Management of unstable angina and non-ST-elevation myocardial infarction: do cardiologists do it better? A comparison of secondary and tertiary centre management in New Zealand.
BACKGROUND
Internationally, differences have been noted in how specialist cardiologists and general physicians manage acute coronary syndromes (ACS). Whether a similar practice difference exists in New Zealand is unclear.


OBJECTIVE
To test the hypothesis that management differences exist between cardiologists and general physicians in patients presenting with a non-ST-segment elevation acute coronary syndrome in a New Zealand setting-and whether these differences (if present) impact on patient outcome.


METHODS
A retrospective chart review of 324 consecutive patients presenting with a non-ST-segment elevation acute coronary syndrome to Taranaki Base and Waikato Hospitals from 1 January 1999 was undertaken. Patients in Taranaki were managed by general physicians and in Waikato they were managed by cardiologists.


RESULTS
Patients presenting to Taranaki Base Hospital were more likely to have high-risk ECG changes with ST-segment depression noted in 34.4% of patients there compared to 16.8% of patients in Waikato (p<0.001). Medical management during patient stabilisation was similar in Taranaki and Waikato with high use of anti-thrombotic (89%) and anti-platelet therapy (94%), respectively. However angiography (5.1% versus 23.4%; p=0.0045) and revascularisation procedures (4% versus 16.7%; p=0.0002) were performed less frequently in Taranaki. No significant difference was noted in mortality at 6 months (9.6% in Waikato versus 13.4% in Taranaki; p=0.4) Readmission rates were also similar; occurring overall in approximately one-quarter of the study population.


CONCLUSIONS
In New Zealand, differences exist in how cardiologists and general physicians manage non-ST-elevation acute coronary syndrome. In particular, the low referral rates for angiography by general physicians is of concern and requires correction as current best-practice guidelines suggest high-risk patients are disadvantaged by a conservative approach to management.
Conaglen
Paul
P
University of Auckland, Auckland, New Zealand.
Sebastian
Cherian
C
Jayaraman
Chandrakanth
C
Abraham
Arun
A
Makkada
Veeraraghavan
V
Devlin
Gerald
G
D000328:Adult; D000368:Aged; D000789:Angina, Unstable / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D002300:Cardiac Care Facilities / Q000592:standards / Q000706:statistics & numerical data; D002309:Cardiology / Q000379:methods*; D016507:Cardiology Service, Hospital / Q000706:statistics & numerical data; D017023:Coronary Angiography / Q000706:statistics & numerical data; D003325:Coronary Care Units / Q000706:statistics & numerical data; D003695:Delivery of Health Care / Q000592:standards / Q000706:statistics & numerical data; D004569:Electroencephalography / Q000706:statistics & numerical data; D005194:Family Practice / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D009520:New Zealand; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data