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presenting with HC (defined as Killip class ≥2, systolicblood pressure <100 mm Hg) were the focus of this inves-tigation. Patient characteristics, management and clinicaloutcomes were assessed.Results: 647 patients fulfilled the inclusion criteria.Patients with HC were younger (mean 63.2 years vs. 69.8years, p < 0.0001), but had a higher prevalence of diabetes(31.9% vs. 21.2%, p < 0.0001) and renal impairment (meaneGFR 64.1 mL/min vs. 73.3 mL/min, p < 0.0001). The pres-ence of HC at hospital presentation was associated withmarkedly increased in-hospital (HR 6.3, 95% CI 2.9–9.4,p < 0.0001) and 12-month (HR 5.1, 3.8–6.8, p < 0.0001) mor-tality, with incremental Killip class predicting worseningsurvival (p = 0.03). After multivariate adjustment, survivalanalysis revealed that an invasive management strategywas the only therapy associated with improved in-hospital(HR 0.41, 0.22–0.74, p = 0.003) and 12-month survival (HR0.43, 0.31–0.60, p < 0.0001).Conclusion: In this large real-world study, an invasivemanagement strategy was the only therapeutic inter-vention associated with improved outcomes in ACScomplicated by HC at hospital presentation. Furtherefforts are necessary to improve the provision of recom-mended therapies in such high-risk ACS patients.

doi:10.1016/j.hlc.2008.05.263

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have included improved access to cardiac revascularisa-tion, improved transparency of decision making, bettercompliance with guideline based treatment, improvedresponse time to within 1 h of submission and greatercustomer (referring centre) satisfaction.Conclusion: A web-based referral and triage system suc-cessfully improved access to invasive services for ACSpatients.

doi:10.1016/j.hlc.2008.05.264

264Effects of Self-presentation to Hospital on the Outcomesin Acute Myocardial Infarction

David Burgess ∗, Gopal Sivagangabalan, Arun Narayan,Norman Sadick, Andrew Ong, David Ross, PrameshKovoor

Westmead Hospital, Sydney, NSW, Australia

Background: Despite national guidelines recommendingpatients with symptoms consistent with AMI use ambu-lance transport to reach hospital 40–50% of patients arrivevia self-transport. We sought to evaluate the effects of self-presentation to hospital by comparing them to those whocame by ambulance.Methods: We prospectively collected the data on 136patients who were triaged by ETAMI (early triage of AMI)

Web-based Referral and Triage System, SuccessfullyImproves Access to Tertiary Cardiac Services withinthe Queensland Health Central Area Health District forPatients with Acute Coronary Syndrome (ACS)

Margaret Dahl ∗, Darren Walters, Lisa Daly-Jelinek, EvonGreener

TPCH, Brisbane, Qld, Australia

Background: The Acute Coronary Syndrome Project(ACS) was established 2004 as collaborative between RoyalBrisbane Women’s Hospital (RBWH) and The PrinceCharles Hospital (TPCH) to improve the referral of ACSpatients from regional, rural and remote areas of CentralArea Health Services (CAHS).The project aimed to develop a centralised coordi-nated system for referral, prioritisation, management andscheduling of patients with ACS from non-tertiary facil-ities who required revascularisation in accordance withCSANZ/NHF guidelines.Method: A prospective database was developed linked toa web based electronic referral interface that allowed pri-oritisation and scheduling of patients across both tertiarysites. The system links seven referral sites with two tertiarycentres and is utilised by Queensland Clinical Coordinat-ing Centre (Queensland Ambulance) to manage transportof patients from rural centres.Results: During a 14 month period (12/06 to 02/08) therehave been 504 total referrals to TPCH, mean age 64.5 ± 12.3(male 66%) with STEMI 65, 12.9% and NSTEACS 327,64.9%. The average time to transfer decreased from 3.7days prior to the project to 1.7 days. Benefits of the system

ambulances [equipped with 12 lead ECG transmissioncapacity], 306 patients in standard ambulance and 155 whoself-presented.Results: Those that self-presented were significantyounger with less prior IHD disease than subjects whoused ambulance transport. Self-presenters had shortersymptom-door times but longer total ischemic times thanthe ETAMI ambulance group. Self-presenters had goodshort- and long-term clinical outcomes (Table).

ETAMIambulance,n = 136

Standardambulance,n = 306

Self-presentation, n = 155

P value

Age, mean (SD) 60 (12) 59 (12) 57 (10) 0.001

DM (%) 23 26 23 0.6

Prior IHD (%) 12 14 7 0.02

Carcinogenic shock (%) 13 11 8 0.4

Time minutes median (IQR)

Symptom to door 108 (103) 91 (104) 83 (121) 0.09

Door to table 43 (32) 91 (64) 95 (45) 0.001

Table to balloon 32 (16) 35 (15) 35 (11) 0.02

Total ischemic time 194 (127) 235 (171) 230 (145) 0.001

Treated with PCI (%) 94 91 96 0.7

Outcomes

LVEF%, mean (S.D.) 52 (12) 50 (12) 48 (12) 0.02

30-day mortality (%) 3 8 3 0.02

30-day MACE (%) 21 25 13 0.02

2-year mortality (%) 10 16 3 0.002

Conclusion: AMI patients who self-present and do not usethe ambulance system have similar total ischemic times,when compared to patients in standard ambulances, but

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significantly prolonged ischemic times when compared tothose using ETAMI ambulance.

