International guidelines for management of patients with an acute coronary syndrome (ACS) seek to improve the care of all patients, regardless of geographic location, and would be expected to reduce variation in outcomes between patients in different countries. However, national differences persist as detailed in the study by Dr. Andre and colleagues (see page 1201) who explored data from a population based cohort of over 12,000 consecutive patients with ACS in six European countries. As might be expected, differences in baseline characteristics explained some of the variation between countries for in-hospital mortality rates, which ranged from 15.1% in Germany to 4.9% in Spain for ST-elevation myocardial infarction (STEMI) patients. However, even after extensive adjustment for baseline factors, significant differences were still evident (Figure 1).