ∼90% of the eligible population to be screened by 2014. This was reputedly achieved but we wished to assess the understanding of patients about the process. Methods: Patients admitted to Wellington Hospital with their first episode of an acute coronary syndrome (ACS) - including transfers from other hospitals - were interviewed about previous CVDRA. Interviewers used a standardised questionnaire to obtain data regarding CVDRA administration, comprehension and any subsequent health behaviour or medication changes. We wrote to the patient's general practitioner (GP) requesting the date and calculated risk level from any logged CVDRA process. Data was described using simple summary statistics. Results: Of 47 patients recruited to the study, 19 were aware of having received a CVDRA score although 41 were reported by GPs. Of those 19, 63% received lifestyle advice and 63% were prescribed cardio-protective medication compared to 64% and 46% of patients who did not recollect a CVDRA. Of the 19 recollecting a CVDRA, all had followed lifestyle advice compared to 67% of those who did not remember a CVDRA. Equal numbers in both groups were taking cardio-protective medication at the time of ACS. Conclusion: Most patients admitted with a first ACS had received a recent CVDRA according to their GP but fewer patients seemed aware of the formal process. Nevertheless most were aware of risk factors and had taken some action to address these.

Approximately 3.5 million Nepalese are working as migrant workers in the Gulf countries, Malaysia, and India. Every year there are more than 1000 deaths and many hundreds cases of injuries among Nepalese workers in these countries excluding India. A postmortem examination of migrant workers is not carried out in most of these countries, and those with work-related injuries are often sent back to home. Uninsured migrant workers also do not have easy access to health care services in host countries due to the high medical and hospital fees. Greater efforts are needed to protect the health and well-being, labor rights, and human rights of migrant workers from Nepal and other South-Asian nations. There is a need to enforce universal labor laws in these countries and to develop accurate records of mortality and morbidity and their causes.

Background: The cardiovascular health of populations resident at high altitude may depend on the degree of consequent adaptation but also on lifestyle factors and genetic predisposition. The aim of this study was to estimate the prevalence of cardiovascular disease (CVD) and distribution of CVD risk factors among high altitude natives of Nepal. Methods: 270 people aged ≥30 years and permanently living at an altitude of ≥2800m were randomly sampled from the Mustang district of Nepal. They completed the WHO STEPS interview questionnaire, undertook measurements of blood pressure (BP), height, weight, waist and hip circumference, and had bio-chemical testing for lipid profile and glycated haemoglobin along with recording of a 12-lead ECG. Results: Abnormal or borderline abnormal ECGs were found in 21.8% of the participants (males 27.4%, females 16.9%). Relative to national prevalence data, the study group had a higher prevalence of alcohol consumption (52.9 vs. 21.5%), hypertension (46.3 vs. 36.8%), diabetes (9.7 vs. 5.9%), obesity (9.3 vs. 5.9%) and raised triglycerides (47.9 vs. 33.4%). They had a lower prevalence of smoking (8.5 vs. 24.7%), raised total cholesterol (20.8 vs. 29.8%) and low high density lipoprotein cholesterol (56.8 vs. 74.5%). There was a positive and statistically significant association of increasing resident altitude levels with systolic and diastolic BP and triglycerides (P < 0.001) after controlling for potential confounders. Conclusion: A locally resident population of Nepal living at high altitude, especially males, have a higher prevalence of CVD and risk factors. The hypoxic and hypobaric environment may contribute to this.

Background: Secondary prevention medications (aspirin, other anti-platelet agents, statins, beta-blockers, angiotensin converting enzyme-inhibitors/angiotensin receptor blockers (ACE-I/ARBs)) following an Acute Coronary Syndrome (ACS) improve patients’ (pt) prognosis. The first National ACS audit (2002) identified a limited uptake of these medications. Subsequent audits in 2007 and 2012 allow comparison of the prescription rates over a decade. Methods: Over 14 days, in May 2002, 2007 and 2012, pts with suspected ACS admitted to a hospital in NZ were audited to assess clinical management. ‘Definite’ ACS pts were determined at discharge, after in-hospital investigations. We assessed discharge secondary prevention medication use in ACS survivors. Results: For ST-segment elevation myocardial infarction/left bundle branch block (STEMI/LBBB) and Non-STEACS pts there have been significant increases in the discharge rates of secondary prevention medications (Table).Tabled 1200220072012PSTEMI/LBBBPts Discharged87 [86%*=% Pts Survived to Discharge.]81 [94%*=% Pts Survived to Discharge.]92 [93%*=% Pts Survived to Discharge.]Aspirin77 (89%)79 (98%)91 (99%)0.0011Other anti-platelet14 (16%)53 (65%)90 (88%)<0.0001Beta-blockers68 (78%)71 (88%)76 (83%)0.030ACE-I or ARB43 (49%)61 (75%)75 (82%)<0.0001Statins58 (67%)76 (94%)87 (95%)<0.0001Non-STEACSPts Discharged608 [98%*=% Pts Survived to Discharge.]732 [99%*=% Pts Survived to Discharge.]422 [98%*=% Pts Survived to Discharge.]Aspirin494 (81%)589 (80%)377 (89%)0.0015Other anti-platelet43 (7.1%)216 (30%)266 (63%)<0.0001Beta-blockers370 (61%)468 (64%)342 (81%)<0.0001ACE-I or ARB255 (42%)396 (54%)244 (58%)<0.0001Statins325 (53%)501 (68%)351 (83%)<0.0001* =% Pts Survived to Discharge. Open table in a new tab Conclusion: The use of secondary prevention medication in discharged ACS pts has significantly increased over a decade. Further improvements to improve long-term pt outcomes may still be possible. CSANZ NZ AbstractsHeart, Lung and CirculationVol. 23Preview Full-Text PDF

