Geographic variation in patient and hospital characteristics, management, and clinical outcomes in ST-elevation myocardial infarction treated with fibrinolysis - Results from InTIME-II

Aims We examined the geographic variations in InTIME-II, a randomized doubl e-blind trial comparing alteplase with lanoteplase for myocardial infarctio n. Methods and Results We compared baseline characteristics management, and ou tcomes in four re.-ions (Western Europe, Eastern Europe, North America, and Latin America) and in countries with historically different management app roaches (Germany vs the U.K., the U.S. vs Canada). Thirty-day mortality in Western Europe, Eastern Europe, North America and Latin America was 6.7%, 7 .3%, 5.7%, 10.1%, P<0.0001. Adjusted mortality for Europe was intermediate between North America and Latin America (odds ratios (OR) [95% confidence i ntervals (CI)] compared to Western Europe: North America 0.84 [0.67-1.0], E astern Europe 1.2 [1.0-1.4], and Latin America 1.8 [1.3-2.7]). Revasculariz ation rates varied 10-fold but did not explain regional mortality differenc es. Germany and the U.K. had similar adjusted 1-year mortality (OR for the U.K. 1.16 [0.92-1.5]), although invasive procedures were four- to 10-fold m ore common in Germany. Similarly the U.S. and Canada had equal adjusted 1-y ear mortality (OR for Canada 0.85 [0.61-1.17]) despite three-fold higher us e of invasive procedures in the U.S. Conclusions Significant geographic variations in practice and adjusted mort ality following fibrinolysis persist despite recent guidelines. These findi ngs have important implications in the design and interpretation of interna tional studies, identify under- and over-utilized therapies, and support fu rther study of treatments with marked worldwide variations.