CardioExchange Archive

Patients with a ruptured abdominal aortic aneurysm (rAAA) have better outcomes in the United States than in England according to a new study published in the Lancet.

Researchers at the University of London compared hospital data from 11,799 rAAA patients in England with 23,838 rAAA patients in the U.S. They found that U.S. patients were more likely than English patients to have a procedure to repair the rAAA and to survive their hospital stay.

• The in-hospital mortality rate was 53.05% in the U.S. compared with 65.9% in England.
• A procedure to repair the rAAA, either surgical or endovascular, was performed in 80.43% of the U.S. patients compared with 58.45% of the English patients.
• U.S. patients were much more likely to receive an endovascular repair (20.88% versus 8.54%).

The intervention rate appeared to play a key role in the outcome, since the mortality rate was 41% in both countries among the patients who received an intervention. U.S. patients had shorter hospital stays and were more likely to be discharged to a skilled nursing facility. These factors may have partly skewed the data to favor the U.S.. The authors did not have access to 30-day mortality rates.

In both countries patients were at higher risk when they were admitted to the hospital on a weekend or to smaller or non teaching hospitals — probably a reflection of the reduced availability of a prompt intervention.

“The large mortality difference is concerning”, said co-author Peter Holt in a Lancet press release. “Our data suggest that failure to deliver proven life-saving surgery is a key reason why in-hospital survival for patients with rAAA is lower in England.”

The study suffers from the limitations of all observational studies, the differences between the groups, and the shorter followup period in the U.S., write Martin Björck and Kevin Manian in an accompanying editorial. But, they state, because of the large difference in outcome “the conclusions would probably not have been changed even if these issues had been addressed.”

However, they point out, the short-term perspective of the study probably masks a grimmer view of rAAA: “With modern intensive care, many patients with rAAA do survive the early postoperative period, but fail to recover fully. This is shown by the fact that mortality remains high up to 90 days following surgery after rAAA.”

Although efforts to improve access to appropriate treatment should be encouraged, appropriate screening and prevention is more important: “Prevention will prolong the lives of many more patients with AAA in the future than efforts to improve treatment of ruptured AAA.”