Copyright © 2003 by the European Society of Cardiology.
Clinical research
International variation in the use of evidence-based medicines for acute coronary syndromes
a Duke University Medical Center, Duke Center for Education and Research on Therapeutics, and Duke Clinical Research Institute, Durham, NC, USA
b Canadian Vigour Centre, University of Alberta, Edmonton, Alberta, Canada
c National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia
d Department of Cardiology, University Hospital Gasthuisberg and Director, Leuven Coordinating Center, Leuven, Belgium
e Biostatistics and Bioinformatics, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
f Green Lane Coordinating Center, Green Lane Hospital, Auckland, New Zealand
g Universidade de Sâo Paulo, Instituto Dante Pazzanese de Cardiologica, Sâo Paulo, Brazil
h Cleveland Clinic Foundation, Cleveland, OH, USA
* Corresponding author. Dr J. M. Kramer, Duke University Medical Center, 2400 Pratt Street, Room 0311 Terrace Level, Durham, NC 27705, USA. Tel.: +1-919-668-8501; Fax: +1-919-668-7059
E-mail address: krame009{at}mc.duke.edu
Received 15 May 2003; accepted 19 September 2003 This paper was guest edited by Christopher P. Cannon, Brigham and Women’s Hospital, Boston, USA
Abstract
Aims We sought to evaluate international patterns of use and factors influencing use of evidence-based medications early after ACS.
Methods and results Using a database of 15 904 ACS patients enrolled in the SYMPHONY and 2nd SYMPHONY trials in 37 countries, we performed descriptive and logistic regression analyses. After controlling for other factors, region was significantly associated with the use of every class of evidence-based medication, most pronounced for intravenous unfractionated heparin (IV UFH), low-molecular-weight heparin (LMWH), angiotensin II converting enzyme inhibitors (ACEI) and discharge use of lipid-lowering agents. Latin America and Eastern Europe were among the highest users of early ACEI, yet the lowest users of discharge lipid-lowering therapy. Relative to the United States, all regions except Canada had greater use of LMWH and lower use of IV UFH. Compared with patients with acute myocardial infarction, those with unstable angina less often received aspirin, beta-blockers, ACEI, or IV UFH. Older age was associated with lower use of aspirin, beta-blockers, IV UFH, and lipid-lowering agents.
Conclusion Use of evidence-based therapies for management of ACS patients is strongly associated with region. To improve patient outcomes, more research is needed to understand this variation, and to institute appropriate solutions.
Key Words: Acute coronary syndromes • Evidence-based medicine • Drug therapy • Cross-cultural comparisons • International differences • Guidelines
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