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Original research article
International comparison of acute myocardial infarction care and outcomes using quality indicators
  1. Oren Zusman1,2,
  2. Owen Bebb3,
  3. Marlous Hall3,
  4. Tatendashe Bernadette Dondo3,
  5. Adam Timmis4,
  6. Francois Schiele5,
  7. Keith AA Fox6,
  8. Ran Kornowski1,2,
  9. Chris P Gale3,
  10. Zaza Iakobishvili1,2,7
  1. 1 Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
  2. 2 Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
  3. 3 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
  4. 4 NIHR Cardiovascular Biomedical Research Unit, Barts Health Centre London, London, UK
  5. 5 Department of Cardiology, University Hospital of Besancon, University of Franche-Comté, Franche-Comté, France
  6. 6 Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
  7. 7 Department of Community Cardiology, Tel Aviv Jaffa District, Clalit Health Services, Tel Aviv, Israel
  1. Correspondence to Zaza Iakobishvili, Department of Community Cardiology, Tel Aviv Jaffa District, Clalit Health Services, 15 Naomi Shemer str., 5840608, Holon, Israel; zaza.iakobishvili{at}


Objective To compare temporal changes in European Society of Cardiology (ESC) acute myocardial infarction (AMI) quality indicator (QI) attainment in the UK and Israel.

Methods Data cross-walking using information from the Myocardial Ischaemia National Audit Project and the Acute Coronary Syndrome in Israel Survey for matching 2-month periods in 2006, 2010 and 2013 was used to compare country-specific attainment of 14 ESC AMI QIs.

Results Patients in the UK (n=17 068) compared with Israel (n=5647) were older, more likely to be women, and had less diabetes, dyslipidaemia and heart failure. Baseline ischaemic risk was lower in Israel than the UK (Global Registry of Acute Coronary Events (GRACE) risk, 110.5 vs 121.0). Overall, rates of coronary angiography (87.6% vs 64.8%) and percutaneous coronary intervention (70.3% vs 41.0%) were higher in Israel compared with the UK. Composite QI performance increased more in the UK (1.0%–86.0%) than Israel (70.2%–78.0%). Mortality rates at 30 days declined in each country, with lower rates in Israel in 2013 (4.2% vs 7.6%). Composite QI adherence adjusted for GRACE risk score was inversely associated with 30-day mortality (OR 0.95; CI 0.95 to 0.97, p<0.001).

Conclusions International comparisons of guideline recommended AMI care and outcomes can be quantified using the ESC AMI QIs. International implementation of the ESC AMI QIs may reveal country-specific opportunities for improved healthcare delivery.

  • acute myocardial infarction
  • quality and outcomes of care

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  • †Dr Oren Zusman died on 29 January 2019.

  • Contributors OZ, OB, ZI and CPG have contributed to the conception or design of the work. OZ, OB, TBD, MH, ZI, CPG and AT have contributed to the acquisition of data. OZ, OB, ZI, CPG, RK, FS, AT and KAAF have contributed to analysis or interpretation of data. OZ, OB, CPG, ZI agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors took part in drafting the work or revising it critically for important intellectual content, and all authors gave final approval of the version published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Author note We respect Dr. Oren Zusman’s untimely death on January 29th, 2019. Dr. Zusman was an extremely talented and passionate physician-researcher, with a brilliant future ahead of him. He will be deeply missed by all of his colleagues, friends, and family. He is survived by his wife, Maayan, and three children. May his memory be a blessing.

  • Patient consent for publication Not required.

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