Romain André1, Vanina Bongard2, Roberto Elosua3, Inge Kirchberger4, Dimitrios Farmakis5, Unto Häkkinen6, Danilo Fusco7, Marina Torre8, Pascal Garel9, Carla Araújo10, Christa Meisinger4, John Lekakis5, Antti Malmivaara6, Maria Dovali7, Marta Pereira10, Jaume Marrugat11, Jean Ferrières12. 1. Department of Cardiology, Toulouse Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France. 2. Department of Epidemiology, Health Economics and Public Health, AEPMCV, UMR1027 INSERM-University of Toulouse III, Toulouse University Hospital (CHU), Toulouse, France. 3. Cardiovascular Epidemiology and Genetics, Municipal Institute of Health Assistance-Municipal Institute of Medical Research (IMAS-IMIM), Barcelona, Spain Centros de Investigación Biomédica en Red (CIBER) Epidemiology and Public Health (CIBERESP), Barcelona, Spain. 4. Helmholtz Centre Munich-German Research Centre for Environmental Health, Institute of Epidemiology II, Neuherberg, Germany; Central Hospital Augsburg, MONICA/KORA Myocardial Infarction Registry, Augsburg, Germany. 5. Second Department of Cardiology, University of Athens Medical School, Attikon University Hospital, Athens, Greece. 6. National Institute for Health and Welfare (THL), Centre for Health and Social Economics (CHESS), Helsinki, Finland Health Services Research of the National Research and Development Centre for Welfare and Health, Helsinki, Finland. 7. Department of Epidemiology, Health Authority Roma E, Lazio Regional Health Service, Rome, Italy. 8. Istituto Superiore di Sanità (ISS), Rome, Italy. 9. European Hospital and Healthcare Federation (HOPE), Brussels, Belgium. 10. Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Porto, Portugal. 11. Cardiovascular Epidemiology and Genetics, Municipal Institute of Health Assistance-Municipal Institute of Medical Research (IMAS-IMIM), Barcelona, Spain. 12. Department of Cardiology, Toulouse Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France Department of Epidemiology, Health Economics and Public Health, AEPMCV, UMR1027 INSERM-University of Toulouse III, Toulouse University Hospital (CHU), Toulouse, France.
Abstract
OBJECTIVE: We aimed to describe current characteristics of patients admitted for acute coronary syndrome (ACS) in Western Europe and to analyse whether international in-hospital mortality variations are explained by differences in patients' baseline characteristics and in clinical management. METHODS: We studied a population-based longitudinal cohort conducted in Finland, France, Germany, Greece, Portugal and Spain, and comprising 12 231 consecutive ACS patients admitted in 53 hospitals between 2008 and 2010. Baseline characteristics, clinical management and inhospital outcomes were recorded. Contextual effect of country on death was analysed through multilevel analysis. RESULTS: Of all patients included, 8221 (67.2%) had NSTEMI (non-ST-elevation myocardial infarction), and 4010 (32.8%) had STEMI (ST-elevation myocardial infarction). Inhospital mortality ranged from 15.1% to 4.9% for German and Spanish STEMI patients, and from 6.8% to 1.9% for Finnish and French NSTEMI patients (p<0.001 for both). These international variations were explained by differences in patients' baseline characteristics (older patients more likely to have cardiogenic shock in Germany) and in clinical management, with differences in rates of thrombolysis (less performed in Germany) and primary percutaneous coronary intervention (high in Germany, low in Greece). A remaining contextual effect of country was identified after extensive adjustment. CONCLUSIONS: Inhospital mortality rates of STEMI and NSTEMI patients were two to three times higher in Finland, Germany and Portugal than in Greece and Spain, with intermediate values for France. Differences in baseline characteristics and clinical management partly explain differences in outcome. Our data also suggest an impact of the healthcare system organisation. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
OBJECTIVE: We aimed to describe current characteristics of patients admitted for acute coronary syndrome (ACS) in Western Europe and to analyse whether international in-hospital mortality variations are explained by differences in patients' baseline characteristics and in clinical management. METHODS: We studied a population-based longitudinal cohort conducted in Finland, France, Germany, Greece, Portugal and Spain, and comprising 12 231 consecutive ACS patients admitted in 53 hospitals between 2008 and 2010. Baseline characteristics, clinical management and inhospital outcomes were recorded. Contextual effect of country on death was analysed through multilevel analysis. RESULTS: Of all patients included, 8221 (67.2%) had NSTEMI (non-ST-elevation myocardial infarction), and 4010 (32.8%) had STEMI (ST-elevation myocardial infarction). Inhospital mortality ranged from 15.1% to 4.9% for German and Spanish STEMI patients, and from 6.8% to 1.9% for Finnish and French NSTEMI patients (p<0.001 for both). These international variations were explained by differences in patients' baseline characteristics (older patients more likely to have cardiogenic shock in Germany) and in clinical management, with differences in rates of thrombolysis (less performed in Germany) and primary percutaneous coronary intervention (high in Germany, low in Greece). A remaining contextual effect of country was identified after extensive adjustment. CONCLUSIONS: Inhospital mortality rates of STEMI and NSTEMI patients were two to three times higher in Finland, Germany and Portugal than in Greece and Spain, with intermediate values for France. Differences in baseline characteristics and clinical management partly explain differences in outcome. Our data also suggest an impact of the healthcare system organisation. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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