Background: The first New Zealand (NZ) Acute Coronary Syndrome (ACS) National audit of 2002 was a collaborative effort between Clinicians and Nurses and demonstrated significant limitations to STEMI patient (pt) care. A momentum for change was created. Subsequent audits in 2007 and 2012 permit comparison of treatments and investigations over time. Methods: Over 14 days, in May 2002, 2007 and 2012, pts with suspected ACS admitted to a hospital in NZ were audited. 'Definite' ACS pts were determined at discharge, after in-hospital investigations; we reviewed STEMI pts. Results: Significant improvements were seen for STEMI pts across the decade. Reperfusion therapy with fibrinolysis or primary percutaneous coronary intervention (PCI) increased, as did related investigations in hospital, including echocardiography, angiography and PCI (Table).Tabled 1200220072012PN (%*)101 (14%)86 (10%)99 (19%)Investigations in HospitalChest X-ray89 (89%)77 (90%)88 (88%)0.95Echacarcliogram35 (35%)53 (62%)70 (70%)<0.0001Exercise test (ETT)18 (18%)10 (12%)4 (4%)0.0083Angiogram31 (31%)50 (58%)87 (87%)<0.0001No ETT/Angiogram57 (57%)29 (34%)11 (11%)<0.0001Treatments in HospitalAspirin87 (88%)81 (94%)98 (99%)0.0015Other anli-platelet14 (14%)63 (73%)96 (97%)<0.0001Any heparin61 (60%)68 (79%)73 (73%)0.014Flbrinolytic therapy56 (55%)47 (55%)31 (31%)0.0006Primary PCI3 (3.0%)13 (15%)42 (42%)<0.0001NO reperfusion therapy42 (42%)26 (30%)27 (27%)<0.0001All PCI13 (13%)39 (45%)66 (66%)<0.0001CABG** surgery4 (4.0%)4 (4.7%)6 (6%)0.78In-hospital deaths14 (14%)5 (5.8%)7 (7.1%)0.11 Open table in a new tab Conclusion: Since 2002, substantial improvements have been seen in the management given to STEMI patients in New Zealand hospitals. However, there is still room for further improvements in patient care, in particular with more than one quarter of pts in 2012 not receiving any reperfusion therapy. CSANZ NZ AbstractsHeart, Lung and CirculationVol. 23Preview Full-Text PDF

Background: The cardiac troponin assay is widely used in Emergency Departments (EDs) to determine the likelihood that a patient's symptoms represent an acute coronary syndrome (ACS). We introduced a high sensitivity troponin assay (hs-cTnT) in 2010 to replace an earlier assay and a new more rapid triage protocol contingent on the improved performance of the assay. We wished to determine if the introduction of the new protocol reduced time spent in the ED. Methods: We reviewed the computerised medical records of those admitted to ED with "chest pain" or "suspected MI" during February 2009 and February 2013 (before and after the introduction of the new assay). Details were recorded of the presenting complaint, admission and discharge times from ED, times of troponin tests done within 24 hours of arrival into ED, troponin test results, location of discharge from ED, final diagnosis on discharge, and demographic information. Results were analysed using non-parametric statistics (Mann-Whitney U test). Results: There were 221 patients admitted to ED in February 2009 and 276 in February 2013 who matched our inclusion criteria. Median times spent in ED were substantially reduced in 2013 for the whole group (from 455 to 286 minutes, P < 0.001) and for all categories of final diagnosis (e.g. ACS: 471 to 280 mins, arrhythmia 453 to 248 mins, and non-cardiac pain 511 to 323 mins – P < 0.005 for each). Conclusion: There was a significant and substantial reduction of triage time in ED for patients with a possible ACS between 2009 and 2013 facilitated by the new hs-cTnT assay. CSANZ NZ AbstractsHeart, Lung and CirculationVol. 23Preview Full-Text PDF

