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To investigate geographic disparity in long-term mortality following revascularization in patients with complex coronary artery disease (CAD). The SYNTAXES trial randomized 1800 patients with three-vessel and/or left main CAD to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) and assessed their survival at 10 years. Patients were stratified according to the region of recruitment: North America (N-A, n = 245), Eastern Europe (E -E, n = 189), Northern Europe (N-E, n = 425), Southern Europe (S-E, n = 263), and Western Europe (W-E, n = 678), which also served as the reference group. Compared to W-E, patients were younger in E-E (62 vs 65 years, p < 0.001), and less frequently male in N-A (65.3% vs 79.6%, p < 0.001). Diabetes (16.0% vs 25.4%, p < 0.001) and peripheral vascular disease (6.8% vs 10.9%, p = 0.025) were less frequent in N-E than W-E. Ejection fraction was highest in W-E (62% vs 56%, p < 0.001). Compared to W-E, the mean anatomic SYNTAX score was higher in S-E (29 vs 31, p = 0.008) and lower in N-A (26, p < 0.001). Crude ten-year mortality was similar in N-A (31.6%), and W-E (30.7%), and significantly lower in E -E (22.5%, p = 0.041), N-E (21.9%, p = 0.003) and S-E (22.0%, p = 0.014). Compared to W-E, adjusted mortality in N-E (HR 0.85, p = 0.019) and S-E (HR 0.72, p = 0.043) remain significantly lower after adjustment for pre- and peri-procedural factors, but no significant interaction (P interaction = 0.728) between region and modality of revascularization was seen. In the era of globalization, knowledge, and understanding of geographic disparity are of paramount importance for the correct interpretation of global studies. [Display omitted] • This is the first report of the geographic disparity in the SYNTAXES trial. • The region was divided into 5 according to the United Nations geoscheme. • Ten-year mortality was significantly higher in Western Europe and North America. • Northern and Southern Europe had lower 10-year mortality even after adjustment. • No significant interactions between the geographic disparity and revascularization. [ABSTRACT FROM AUTHOR]

Despite the overall neutral results of the GLOBAL-LEADERS trial, results from a prespecified subgroup analysis showed that patients from Western Europe had a significantly lower rate of the primary endpoint when treated with ticagrelor monotherapy. Therefore, we aimed to examine the regional disparities in patients' baseline characteristics and their response to ticagrelor monotherapy. Patients' baseline characteristics and the treatment effects of ticagrelor combined with aspirin for 1 month, followed by ticagrelor monotherapy for 23-months versus 12-months of standard dual antiplatelet therapy (DAPT) were compared according to participating countries. The primary endpoint was a composite endpoint of all-cause death or new Q-wave myocardial infarction at two years. Significant variances in patients' baseline characteristics were found between participating countries. The primary endpoint varied significantly according to the country (P interaction = 0.027). Patients from France (1.6% versus 5.2%, HR: 0.31, 95%CI: 0.13–0.73) and The Netherlands (2.4% versus 4.8%, HR, 0.50, 95%CI: 0.26–0.94) had lower rates of the primary endpoint when allocated to ticagrelor monotherapy, compared with the standard DAPT regimen. Of the 26 baseline and post-randomization factors explored, variance in the rate of complex PCI between countries was identified as the top contributor to this regional interaction. Patients' baseline characteristics varied between participating countries in the GLOBAL-LEADERS trial. There is a significant regional variance in the treatment effect of ticagrelor monotherapy, which could partly be explained by the differences in complex PCI being performed. Clinical Trial Registration: ClinicalTrials.gov (NCT01813435). • A geographic heterogeneity in the primary outcome of the GLOBAL-LEADERS trial was observed. • Variances in the complexity of PCI between countries might be the leading cause of the geographic heterogeneity. • Stratifying enrollment per country will strengthen the internal validity of the trial results. [ABSTRACT FROM AUTHOR]