Heart attack outcomes vary widely among wealthy nations, study finds

U.S. has second-highest mortality rate, but ranks well in hospital readmissions

High-income nations, including the U.S., have much to learn from each other about how best to treat heart attacks, a new study finds.

The study compared treatments and outcomes among patients hospitalized for heart attack, or acute myocardial infarction (AMI), in the U.S. Canada, England, Israel, the Netherlands and Taiwan between 2014 and 2017. It found substantial variation in outcomes, despite established international diagnostic criteria and consensus about evidence-based treatments for AMI.

The study was produced by the International Health Systems Research Collaborative, which uses participants’ data to compare processes of care, outcomes, and efficiency measures across nations with highly developed health care systems but different methods of organizing and financing them.

The authors looked at three categories of AMI outcomes: coronary artery bypass procedures, mortality, and efficiency (measured by lengths of hospital stay and 30-day readmission rates.) In the category of procedures, they found large differences in the use of percutaneous coronary intervention (PCI), despite numerous studies demonstrating its benefits. Between 65% and 80% of patients hospitalized for heart attack in 2017 in the U.S., Israel, and Canada had PCI, compared with 35% in England and 50% in the Netherlands.

The study also showed that another procedure, coronary artery bypass grafting, was used from 50% to 100% more often in the U.S. than the other countries, even though current guidelines recommend it only for a small subset of patients, such as those with diabetes and extensive coronary artery disease. The authors speculate the difference is due to “the unique combination of a permissive regulatory environment in the U.S.” and high Medicare reimbursement.

Taiwan and the U.S. ranked worst in the mortality category, with deaths within one year of admission for ST-elevation myocardial infarction (STEMI) rates of 32.3% and 27.8%, respectively, while the Netherlands was best with a rate of 18.9%. However, the U.S. ranked second both for mean hospital length of stay (5.0 days) and 30-day readmission for STEMI (12.2%), behind the Netherlands and Taiwan, respectively.

“No health care system seemed to be excelling in every aspect of heart attack care,” Peter Cram, M.D., professor and chair of internal medicine at the University of Texas Medical Center at Galveston and one of the study’s authors, said in an accompanying news release, adding that the U.S.’s mortality rate “concernedly high.”

“The U.S. seems to focus really hard on those technologically advanced new and shiny things,” he said. “Maybe, from a policy perspective, we should focus more on the mortality rate instead of getting people in and out of the hospital.”

The study, “Variation in revascularisation use and outcomes of patients in hospital with acute myocardial infarction across six high income countries: cross sectional cohort study” was published May 4 in The BMJ.