Regional variations in hospital management and post-discharge mortality in patients with non-ST-segment elevation acute coronary syndrome
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Therapeutic variability not explained by patient clinical characteristics is a potential source of avoidable morbidity and mortality. We aimed to explore regional variability in the management and mortality of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS).
Methods and results
11,931 NSTE-ACS hospital survivors enrolled in two prospective registries: EPICOR [5625 patients, 555 hospitals, 20 countries in Europe (E) and Latin America (LA), September 2010–March 2011] and EPICOR Asia (6306 patients, 218 hospitals, 8 countries, June 2011–May 2012) were compared among eight pre-defined regions: Northern E (NE), Southern E (SE), Eastern E (EE); Latin America (LA); China (CN), India (IN), South-East Asia (SA), and South Korea, Hong Kong and Singapore (KS). Patient characteristics differed between regions: mean age (lowest 59 years, IN; highest 65.9 years, SE), diabetes (21.4% NE; 35.5% IN) and smoking (32% NE; 62% IN). Variations in dual antiplatelet therapy at discharge (lowest 83.1%, IN; highest 97.5%, SA), coronary angiography (53.9% SA; 90.6% KS), percutaneous coronary intervention (35.8% SA; 78.6% KS) and coronary artery bypass graft (0.7% KS; 5.7% NE) were observed. Unadjusted 2-year mortality ranged between 3.8% in KS and 11.7% in SE. Two-year, risk-adjusted mortality rates ranged between 5.1% (95% confidence interval 2.9–7.3%) in KS to 10.5% (8.3–12.7%) in LA.
Wide regional variations in patient features, hospital care, coronary revascularization and post-discharge mortality are present among patients hospitalized for NSTE-ACS. Focused regional interventions to improve the quality of care for NSTE-ACS patients are still needed.
KeywordsAcute coronary syndrome Hospital discharge Mortality Regional variability
Editorial support was provided by Carl V Felton PhD of Prime (Knutsford, Cheshire, UK), supported by AstraZeneca. Ultimate responsibility for opinions, conclusions, and data interpretation lies with the author. X.R. has received support from the SEC-CNIC CARDIOJOVEN fellowship program.
Compliance with ethical standards
Conflict of interest
H.B. has received consulting fees from Abbott, AstraZeneca, Bayer, BMS, Novartis and Pfizer; speaking fees from AstraZeneca, Bayer, BMS-Pfizer, Ferrer, Novartis, Servier and MEDSCAPE-the heart.org; and fees for research activities from AstraZeneca, BMS, Janssen, Novartis; S.P. has received research funding from AstraZeneca. F.v.d.W. has received consulting fees and research grants from Boehringer Ingelheim and Merck, and consulting fees from Roche, Sanofi-Aventis, AstraZeneca, and The Medicines Company. C.T.C. has received research support from Eli Lilly, honoraria from Medtronic, and has been a consultant or advisory board member for AstraZeneca. N.D. has received consulting or speaking fees from AstraZeneca, BMS, Boehringer-Ingelheim, GSK, MSD-Schering Plough, Novartis, Pierre Fabre, Pfizer, Roche, Sanofi-Aventis, Servier, Takeda, and The Medicines Company. J.M. and A.V. are employees of AstraZeneca. X.R., S.W-L.L. and Y.H. have nothing to disclose.
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