International differences in acute coronary syndrome patients' baseline characteristics, clinical management and outcomes in Western Europe: the EURHOBOP study.
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.
Department of Cardiology, Toulouse Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France.
Romain
R
André
Department of Epidemiology, Health Economics and Public Health, AEPMCV, UMR1027 INSERM-University of Toulouse III, Toulouse University Hospital (CHU), Toulouse, France.
Vanina
V
Bongard
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.
Roberto
R
Elosua
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.
Inge
I
Kirchberger
Second Department of Cardiology, University of Athens Medical School, Attikon University Hospital, Athens, Greece.
Dimitrios
D
Farmakis
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.
Unto
U
Häkkinen
Department of Epidemiology, Health Authority Roma E, Lazio Regional Health Service, Rome, Italy.
Danilo
D
Fusco
Istituto Superiore di Sanità (ISS), Rome, Italy.
Marina
M
Torre
European Hospital and Healthcare Federation (HOPE), Brussels, Belgium.
Pascal
P
Garel
Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Porto, Portugal.
Carla
C
Araújo
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.
Christa
C
Meisinger
Second Department of Cardiology, University of Athens Medical School, Attikon University Hospital, Athens, Greece.
John
J
Lekakis
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.
Antti
A
Malmivaara
Department of Epidemiology, Health Authority Roma E, Lazio Regional Health Service, Rome, Italy.
Maria
M
Dovali
Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Porto, Portugal.
Marta
M
Pereira
Cardiovascular Epidemiology and Genetics, Municipal Institute of Health Assistance-Municipal Institute of Medical Research (IMAS-IMIM), Barcelona, Spain.
Jaume
J
Marrugat
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.
Jean
J
Ferrières
D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy; D017677:Age Distribution; D000368:Aged; D005060:Europe / Q000453:epidemiology; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000379:methods*; D011159:Population Surveillance / Q000379:methods*; D011446:Prospective Studies; D012042:Registries; D018570:Risk Assessment / Q000379:methods*; D017678:Sex Distribution; D015912:Thrombolytic Therapy / Q000379:methods*; D016896:Treatment Outcome