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European Heart Journal 2001 22(18):1702-1715; doi:10.1053/euhj.2001.2583
Copyright © 2001 by the European Society of Cardiology.
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Geographic variation in patient and hospital characteristics, management, and clinical outcomes in ST-elevation myocardial infarction treated with fibrinolysis. Results from InTIME-II

R.P Giuglianoa,f1,f2, J Llevadota,f1, R.G Wilcoxb, E.P Gurfinkelc, C.H McCabea, A Charlesworthd, S.L Thompsond, E.M Antmana and E Braunwald for the In TIME (Intravenous nPA for Treatment of Infarcting Myocardium Early) II Investigatorsa

a TIMI Study Group, Cardiovascular Division, Brigham & Women's Hospital and Harvard Medical School, Boston, MA
b Division of Cardiovascular Medicine, Queen's Medical Centre, Nottingham, U.K.
c Fundacion Favaloro, Buenos Aires, Argentina
d Nottingham Clinical Research Group, Nottingham, U.K.

revised December 21, 2000; accepted January 2, 2001

Abstract

Aims We examined the geographic variations in InTIME-II, a randomized double-blind trial comparing alteplase with lanoteplase for myocardial infarction.

Methods and Results We compared baseline characteristics, management, and outcomes in four regions (Western Europe, Eastern Europe, North America, and Latin America) and in countries with historically different management approaches (Germany vs the U.K., the U.S. vs Canada). Thirty-day mortality in Western Europe, Eastern Europe, North America and Latin America was 6·7%, 7·3%, 5·7%, 10·1%, P<0·0001. Adjusted mortality for Europe was intermediate between North America and Latin America (odds ratios (OR) [95% confidence intervals (CI)] compared to Western Europe: North America 0·84 [0·67–1·0], Eastern Europe 1·2 [1·0–1·4], and Latin America 1·8 [1·3–2·7]). Revascularization rates varied 10-fold but did not explain regional mortality differences. Germany and the U.K. had similar adjusted 1-year mortality (OR for the U.K. 1·16 [0·92–1·5]), although invasive procedures were four- to 10-fold more common in Germany. Similarly the U.S. and Canada had equal adjusted 1-year mortality (OR for Canada 0·85 [0·61–1·17]) despite three-fold higher use of invasive procedures in the U.S.

Conclusions Significant geographic variations in practice and adjusted mortality following fibrinolysis persist despite recent guidelines. These findings have important implications in the design and interpretation of international studies, identify under- and over-utilized therapies, and support further study of treatments with marked worldwide variations.

Key Words: Myocardial infarction, fibrinolysis, geographic variation, management, outcomes

f1 These authors contributed equally to the manuscript.

f2 Correspondence: Dr Robert P. Giugliano, TIMI Study Office, 333 Longwood Avenue, Suite 402, Boston, MA 02115, U.S.A.

