Downloaded from http://heart.bmj.com/ on June 11, 2015 - Published by group.bmj.com
Editorial
Seeking actual benchmarks in acute coronary syndromes for European countries: insights from the EURHOBOP registry Henrique B Ribeiro,1 Pedro A Lemos2
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 1
Department of Medicine, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; 2Department of Interventional Cardiology, Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil 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; [email protected]
Ribeiro HB, et al. Heart August 2014 Vol 100 No 15
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 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.
1147
Downloaded from http://heart.bmj.com/ on June 11, 2015 - Published by group.bmj.com
Editorial Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
To cite Ribeiro HB, Lemos PA. Heart 2014;100:1147–1148. Published Online First 14 May 2014
▸ http://dx.doi.org/10.1136/heartjnl-2013-305196 Heart 2014;100:1147–1148. doi:10.1136/heartjnl-2014-305957
REFERENCES 1
2
3
4
5
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
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
1148
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.
6
7
8
Steg PG, James SK, Atar D, et al.; Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33: 2569–619. Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054. Moran AE, Forouzanfar MH, Roth GA, et al. Temporal trends in ischemic heart disease mortality in 21 world regions, 1980 to 2010: the global burden of disease 2010 study. Circulation 2014;129:1483–92. Andre R, Bongard V, Elousa R, et al. International differences in acute coronary syndrome patients’ baseline characteristics, clinical management and outcomes in Western Europe: The EURHOBOP study. Heart 2014;100:1201–7. Mandelzweig L, Battler A, Boyko V, et al. The second Euro Heart Survey on acute coronary syndromes: Characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean Basin in 2004. Eur Heart J 2006;27:2285–93. Widimsky P, Wijns W, Fajadet J, et al. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. Eur Heart J 2010;31:943–57. Schiele F, Hochadel M, Tubaro M, et al. Reperfusion strategy in Europe: temporal trends in performance measures for reperfusion therapy in ST-elevation myocardial infarction. Eur Heart J 2010;31: 2614–24. Puymirat E, Battler A, Birkhead J, et al. Euro Heart Survey 2009 Snapshot: regional variations in presentation and management of patients with AMI in 47 countries. Eur Heart J Acute Cardiovasc Care 2013;2:359–70.
Ribeiro HB, et al. Heart August 2014 Vol 100 No 15
Downloaded from http://heart.bmj.com/ on June 11, 2015 - Published by group.bmj.com
Seeking actual benchmarks in acute coronary syndromes for European countries: insights from the EURHOBOP registry Henrique B Ribeiro and Pedro A Lemos Heart 2014 100: 1147-1148 originally published online May 14, 2014
doi: 10.1136/heartjnl-2014-305957 Updated information and services can be found at: http://heart.bmj.com/content/100/15/1147
These include:
References Email alerting service
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This article cites 7 articles, 7 of which you can access for free at: http://heart.bmj.com/content/100/15/1147#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Epidemiology (3482) Drugs: cardiovascular system (8370) Acute coronary syndromes (2602) Clinical diagnostic tests (4594) Diabetes (816) Interventional cardiology (2801) Metabolic disorders (981) Percutaneous intervention (921) Tobacco use (592)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Editorial
Seeking actual benchmarks in acute coronary syndromes for European countries: insights from the EURHOBOP registry Henrique B Ribeiro,1 Pedro A Lemos2
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 1
Department of Medicine, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; 2Department of Interventional Cardiology, Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil 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; [email protected]
Ribeiro HB, et al. Heart August 2014 Vol 100 No 15
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 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.
1147
Downloaded from http://heart.bmj.com/ on June 11, 2015 - Published by group.bmj.com
Editorial Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
To cite Ribeiro HB, Lemos PA. Heart 2014;100:1147–1148. Published Online First 14 May 2014
▸ http://dx.doi.org/10.1136/heartjnl-2013-305196 Heart 2014;100:1147–1148. doi:10.1136/heartjnl-2014-305957
REFERENCES 1
2
3
4
5
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
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
1148
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.
6
7
8
Steg PG, James SK, Atar D, et al.; Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33: 2569–619. Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054. Moran AE, Forouzanfar MH, Roth GA, et al. Temporal trends in ischemic heart disease mortality in 21 world regions, 1980 to 2010: the global burden of disease 2010 study. Circulation 2014;129:1483–92. Andre R, Bongard V, Elousa R, et al. International differences in acute coronary syndrome patients’ baseline characteristics, clinical management and outcomes in Western Europe: The EURHOBOP study. Heart 2014;100:1201–7. Mandelzweig L, Battler A, Boyko V, et al. The second Euro Heart Survey on acute coronary syndromes: Characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean Basin in 2004. Eur Heart J 2006;27:2285–93. Widimsky P, Wijns W, Fajadet J, et al. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. Eur Heart J 2010;31:943–57. Schiele F, Hochadel M, Tubaro M, et al. Reperfusion strategy in Europe: temporal trends in performance measures for reperfusion therapy in ST-elevation myocardial infarction. Eur Heart J 2010;31: 2614–24. Puymirat E, Battler A, Birkhead J, et al. Euro Heart Survey 2009 Snapshot: regional variations in presentation and management of patients with AMI in 47 countries. Eur Heart J Acute Cardiovasc Care 2013;2:359–70.
Ribeiro HB, et al. Heart August 2014 Vol 100 No 15
Downloaded from http://heart.bmj.com/ on June 11, 2015 - Published by group.bmj.com
Seeking actual benchmarks in acute coronary syndromes for European countries: insights from the EURHOBOP registry Henrique B Ribeiro and Pedro A Lemos Heart 2014 100: 1147-1148 originally published online May 14, 2014
doi: 10.1136/heartjnl-2014-305957 Updated information and services can be found at: http://heart.bmj.com/content/100/15/1147
These include:
References Email alerting service
Topic Collections
This article cites 7 articles, 7 of which you can access for free at: http://heart.bmj.com/content/100/15/1147#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Epidemiology (3482) Drugs: cardiovascular system (8370) Acute coronary syndromes (2602) Clinical diagnostic tests (4594) Diabetes (816) Interventional cardiology (2801) Metabolic disorders (981) Percutaneous intervention (921) Tobacco use (592)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
