Outcomes, Health Policy, and Managed Care
Variation in patient management and outcomes for acute coronary syndromes in Latin America and North America: Results from the Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial,☆☆

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Abstract

Background Although more than 9500 patients have been enrolled in major clinical trials in Latin America, practice patterns in this region have rarely been examined. We sought to compare characteristics, resource utilization, and outcomes of patients treated for acute coronary syndromes in Latin America with those in North America. Methods The Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Theraphy Trial (PURSUIT) enrolled 10,948 patients with non-ST-segment elevation acute coronary syndromes, including 585 in Latin America and 4358 in North America. We analyzed regional differences in patient groups, treatment patterns, and outcomes and used logistic regression analysis to identify association of enrollment region and survival. Results For patients in Latin America, the length of hospital stay was significantly longer (10 [7, 15] days vs 6 [4, 9], P <.001). Angiograms, angioplasty, and bypass surgery were significantly less common in Latin America (46.2%, 17.6%, and 11.3% vs 79.4%, 33.6%, and 19.4%, P <.001). Thirty-day death/myocardial infarction was not significantly higher, although mortality alone was significantly higher (6.8% vs 3.1%, P <.001). After adjustment for baseline characteristics, enrollment in Latin America remained an independent predictor for death at 30 days (odds ratio [OR] [95% confidence interval (CI)] 2.42 [1.60–3.67]) and persisted at 6 months (OR [95% CI] 2.5 [1.8-3.4]). Conclusions Latin American patients treated for acute coronary syndromes were managed less invasively and were twice as likely as their North American counterparts to die within 6 months. This mortality difference was not explained by imbalances in baseline risk. (Am Heart J 2001;141:391-401.)

Section snippets

Patient population

The design and results of the PURSUIT study have been published elsewhere.13 Between November 1995 and January 1997, 10,948 patients were randomized in 726 participating hospitals in 28 countries. Briefly, patients with ischemic chest pain at rest within the previous 24 hours and either creatine kinase subfraction MB (CK-MB) elevation or electrocardiographic changes were randomly assigned in a double-blind manner to placebo or 2 regimens of eptifibatide. Study drug was infused for 72 hours or

Patient characteristics

A total of 585 patients were enrolled in 68 hospitals from 8 Latin American countries and 4358 patients were enrolled in 307 hospitals in North America. Table I depicts the distribution of enrollment by country.

. Latin American enrollment by country

CountryNo.%
Mexico20034.2
Argentina15125.8
Venezuela9315.9
Colombia6110.4
Chile467.9
Guatemala203.4
Uruguay91.5
El Salvador50.9
Total585100.0
Compared with North Americans, Latin Americans were younger, shorter, lighter, and had fewer previous revascularization

Discussion

This study explored the process of care and outcomes of 585 patients treated for non-ST-segment elevation acute coronary syndromes in Latin America. It provides the first international comparison of Latin America as a region with North America (United States and Canada) with respect to these variables. In summary, the findings suggest that patient management in Latin America is more conservative and associated with higher mortality at 1 and 6 months than in North America. These differences in

Acknowledgements

We would like to acknowledge the excellent editorial assistance of Mr John M. Daniel in the preparation of the manuscript.

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    Supported by grants from Cor Therapeutics, San Francisco, Calif, and Key Schering Plough, Kenilworth, NJ.

    ☆☆

    Reprint requests: Mauricio G. Cohen, MD, Servicio de Cardiología Intervencionista, Hospital Italiano de Buenos Aires, Cervino 3670-7° piso, 1425-Buenos Aires, Argentina. E-mail: [email protected]

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