doi:10.1016/j.hlc.2008.05.265

265Prevalence of Smoking and Adherence to Lipid-loweringTherapy in Patients Following Percutaneous CoronaryIntervention

William Chan 1,∗, Angela Brennan 2, Michelle J. Butler 1,Nick Andrianopoulos 2, David J. Clark 3, Christopher M.Reid 2, Andrew E. Ajani 4, Catherine Farrington 1, AnthonyM. Dart 1, Stephen J. Duffy 1

1 Alfred Hospital, Melbourne, Victoria, Australia; 2 MonashUniversity, Department of Epidemiology & PreventiveMedicine, Clayton, Victoria, Australia; 3 Austin Hospital,Heidelberg, Victoria, Australia; 4 Royal Melbourne Hospital,Melbourne, Victoria, Australia

Background: Percutaneous coronary intervention (PCI)has prognostic benefit in patients with acute coronary syn-dromes (ACS). However, long-term prognosis in coronarydisease is largely determined by risk-factor modification.We aimed to assess the adherence to smoking cessationadvice and compliance with lipid-lowering therapy 12-months after PCI.Methods: We analysed 12-month smoking status andltwRranympeHl(dflc(owaCms

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266Aspirin Resistance Predicts an Increased Risk of In-hospital Events in Australian Patients with AcuteCoronary Syndromes: Results from the CARS Study

David Eccleston 1,∗, David Brieger 3, Darren Walters 4,Jamie Rankin 5, Suellen Mattschoss 2, Luan Huynh 2, Car-olyn Astley 2, Derek Chew 2

1 Royal Melbourne Hospital, Melbourne, Victoria, Australia;2 Flinders Medical Centre/Flinders University, Adelaide, SouthAustralia, Australia; 3 Concord Hospital, Sydney, New SouthWales, Australia; 4 Prince Charles Hospital, Brisbane, Queen-land, Australia; 5 Royal Perth Hospital, Perth, WesternAustralia, Australia

Background: Aspirin resistance (AR) is associated with anincreased risk of cardiovascular events in patients with sta-ble coronary artery disease, however, this relationship andthat of clopidogrel resistance (CR) has not been well char-acterised in those with acute coronary syndromes (ACS)or in the Australian population. This study assessed theprevalence of AR/CR and its associations with cardiovas-cular outcomes.Methods: Clopidogrel and Aspirin Resistance Study(CARS) was a prospective multicentre Australian registryof 525 consecutive patients with ST-elevation myocardialinfarction or high-risk non-ST-elevation ACS, in whomdata is available in 453 patients. Patients were either loadedwi(tr(wBtMRcdm7McapbCape

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ipid-lowering usage data from 2148 patients enrolled inhe Melbourne Interventional Group registry who under-ent PCI (October 2005 to August 2006).esults: At the time of index PCI, 482 (22%) were cur-

ent smokers, 922 (43%) were ex-smokers (of >1 month),nd 744 (35%) had never smoked. Compared to ex- andever-smokers, current smokers were younger (56.7 ± 108ears vs. 66.4 ± 11.5 years, p < 0.0001), more likely to beale (78% vs. 73%, p = 0.02), a public patient (92% vs. 86%,= 0.001), and present with ACS (either ST- or non-ST-levation myocardial infarction) (76% vs. 54%, p < 0.0001).owever, they were less likely to have hypertension, dys-

ipidaemia, diabetes, a prior MI, or prior revascularisationPCI or CABG) (all p < 0.01). Smoking status at baselineid not affect major adverse cardiac events after 12-month

ollow-up. At 12 months, 42.7% of current smokers at base-ine were known to have stopped smoking. In the overallohort, 12.6% of patients were reportedly still smokingincluding 54 who were not smoking at baseline). 89.4%f patients known to be taking a statin 30-days post-PCIere still taking a statin at 12 months. Of those not takingstatin, only 22.4% were taking fibrates or ezetimibe.onclusions: Approximately 1 in 10 patients have notodified important risk factors 12 months post-PCI. New

trategies are required to reduce this treatment gap.

oi:10.1016/j.hlc.2008.05.266

ith aspirin (300 mg) +/or clopidogrel (>300 mg) or tak-ng aspirin (100 mg) +/or clopidogrel (75 mg) long-term>1 week). Data collected included clinical risk stratifica-ion factors, in-hospital management and death, stroke,e-myocardial infarction and unplanned revascularisationMACE). AR (ARU > 550) and CR (platelet inhibition <10%)ere assessed using the Accumetrics Ultegra device.ivariate analysis and logistic regression were performed

o assess associations between clinical factors, AR/CR andACE.

esults: All patients received aspirin, 314 patients receivedlopidogrel. The prevalence of AR was 7.5% and CR 36.3%;ual resistance occurred in 1.3% of patients. CR occurredore frequently in those with lower platelet counts(<150:

0.6%, 150–400: 37.1%, >400: 25.9%, p = 0.003). In-hospitalACE occurred in 22/453 (4.9%). AR was strongly asso-

iated with MACE (OR 6.9, 95% C.I. 2.2–20.0, p < 0.0001),nd MACE and major bleeding(OR 4.1, 95% C.I. 1.5–10.5,= 0.0007). At the definition of CR used, no relationshipetween CR and in hospital events was seen.onclusions: Aspirin resistance appears to be associ-ted with an increase in adverse ischemic events amongatients with ACS. This data may aid in developing moreffective anti-platelet therapies.

oi:10.1016/j.hlc.2008.05.267