A Comparison of Management Patterns after Acute Myocardial Infarction in Canada and the United States
Jean L. Rouleau, Lemuel A. Moye, Marc A. Pfeffer, J. Malcolm O. Arnold, Victoria Bernstein, Thomas E. Cuddy, Gilles R. Dagenais, Edward M. Geltman, Steven Goldman, David Gordon, Peggy Hamm, Marc Klein, Gervasio A. Lamas, John McCans, Patricia McEwan, Francis J. Menapace, John O. Parker, Francois Sestier, Bruce Sussex, Eugene Braunwald, for The SAVE Investigators
Background There are major differences in the organization ofthe health care systems in Canada and the United States. Wehypothesized that these differences may be accompanied by differencesin patient care.
Methods To test our hypothesis, we compared the treatment patternsfor patients with acute myocardial infarction in 19 Canadianand 93 United States hospitals participating in the Survivaland Ventricular Enlargement (SAVE) study, which tested the effectivenessof captopril in this population of patients after a myocardialinfarction.
Results In Canada, 51 percent of the patients admitted to aparticipating coronary care unit had acute myocardial infarctions,as compared with only 35 percent in the United States (P<0.001).Despite the similar clinical characteristics of the 1573 U.S.patients and 658 Canadian patients participating in the study,coronary arteriography was more commonly performed in the UnitedStates than in Canada (in 68 percent vs. 35 percent, P<0.001),as were revascularization procedures before randomization (31percent vs. 12 percent, P<0.001). During an average follow-upof 42 months, these procedures were also performed more commonlyin the United States than in Canada. These differences werenot associated with any apparent difference in mortality (22percent in Canada and 23 percent in the United States) or rateof reinfarction (14 percent in Canada and 13 percent in theUnited States), but there was a higher incidence of activity-limitingangina in Canada than in the United States (33 percent vs. 27percent, P<0.007).
Conclusions The threshold for the admission of patients to acoronary care unit or for the use of invasive diagnostic andtherapeutic interventions in the early and late periods afteran infarction is higher in Canada than in the United States.This is not associated with any apparent difference in the rateof reinfarction or survival, but is associated with a higherfrequency of activity-limiting angina.
Source Information
From the Universite de Sherbrooke, Sherbrooke, Que. (J.L.R.); Victoria Hospital, London, Ont. (J.M.O.A.); University of British Columbia, Vancouver (V.B.); University of Manitoba, Winnipeg (T.E.C.); Institut de Cardiologie de Quebec, Quebec City (G.R.D.); Hopital du Sacre-Coeur de Montreal, Montreal (M.K.); Jewish General Hospital, Montreal (J.M.); the Wellesley Hospital, Toronto (P.M.); Kingston General Hospital, Kingston, Ont. (J.O.P.); Hopital Notre-Dame de Montreal, Montreal (F.S.); and Memorial University of St. John's, Newf. (B.S.) -- all in Canada; and the University of Texas Health Science Center at Houston (L.A.M., P.H.); Harvard Medical School and Brigham and Women's Hospital, Boston (M.A.P., G.A.L., E.B.); Washington University School of Medicine, St. Louis (E.M.G.); Veterans Affairs Medical Center, Tucson, Ariz. (S.G.); Cardiology Associates, Des Moines, Iowa (D.G.); and the Geisinger Medical Center, Danville, Pa. (F.J.M.).
Address reprint requests to Dr. Rouleau at the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada.
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