Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK

Sheng-Chia Chung, Rolf Gedeborg, Owen Nicholas, Stefan James, Anders Jeppsson, Charles Wolfe, Peter Heuschmann, Lars Wallentin, John Deanfield, Adam Timmis, Tomas Jernberg, Harry Hemingway, Sheng-Chia Chung, Rolf Gedeborg, Owen Nicholas, Stefan James, Anders Jeppsson, Charles Wolfe, Peter Heuschmann, Lars Wallentin, John Deanfield, Adam Timmis, Tomas Jernberg, Harry Hemingway

Abstract

Background: International research for acute myocardial infarction lacks comparisons of whole health systems. We assessed time trends for care and outcomes in Sweden and the UK.

Methods: We used data from national registries on consecutive patients registered between 2004 and 2010 in all hospitals providing care for acute coronary syndrome in Sweden and the UK. The primary outcome was all-cause mortality 30 days after admission. We compared effectiveness of treatment by indirect casemix standardisation. This study is registered with ClinicalTrials.gov, number NCT01359033.

Findings: We assessed data for 119,786 patients in Sweden and 391,077 in the UK. 30-day mortality was 7·6% (95% CI 7·4-7·7) in Sweden and 10·5% (10·4-10·6) in the UK. Mortality was higher in the UK in clinically relevant subgroups defined by troponin concentration, ST-segment elevation, age, sex, heart rate, systolic blood pressure, diabetes mellitus status, and smoking status. In Sweden, compared with the UK, there was earlier and more extensive uptake of primary percutaneous coronary intervention (59% vs 22%) and more frequent use of β blockers at discharge (89% vs 78%). After casemix standardisation the 30-day mortality ratio for UK versus Sweden was 1·37 (95% CI 1·30-1·45), which corresponds to 11,263 (95% CI 9620-12,827) excess deaths, but did decline over time (from 1·47, 95% CI 1·38-1·58 in 2004 to 1·20, 1·12-1·29 in 2010; p=0·01).

Interpretation: We found clinically important differences between countries in acute myocardial infarction care and outcomes. International comparisons research might help to improve health systems and prevent deaths.

Funding: Seventh Framework Programme for Research, National Institute for Health Research, Wellcome Trust (UK), Swedish Association of Local Authorities and Regions, Swedish Heart-Lung Foundation.

Copyright © 2014 Chung et al. Open Access article distributed under the terms of CC BY-NC-ND. Published by Elsevier Ltd. All rights reserved.

Figures

Figure 1
Figure 1
Study population AMI=acute myocardial infarction. ID=identifier.
Figure 2
Figure 2
Use of reperfusion or fibrinolysis to treat STEMI and medication at discharge among all patients, by year (A) Primary PCI and (B) fibrinolysis, including any given before admission or in hospital. (C) Any antiplatelet therapy and statin and (D) use of β blockers and ACEI or ARBs among all acute myocardial infarction patients who survived to discharge. STEMI=ST-segment-elevation myocardial infarction. PCI=percutaneous coronary intervention. ACEI=angiotensin-converting-enzyme inhibitor. ARB=angiotensin-receptor blocker.
Figure 3
Figure 3
Kaplan-Meier curves for cumulative mortality at 30 days after admission with acute myocardial infarction in Sweden and the UK *Time of censoring or vital status at 30 days missing for 129 patients in the UK.
Figure 4
Figure 4
30-day mortality of UK patients admitted in each study year, standardised according to the Swedish casemix model p=0·01 for linear trend across years for the relative risks. AMI=acute myocardial infarction.

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