Fungal polyketides comprise a very large and structurally diverse group and many display important biological activities [1]. These are produced by large multifunctional iterative enzymes, the polyketide synthases (PKS). Recent advances in genomic analysis revealed a large number of PKS-encoding genes in fungal genomes, most of which are related to unknown metabolites. In this context, we are interested in using a genome mining approach to discover novel chemical entities from fungi, particularly those derived from hybrid PKSs and non-ribosomal peptide synthetases (NRPS). The fungus Talaromyces stipitatus was chosen in this study. Several new polyketides (e.g. 1 and 2) have been isolated and characterized by extensive 2D NMR analysis. Absolute configurations of some new structures were assigned by CD. Comparison between experimental and theoretical electronic CD (ECD) was used to assess the relative and absolute configurations. Additionally, elucidation of the biosynthetic pathway leading to the original spiro-bis(oxaphenalenone) dimer (2) is under study by feeding experiments. Finally, some of these compounds showed potent cytotoxic activities against HeLa cell line compared to cisplatin.

Background: Invasive assessment and revascularisation is essential for optimal ACS patient (pt) management. The NZ Cardiac Society ACS audit group has provided 'momentum' for improved service provision over a decade. We assessed pts receiving invasive management over the three National ACS pts audits in May 2002, 2007 and most recently from the 2012 'SNAPSHOT' audit. Methods: NZ Hospitals which admit ACS pts collected information on all suspected ACS admission over 14 consecutive days. Those discharged with STEMI/LBBB, NSTEMI or unstable angina pain were further classified as 'definite' ACS. Results: There has been an increase in the total number of suspected ACS pts admitted to hospital, with a significant trend to increasing investigations and revascularisation over the last 10 years (table).Tabled 1Suspect ACS Admissions2002 (n = 930)2007 (n = 1003)2012 (n = 1007)Chest X-ray794 (85%)880 (88%)911 (90%)*Test for trend P<0.0001.Echocardiogram184 (20%)195 (19%)287 (29%)*Test for trend P<0.0001.Exercise test190 (20%)214 (21%)229 (23%)*Test for trend P<0.0001.Conventional angiogram199 (21%)317 (32%)331 (33%)*Test for trend P<0.0001.Definite ACS discharges n=721 (73%)828 (83%)531 (53%)Conventional angiogram159 (22%)291 (35%)284(53%)*Test for trend P<0.0001.Percutaneous coronary intervention (PCI)50 (6.9%)157 (19%)165 (31%)*Test for trend P<0.0001.Coronary artery bypass grafts (CABG)25 (3.5%)23 (2.8%)30 (5.7%)*Test for trend P<0.0001.PCI or CABG72 (9.9%)178 (22%)194 (37%)*Test for trend P<0.0001.* Test for trend P < 0.0001. Open table in a new tab Conclusion: The number of pts admitted with a suspected ACS has increased. Patients discharged with a 'definite' ACS are increasingly more likely to have guideline directed invasive investigations and revascularisation. Despite changes in the definition of a 'definite' ACS, over time, this third (2012) NZ ACS audit has demonstrated small, but clear, improvements in the invasive management of ACS patients and highlights the utility of audit as a catalyst for change.

Purpose: We examined the relationship between renal impairment and high-sensitivity troponin T levels (hs-TnT) in patients presenting to an emergency department with no known acute cause of hs-TnT elevation. Methods: We identified all patients presenting to the emergency department over a two-year period who had hs-TnT and serum creatinine measured. eGFR values were determined using the MDRD175 equation. We reviewed all individuals with eGFR < 30 ml/min/1.73 m2 and excluded those with a recognised acute cause for elevated hs-TnT or a dynamic change in hs-TnT on repeat measurement. We then randomly selected age and sex matched individuals with eGFR levels 30–44, 45–59 and >60 ml/min/1.73 m2 and applied the same exclusion criteria to give fourequal sized groups for comparison. Results: After excluding acute causes of hs-TnT elevation, we identified 101 patients with an eGFR < 30 ml/min/1.73 m2 of whom 55% were male with a mean age of 72 ± 15 years. These were matched in the other three groups. There was an inverse correlation between eGFR and hs-TnT (r = −0.48, P < 0.001) with median (interquartile range) hs-TnT levels of 4 (4–14) in the eGFR > 60 group, 12 (4–19) in the eGFR 45–59 group, 16 (8–32) in the eGFR 30–44 group and 40 (21–77) in the eGFR < 30 ml/min/1.73 m2 group (p < 0.001). After correcting for cardiovascular risk factors and comorbidities, eGFR < 60 ml/min/1.73 m2 was the strongest independent predictor of a raised hs-TnT > 13 ng/L (OR = 4.2). Conclusions: Renal impairment is an independent cause of raised hs-TnT levels in the emergency department that needs to be considered prior to classifying a patient as having an acute coronary syndrome.

Background: Equitable access to guideline directed care for ACS patients (pts) is an important management goal. We review median time to angiography over the last decade with three NZ ACS audits, contrasting intervention and non-intervention centres.

Background: We describe all cause mortality 18 months after comprehensive 14-day audits in 2002 and 2007 in all NZ hospitals admitting ACS patients.