Myocardial infarction case-fatality gradient in three French regions: the influence of acute coronary care.
Level 3 - non-randomized controlled study
Multi-centre prospective observational cohort/registry study
PubMed 8002182 · doi:10.1093/ije/23.4.700
What was done
Researchers analyzed 813 hospitalized premature myocardial infarction (MI) cases in patients aged 25–64 registered during 1989 across three French WHO-MONICA registry centers: Lille (North), Strasbourg (East), and Toulouse (South). The study compared pre-hospital, in-hospital, and discharge cardiovascular management and evaluated 28-day case-fatality rates using multivariable modeling adjusting for disease severity and acute coronary care interventions.
What was found
Unadjusted 28-day case fatality exhibited a pronounced geographic gradient: 30.6% in Lille, 17.5% in Strasbourg, and 9.9% in Toulouse (P < 0.0001). Treatment patterns differed significantly across sites: Toulouse used thrombolytic agents (P < 0.01) and invasive procedures (coronary angiography, angioplasty, bypass surgery; P < 0.0001) most frequently; Strasbourg prescribed 15% less aspirin/antiplatelet therapy (P < 0.0001) and twice as many diuretics as Toulouse (P < 0.0001). Lille patients presented with markers of higher baseline disease severity, including more frequent anterior ECG changes (P < 0.02), co-prescription of inotropes and diuretics (P < 0.04), and longer intensive care unit stays (P < 0.0001). After adjusting for these clinical and therapeutic factors, the 28-day case-fatality rate remained significantly elevated in Lille compared to the other centers (adjusted OR 3.27, 95% CI: 1.69–6.32, P < 0.0001).
Why it matters
Regional disparities in MI survival across France are not primarily explained by differences in acute hospital care or invasive intervention rates, indicating that underlying population risk profiles, baseline disease severity, or pre-hospital factors drive the North–South mortality gradient.
Limits
The cohort was restricted to individuals aged 25–64 presenting in 1989, excluding older patients who bear the majority of MI mortality. The observational registry design cannot rule out residual confounding from unmeasured clinical severity, socioeconomic disparities, out-of-hospital delays, or lifestyle differences between regions. Clinical management practices have also evolved substantially since the 1989 study period.
Cited by
- supports Toulouse has the lowest rate of coronary artery disease in France.