Geographic variation in patient and hospital characteristics, management, and clinical outcomes in ST-elevation myocardial infarction treated with fibrinolysis. Results from InTIME-II.
OBJECTIVE
We examined the geographic variations in InTIME-II, a randomized double-blind trial comparing alteplase with lanoteplase for myocardial infarction.


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.
Giugliano
R P
RP
TIMI Study Group, Cardiovascular Division, Brigham & Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
Llevadot
J
J
Wilcox
R G
RG
Gurfinkel
E P
EP
McCabe
C H
CH
Charlesworth
A
A
Thompson
S L
SL
Antman
E M
EM
Braunwald
E
E
D000328:Adult; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D006348:Cardiac Surgical Procedures / Q000706:statistics & numerical data; D003625:Data Collection; D004311:Double-Blind Method; D004562:Electrocardiography; D023381:Endpoint Determination; D005060:Europe / Q000453:epidemiology; D005061:Europe, Eastern / Q000453:epidemiology; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005500:Follow-Up Studies; D005843:Geography; D006761:Hospitals; D006801:Humans; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D007843:Latin America / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality* / Q000628:therapy*; D009656:North America / Q000453:epidemiology; D010361:Patients; D011945:Receptors, Angiotensin / Q000627:therapeutic use; D016896:Treatment Outcome
D000806:Angiotensin-Converting Enzyme Inhibitors; D005343:Fibrinolytic Agents; D000960:Hypolipidemic Agents; D011945:Receptors, Angiotensin