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Seeking actual benchmarks in acute coronary syndromes for European countries: insights from the EURHOBOP registry
  1. Henrique B Ribeiro1,
  2. Pedro A Lemos2
  1. 1Department of Medicine, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
  2. 2Department of Interventional Cardiology, Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
  1. Correspondence to Dr Pedro A Lemos, Department of Interventional Cardiology, Heart Institute (InCor), University of São Paulo Medical School, Dr. Eneas Carvalho de Aguiar, 44. Bloco I, 3 andar, Hemodinâmica, São Paulo-SP 05403-000 Brazil; pedro.lemos{at}

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Cardiovascular diseases are the leading cause of morbidity and mortality worldwide, frequently elicited by acute coronary syndromes (ACS). Over the past decades, numerous large-scale randomised clinical trials have demonstrated the benefits of several interventions for the care of patients with ACS, including antiplatelet therapy, anticoagulation, and urgent or emergent cardiac catheterisation followed by revascularisation as appropriate. As a result, an increasing array of evidence-based cardiac medications and interventions have been rapidly adopted worldwide, fostered by multiple practice guidelines providing clear recommendations for clinicians.1 ,2

Recent evidences suggest that these remarkable advancements were associated with a significant decline in mortality from cardiovascular diseases in the recent years, more pronounced in high-income regions (especially Australasia, Western Europe and North America).3 Nonetheless, there are still marked disparities, with respect to the epidemiology, diagnostics and treatment of such patients with ACS, also leading to various morbidity and mortality rates throughout the globe. In this regard, a large number of prospective registries worldwide have been conducted over the last years in the context of ACS, aiming to provide standardised regional data to physicians, institutions and policy makers. The EURHOBOP registry (EURopean HOspital Benchmarking by Outcomes in acute coronary syndrome Processes) is one of these successful initiatives. Created in 2008, it intends to provide the European Community with valid standardised and adjusted benchmarking tools to allow European hospitals to monitor their outcomes in key procedures used in coronary artery disease.

Andre et al4 have evaluated within the EURHOBOP the current characteristics and in-hospital mortality of 12 231 patients admitted with ACS in 43 hospitals from six European countries. Similar to what has been previously shown, overall, approximately one-third of the patients were female and one-third presented with ST-segment elevation myocardial infarction (STEMI)5–7; diabetes mellitus was more prevalent in the Mediterranean countries, and smoking was more frequent in Greece and France. The average in-hospital mortality rates for STEMI and non-STEMI (NSTEMI) were 8.4% and 4.4%, respectively, but varied significantly among the studied countries, being higher in Finland, Germany and Portugal than in Greece and Spain.

Recently, another large-scale registry, the Euro Heart Survey series, detected a clear trend towards decreasing ACS mortality rates in Europe. In a report from the year 2006, there was a significant temporal reduction in the mortality of STEMI (from 8.1% to 6.6%; p=0.047),7 which was shown to continue to decrease in 2009, reaching 4.1% in Northern, 5.2% in Western, and 6.1% in Mediterranean countries.8 A number of factors have been raised as possible explanations for the improvement in outcomes seen in the Euro Heart Survey, including a more widespread use of prehospital thrombolysis and percutaneous coronary intervention, a greater proportion of patients reperfused in a timely manner, as well as a more appropriate use of adjunctive pharmacotherapy.7

The mortality rates reported in the present EURHOBOP study were somewhat higher than those in the previous Euro Heart Survey series. The apparent discrepancy may be, at least partially, explained by methodological differences between the two studies. While the Euro Heart Survey is a voluntary self-reporting observational study, the EURHOBOP is based on a group of European hospitals selected according to prespecified criteria, with a limited population of 200 consecutive patients/hospital. It is, therefore, evident that the potential impact of unforeseeable confounders and selection bias cannot be excluded to explain the differences in results. These differences in mortality among the various countries may also be appraised in figure 1, where the results from the EURHOBOP are compared to a recent survey among European societies of interventional cardiology, coordinated by the European Association for Percutaneous Cardiovascular Interventions (EAPCI), on reperfusion therapy for acute myocardial infarction.6

Figure 1

Comparison of the mortality rates for STEMI (A) and overall acute myocardial infarction (AMI; including STEMI and NSTEMI) (B) in the EURHOBOP (EURopean HOspital Benchmarking by Outcomes in acute coronary syndrome Processes) registry4 and in the European Association for Percutaneous Cardiovascular Interventions (EAPCI) survey for AMI.6

The death ensuing from ACS can occur either before, during, or after hospital admission. Obviously, in any given population, the specific prognoses of each of the three phases are markedly interdependent. Prehospital care has a major impact in modulating the profile of patients eventually reaching the hospital. Similarly, postdischarge outcomes rely strongly on the quality of the treatment during the index hospitalisation. Therefore, any study aiming to solely evaluate an isolate component of this complex chain will have to acknowledge that its results must be cautiously interpreted. The present study by Andre et al4 aimed to analyse the in-hospital outcomes of patients with ACS in six European countries. The comparative interpretation of their data is not straightforward. For instance, the authors observed that Germany has the worst in-hospital mortality for STEMI (15.1%) while maintaining a large use of primary PCI (84.7%). Conversely, Greece had a 5.0% in-hospital death even in a context of low reperfusion rate (thrombolysis in 46.2% and primary PCI in 18.4%). How should these contra-intuitive results be interpreted? Most probably, a more comprehensive appreciation about in-hospital outcomes would need additional information regarding prehospital features of the same populations. Accordingly, the authors acknowledged that the observed differences in in-hospital mortality could not be completely explained neither by baseline characteristics, nor in-hospital clinical management, or socioeconomic characteristics.

Nevertheless, with the inherent limitations of a registry, the EURHOBOP provided good quality data that should help to the better understanding of the actual scenario of the management of ACS in Western European countries.


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  • Contributors Both authors have read and approved submission of the manuscript. Both authors have contributed to this work as follows: (1) substantial contributions to the conception and design, acquisition of data or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; (3) final approval of the version to be published.

  • Funding HBR is supported by a research PhD grant from The National Council for Scientific and Technological Development (CNPq), Brazil. PAL is supported in part by a Researcher grant from CNPq.

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed. 

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