References

  1. Braunwald E. Shattuck lecture—cardiovascular medicine at the turn of the millennium: triumphs, concerns, and opportunities [see comments]. N Engl J Med. 1997;337:1360–1369[Free Full Text]
  2. Rouleau JL, Moye LA, Pfeffer MA. A comparison of management patterns after acute myocardial infarction in Canada and the United States. The SAVE investigators [see comments]. N Engl J Med. 1993;328:779–784[Abstract/Free Full Text]
  3. Barbash GI, Modan M, Goldbourt U. Comparative case fatality analysis of the International Tissue Plasminogen Activator/Streptokinase Mortality Trial: variation by country beyond predictive profile. The Investigators of the International Tissue Plasminogen Activator/Streptokinase Mortality Trial. J Am Coll Cardiol. 1993;21:281–286[Abstract]
  4. Van de Werf F, Topol EJ, Lee KL. Variations in patient management and outcomes for acute myocardial infarction in the United States and other countries. Results from the GUSTO trial. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. JAMA. 1995;273:1586–1591[Abstract/Free Full Text]
  5. Pilote L, Califf RM, Sapp S. Regional variation across the United States in the management of acute myocardial infarction. GUSTO-1 Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries [see comments]. N Engl J Med. 1995;333:565–572[Abstract/Free Full Text]
  6. Fox KA, Cokkinos DV, Deckers J. The ENACT study: a pan-European survey of acute coronary syndromes. Eur Heart J. 2000;21:1440–1449[Abstract/Free Full Text]
  7. Collinson J, Flather MD, Fox KA. Clinical outcomes, risk stratification and practice patterns of unstable angina and myocardial infarction without ST elevation: Prospective Registry of Acute Ischaemic Syndromes in the UK (PRAIS-UK). Eur Heart J. 2000;21:1450–1457[Abstract/Free Full Text]
  8. Fox KA, Goodman S, Bigonzi F. Inter-regional differences and outcome in unstable angina. Analysis of the International ESSENCE trial. Eur Heart J. 2000;21:1433–1439[Abstract/Free Full Text]
  9. Eur Heart J. 1996;17:43–63[Free Full Text]
  10. Ryan TJ, Anderson JL, Antman EM. ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol. 1996;28:1328–1428[CrossRef][Web of Science][Medline]
  11. Gurfinkel E. Current treatment and future prospects for the management of acute coronary syndromes. Clin Drug Invest. 1998;15:367–380[CrossRef]
  12. Eur Heart J. 2000;21:2005–2013[Abstract/Free Full Text]
  13. Guadagnoli E, Hauptman PJ, Ayanian JZ. Variation in the use of cardiac procedures after acute myocardial infarction. N Engl J Med. 1995;333:573–578[Abstract/Free Full Text]
  14. Tu JV, Pashos CL, Naylor CD. Use of cardiac procedures and outcomes in elderly patients with myocardial infarction in the United States and Canada. N Engl J Med. 1997;336:1500–1505[Abstract/Free Full Text]
  15. Venturini F, Romero M, Tognoni G. Patterns of practice for acute myocardial infarction in a population from ten countries. Eur J Clin Pharmacol. 1999;54:877–886[CrossRef][Web of Science][Medline]
  16. Woods KL, Ketley D, Agusti A. Use of coronary angiography and revascularization procedures following acute myocardial infarction. A European perspective. Eur Heart J. 1998;19:1348–1354[Abstract/Free Full Text]
  17. Llevadot J, Giugliano RP, Antman EM. Availability of on-site catheterization and clinical outcomes in patients receiving fibrinolysis for ST-elevation myocardial infarction. Eur Heart J. 2001;:
  18. Morrow DA, Antman EM, Charlesworth A. TIMI risk score for ST-elevation myocardial infarction: a convenient, bedside, clinical score for risk assessment at presentation: an intravenous nPA for Treatment of Infarcting Myocardium Early II Trial Substudy. Circulation. 2000;102:2031–2037[Abstract/Free Full Text]
  19. Yusuf S, Flather M, Pogue J. Variations between countries in invasive cardiac procedures and outcomes in patients with suspected unstable angina or myocardial infarction without initial ST elevation. OASIS (Organisation to Assess Strategies for Ischaemic Syndromes) Registry Investigators [see comments]. Lancet. 1998;352:507–514[CrossRef][Web of Science][Medline]
  20. Akkerhuis KM, Deckers JW, Boersma E. Geographic variability in outcomes within an international trial of glycoprotein IIb/IIIa inhibition in patients with acute coronary syndromes. Results from PURSUIT. Eur Heart J. 2000;21:371–381[Abstract/Free Full Text]
  21. O'Shea JC, Califf RM. Inter-regional differences in acute coronary syndrome trials. Eur Heart J. 2000;21:1397–1399[Free Full Text]
  22. Roberts R, Rogers WJ, Mueller HS. Immediate versus deferred beta-blockade following thrombolytic therapy in patients with acute myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI) II-B Study. Circulation. 1991;83:422–437[Abstract/Free Full Text]
  23. N Engl J Med. 1981;304:801–807[Abstract]
  24. Hjalmarson A, Elmfeldt D, Herlitz J. Effect on mortality of metoprolol in acute myocardial infarction. A double-blind randomised trial. Lancet. 1981;2:823–827[CrossRef][Web of Science][Medline]
  25. Gottlieb SS, McCarter RJ, Vogel RA. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. N Engl J Med. 1998;339:489–497[Abstract/Free Full Text]
  26. Ryan TJ, Antman EM, Brooks NH. 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol. 1999;34:890–911[Free Full Text]
  27. Batchelor WB, Peterson ED, Mark DB. A comparison of U.S. and Canadian cardiac catheterization practices in detecting severe coronary artery disease after myocardial infarction: efficiency, yield and long-term implications. J Am Coll Cardiol. 1999;34:12–19[Abstract/Free Full Text]
  28. Alderman EL, Bourassa MG, Cohen LS. Ten-year follow-up of survival and myocardial infarction in the randomized Coronary Artery Surgery Study. Circulation. 1990;82:1629–1646[Abstract/Free Full Text]
  29. Yusuf S, Zucker D, Peduzzi P. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet. 1994;344:563–570[CrossRef][Web of Science][Medline]
  30. Mark DB, Naylor CD, Hlatky MA. Use of medical resources and quality of life after acute myocardial infarction in Canada and the United States. N Engl J Med. 1994;331:1130–1135[Abstract/Free Full Text]
  31. Pilote L, Lauzon C, Mines TEA. Quality of life after acute myocardial infarction in patients treated at sites with and without catheterization laboratories. Circulation. 1999;100:I-806

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