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Original article
International differences in acute coronary syndrome patients’ baseline characteristics, clinical management and outcomes in Western Europe: the EURHOBOP study
  1. Romain André1,
  2. Vanina Bongard2,
  3. Roberto Elosua3,4,
  4. Inge Kirchberger5,
  5. Dimitrios Farmakis6,
  6. Unto Häkkinen7,
  7. Danilo Fusco8,
  8. Marina Torre9,
  9. Pascal Garel10,
  10. Carla Araújo11,
  11. Christa Meisinger5,
  12. John Lekakis6,
  13. Antti Malmivaara7,
  14. Maria Dovali8,
  15. Marta Pereira11,
  16. Jaume Marrugat3,
  17. Jean Ferrières1,2
  1. 1Department of Cardiology, Toulouse Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France
  2. 2Department of Epidemiology, Health Economics and Public Health, AEPMCV, UMR1027 INSERM-University of Toulouse III, Toulouse University Hospital (CHU), Toulouse, France
  3. 3Cardiovascular Epidemiology and Genetics, Municipal Institute of Health Assistance—Municipal Institute of Medical Research (IMAS-IMIM), Barcelona, Spain
  4. 4Centros de Investigación Biomédica en Red (CIBER) Epidemiology and Public Health (CIBERESP), Barcelona, Spain
  5. 5Helmholtz Centre Munich—German Research Centre for Environmental Health, Institute of Epidemiology II, Neuherberg, Germany; Central Hospital Augsburg, MONICA/KORA Myocardial Infarction Registry, Augsburg, Germany
  6. 6Second Department of Cardiology, University of Athens Medical School, Attikon University Hospital, Athens, Greece
  7. 7National Institute for Health and Welfare (THL), Centre for Health and Social Economics (CHESS), Helsinki, Finland Health Services Research of the National Research and Development Centre for Welfare and Health, Helsinki, Finland
  8. 8Department of Epidemiology, Health Authority Roma E, Lazio Regional Health Service, Rome, Italy
  9. 9Istituto Superiore di Sanità (ISS), Rome, Italy
  10. 10European Hospital and Healthcare Federation (HOPE), Brussels, Belgium
  11. 11Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Porto, Portugal
  1. Correspondence to Professor Jean Ferrieres, Department of Cardiology, Toulouse University Rangueil Hospital, TSA 50032, 31059 Toulouse Cedex 9, France; jean.ferrieres{at}


Objective We aimed to describe current characteristics of patients admitted for acute coronary syndrome (ACS) in Western Europe and to analyse whether international in-hospital mortality variations are explained by differences in patients’ baseline characteristics and in clinical management.

Methods We studied a population-based longitudinal cohort conducted in Finland, France, Germany, Greece, Portugal and Spain, and comprising 12 231 consecutive ACS patients admitted in 53 hospitals between 2008 and 2010. Baseline characteristics, clinical management and inhospital outcomes were recorded. Contextual effect of country on death was analysed through multilevel analysis.

Results Of all patients included, 8221 (67.2%) had NSTEMI (non-ST-elevation myocardial infarction), and 4010 (32.8%) had STEMI (ST-elevation myocardial infarction). Inhospital mortality ranged from 15.1% to 4.9% for German and Spanish STEMI patients, and from 6.8% to 1.9% for Finnish and French NSTEMI patients (p<0.001 for both). These international variations were explained by differences in patients’ baseline characteristics (older patients more likely to have cardiogenic shock in Germany) and in clinical management, with differences in rates of thrombolysis (less performed in Germany) and primary percutaneous coronary intervention (high in Germany, low in Greece). A remaining contextual effect of country was identified after extensive adjustment.

Conclusions Inhospital mortality rates of STEMI and NSTEMI patients were two to three times higher in Finland, Germany and Portugal than in Greece and Spain, with intermediate values for France. Differences in baseline characteristics and clinical management partly explain differences in outcome. Our data also suggest an impact of the healthcare system organisation.

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