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Another possibility is that regulations in Germany for catheterisation laboratories are less stringent than for cardiac surgery facilities, creating an environment conducive to a greater number of catheterisation laboratories. Of course, less stringent regulations for catheterisation laboratories are also likely the case in other countries as well. This is because high capital and resource costs associated with cardiac surgery facilities would make them a likelier target of regulations than less costly catheterisation laboratories.

3 the interrelationship between constraints on facilities, the number of facilities and number of revascularisations performed is not as straightforward. Certainly for Canada and Denmark, strong constraints have created an environment that is less conducive to having a large number of facilities per population than the US. However, in Germany for example, there are fewer cardiac surgery facilities per 100 000 population aged 40 and over than in Denmark, yet CABG utilisation rates in Germany are higher.

Another explanation is that these data may have captured a shift to PTCA for the younger age group. As mentioned previously, CABG is rarely used to treat AMI except in an emergency or as a follow-up elective procedure. It is possible the decline in the number of CABG performed within 90 days for younger persons in the US was due to a shift to more aggressive treatment of AMI, primary PTCA, where PTCA was used during the initial admission for AMI. 12 There also appears to be no significant differences between the proportion of males undergoing CABG and the corresponding proportions for females, with the exception of the United States, where the proportion of males undergoing CABG is higher than females for all age groups.

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