The Cardiovascular World Is Definitely Not Flat

Thomas Friedman’s revolutionary book The World Is Flat describes how recent changes in technology are transforming the world.1 The ubiquitous nature of the Internet now facilitates rapid information exchange, thus empowering the consumer. As a result, the world is becoming more “flat”; ie, traditional regional boundaries are breaking down, and opportunities are more evenly spread. In stark contrast to this new world of commerce, Ko and colleagues2 demonstrate just how “nonflat” the cardiovascular world has been. Rather than homogenized delivery of evidence-based care, the authors observe remarkable intercountry and intracountry variability in both treatments and outcomes.Article p 196 The study by Ko et al, published in this week’s Circulation , was well performed. The authors had access to detailed clinical information on a large random sample of US Medicare acute myocardial infarction (AMI) patients and a similar cohort of elderly AMI patients from Ontario, Canada, all hospitalized between 1998 and 2001. The authors paid special attention to creating similar entry criteria and examining comparable process indicators. Short and intermediate outcomes also were compared only after risk adjustment. Overall, the study found that AMI patients hospitalized in the United States were slightly less likely to receive aspirin, β-blockers, or angiotensin-converting enzyme inhibitors but much more likely to receive invasive cardiac procedures than their Canadian peers. Yet, the study also demonstrates that the term, US AMI care, is a misnomer in that regional differences within the United States were as large as or larger than those seen across international boundaries.An important first question is whether these findings are of historical interest or applicable to current day practice. Since the 1990s, many publications have highlighted the problems of underuse of evidence-based AMI therapies. Thankfully, recent data demonstrate that the gap between evidence and practice is narrowing.3–6 Using data …