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MI survival rates higher in Sweden than UK
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New data suggest that MI survival rates are markedly higher in Sweden than in the United Kingdom, likely because of quicker adoption of new technologies and guidelines.
“Our findings are a cause for concern,” researcher Harry Hemingway, PhD, of University College London, said in a press release. “The uptake and use of new technologies and effective treatments recommended in guidelines has been far quicker in Sweden. This has contributed to large differences in the management and outcomes of patients.”
The researchers chose to compare outcomes for acute MI in Sweden and the United Kingdom (England and Wales) because they are the only countries with continuous national clinical registries for ACS with mandated participation for all hospitals. They also noted similarities in the structure of the countries’ health systems, the proportion of gross domestic product spent on health care, and national policy guidance provided for evidence-based management of acute MI.
The study included data for 119,786 patients in Sweden and 391,077 in the United Kingdom admitted for acute MI between 2004 and 2010.
The rate of the primary outcome, all-cause mortality within 30 days of admission, was 7.6% (95% CI, 7.4-7.7) in Sweden vs. 10.5% (95% CI, 10.4-10.6) in the United Kingdom. Mortality rates were higher in the United Kingdom in the following subgroups: all strata of troponin concentration, age and heart rate at admission; STEMI and non-STEMI patients; men; women; BP ≥110 mm Hg at admission; patients with and without diabetes; current smokers, and nonsmokers.
The researchers identified two effective treatments for which uptake was faster in Sweden than in the United Kingdom: primary PCI (Sweden, 59%; UK, 22%) and use of beta-blockers at discharge (Sweden, 89%; UK, 78%). However, prescription of ACE inhibitors, angiotensin receptor blockers and statins at discharge was higher in the United Kingdom than in Sweden.
After casemix standardization, Hemingway and colleagues found that the 30-day mortality ratio for the United Kingdom vs. Sweden was 1.37 (95% CI, 1.3-1.45), which corresponds to 11,263 excess deaths. However, the ratio declined from 1.47 in 2004 (95% CI, 1.38-1.58) to 1.2 in 2010 (95% CI, 1.12-1.29; P=.01).
“International comparisons of care and outcome registries might inform new research and policy initiatives to improve the quality of health systems,” the researchers wrote.
In a related editorial, Chris P. Gale, MRCP, PhD, of the University of Leeds, United Kingdom, and Keith A.A. Fox, MB, ChB, of the University of Edinburgh, Scotland, wrote that “through highlighting the prospect of a substantial excess of deaths in the [United Kingdom] compared with Sweden, Chung and colleagues have drawn our attention to the need to further concentrate on data enhancement through the linkage of electronic health care records and the early and systematic implementation of evidence-based therapies across the National Health Service.”
For more information:
Chung S-C. Lancet. 2014;doi:10.1016/S0140-6736(13)62070-X.
Gale CP. Lancet. 2014;doi:10.1016/S0140-6736(13)62367-3.
Disclosure: The researchers, Fox and Gale report no relevant financial disclosures.
Perspective
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Sripal Bangalore, MD
The article is interesting in that it highlights the difference in care patterns between two countries and possible differences in outcomes at least partially attributable to differences in care measures.
It is very difficult to make a causal association with this kind of analysis. It is in essence comparing apples to oranges. Primary PCI differences can certainly explain some aspects of it. Of note, even if the UK had adopted the primary PCI rates of Sweden, the mortality rate would have only been slightly reduced and still remained higher in the UK. The same was true for beta-blockers and the relationship was much weaker. To my thinking, this suggests a role for unmeasured confounders.
The No. 1 practice to achieve better 30-day survival is to shorten the total ischemic time. This starts with better-educated people who are aware of the perils of waiting too long after the onset of chest pain to seek help and a better-prepared emergency management system that can triage and identify these patients and send them to PCI-capable facilities. Finally, we have to make sure that the door-to-balloon time is short in these patients. Of course medical therapy with statins, beta-blockers and ACE inhibitors does help, but timely reperfusion is the key.
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