“Substantial differences” in care for patients with acute myocardial infarction have been found in six high-income countries, according to an analysis published today.
Despite the establishment of an international consensus on diagnosis and treatment of heart attacks, research by international health system research collaborative (IHSRC) investigators found different outcomes when they compared the USA, Canada, England, Netherlands, Israel, and Taiwan.
Writing in the latest edition of The BMJ, the team said they found low use of procedures to open up blood vessels in England and the Netherlands and high death rates after one year in the US and Taiwan.
The researchers compared treatment and outcomes for patients, aged 66 and over, admitted to hospital with acute myocardial infarction in the six countries between 2011 and 2017. The total number of hospital admissions ranged from 19,043 in Israel to 1,064,099 in the US.
The six countries were selected because all have highly developed healthcare systems and accessible administrative data, but differ in their financing, organisation, and overall performance in international rankings.
Outcomes were assessed separately for patients with two different types of heart attack: ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI).
Large differences were found between countries for all outcomes. The proportion of patients admitted to hospital with STEMI who received percutaneous coronary intervention in 2017 ranged from 36.9% in England to 78.6% in Canada.
Use of percutaneous coronary intervention for STEMI increased in all countries between 2011 and 2017, with particularly large rises in Israel, from 48.4% to 65.9%, and Taiwan, which rose from 49.4 to 70.2%.
The proportion of patients with NSTEMI who underwent coronary artery bypass graft within 90 days of admission during 2017 was lowest in the Netherlands at 3.5% and highest in the USA at 11.7%.
Death within one year of admission for STEMI in 2017 ranged from 18.9% in the Netherlands to 32.3% in Taiwan.
The average hospital length of stay in 2017 for STEMI was lowest in the Netherlands and the USA at 5.0 and 5.1 days respectively and highest in Taiwan at 8.5 days. The 30-day readmission for STEMI was lowest in Taiwan at 11.7% and the USA (12.2%) and highest in England, at 23.1%.
Although this is an observational study, the researchers say while all countries had areas of high performance, no country excelled in all three domains, which means all countries have important opportunities for improvement.
The BMJ also carries a report on new advice from a panel of experts, who recommend additional cholesterol-lowering drugs for adults who are at high risk of heart disease.
Writing as part of the “Rapid Recommendations” initiative, the international panel says patients should be offered additional cholesterol lowering drugs if they have 70mg/dl or higher of LDL cholesterol and are also at high risk of heart disease.
The experts assessed ezetimibe and PCSK9 inhibitors, after new evidence from 14 trials involving 83,660 patients showed these drugs probably reduce heart attacks and strokes in patients with very high and high cardiovascular risk, but not in patients with moderate and low cardiovascular risk.
PCSK9 inhibitors are more expensive than ezetimibe and statins and while the panel favours ezetimibe they say both “would provide important benefits for adults in the high and very high risk group but would be of little benefit for adults in the low risk group”.
Cram P, Hatfield LA, Bakx P et al. Variation in revascularisation use and outcomes of patients in hospital with acute myocardial infarction across six high income countries: cross sectional cohort study. BMJ 5 May 2022
Hao Q, Aertgeerts B, Guyatt G et al. PCSK9 inhibitors and ezetimibe for the reduction of cardiovascular events: a clinical practice guideline with risk-stratified recommendations. BMJ 5 May 2022.
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