International comparisons of acute myocardial infarction

Sheng-Chia Chung and colleagues report in The Lancet that, in their comparison of short-term outcomes in patients with acute myocardial infarction, unadjusted 30-day mortality was more than a third higher in the UK than in Sweden during 2004–10. They suggest that this diff erence is due largely to the divergent speed of implementation of policy initiatives to improve care. Chung and colleagues compared the UK data with those for Sweden because the two countries have similar health systems for, and spending on, acute myocardial infarction, but diff usion of evidence-based changes to practice and new technologies has been notably quicker in Sweden. Records for 119 786 patients in Sweden and 391 077 in the UK were assessed. This fundamental prognosis research, which used whole-country data, showed much higher unadjusted mortality in patients with acute myocardial infarction in the UK than in Sweden: 30-day mortality was 10·5% (95% CI 10·4–10·6) in the UK and 7·6% (7·4–7·7) in Sweden. The UK to Sweden standardised mortality ratio was 1·37 (1·30–1·45), which suggests that more than 11 000 deaths due to acute myocardial infarction might have been avoided during the period of the study. Importantly, although the diff erence in mortality rates decreased over time, mortality was always higher in the UK, even in clinical subgroups such as those defi ned by troponin concentration or ST-segment elevation. After standardisation for the Swedish casemix by use of a 17-variable model that took into account patients’ risk at baseline, UK 30-day mortality decreased by around 3%. This fi nding suggests that factors from the point of fi rst medical contact to 30 days from hospital admission diff erentially aff ect outcomes. Chung and colleagues explored what factors might account for the international diff erences in mortality. Their fi ndings imply that between-country diff erences in the use and dissemination of treatments recommended in guidelines was an important factor, as they noted that in the UK the uptake of primary percutaneous coronary In conclusion, although Anagnostou and colleagues provide further evidence that OIT is a potential treatment for food allergy, more high-quality data are needed. It is important to understand that OIT research cannot be rushed, and is years away from routine clinical use. Investigative groups need time to refi ne protocols, revalidate data, understand the mechanisms of OIT, and minimise adverse eff ects. This must be done without added pressure or heightened expectations to quickly produce a marketable therapy.