Document Detail

Long-term mortality of patients with acute myocardial infarction in the United States and Canada: comparison of patients enrolled in Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-I.
MedLine Citation:
PMID:  15381645     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: In a previous substudy of the GUSTO-I trial, we observed better functional and quality-of-life outcomes among patients in the United States (US patients) compared with patients in Canada. Rates of invasive therapy were significantly higher in the United States and were associated with a small mortality benefit (0.4%, adjusted P=0.02). We sought to determine whether Canadian-US differences in practice patterns in GUSTO-I had an impact on 5-year mortality. METHODS AND RESULTS: Mortality data for 23,105 US and 2898 Canadian patients enrolled in GUSTO-I were obtained from national mortality databases. Median follow-up was 5.46 years in the US and 5.33 years in the Canadian cohort. Five-year mortality rate was 19.6% among US and 21.4% among Canadian patients (P=0.02). After baseline adjustment, enrollment in Canada was associated with a higher hazard of death (1.17; 95% confidence interval, 1.07 to 1.28, P=0.001). Revascularization rates during the index hospitalization in the United States were almost 3 times those in Canada: 30.5% versus 11.4% for angioplasty and 13.1% versus 4.0% for bypass surgery (P<0.01 for both). After accounting for revascularization status as a time-dependent covariate, country was no longer a significant predictor of long-term mortality. These results were confirmed in a propensity-matched analysis. CONCLUSIONS: Our results suggest, for the first time, that the more conservative pattern of care with regard to early revascularization in Canada for ST-segment elevation acute myocardial infarction may have a detrimental effect on long-term survival. Our results have important policy implications for cardiac care in countries and healthcare systems wherein use of invasive procedures is similarly conservative.
Padma Kaul; Paul W Armstrong; Wei-Ching Chang; C David Naylor; Christopher B Granger; Kerry L Lee; Eric D Peterson; Robert M Califf; Eric J Topol; Daniel B Mark
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Publication Detail:
Type:  Clinical Trial; Comparative Study; Journal Article; Multicenter Study; Randomized Controlled Trial; Research Support, Non-U.S. Gov't     Date:  2004-09-20
Journal Detail:
Title:  Circulation     Volume:  110     ISSN:  1524-4539     ISO Abbreviation:  Circulation     Publication Date:  2004 Sep 
Date Detail:
Created Date:  2004-09-28     Completed Date:  2005-05-24     Revised Date:  2006-11-15    
Medline Journal Info:
Nlm Unique ID:  0147763     Medline TA:  Circulation     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1754-60     Citation Subset:  AIM; IM    
University of Alberta, 7221 Aberhart Center I, 8440 112 St, Edmonton, AB T6G 2B7, Canada.
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MeSH Terms
Angioplasty / utilization
Anticoagulants / administration & dosage,  therapeutic use
Canada / epidemiology
Case Management
Cohort Studies
Coronary Artery Bypass / utilization
Drug Therapy, Combination
Fibrinolytic Agents / administration & dosage,  therapeutic use
Follow-Up Studies
Heparin / administration & dosage,  therapeutic use
Injections, Intravenous
Injections, Subcutaneous
Middle Aged
Myocardial Infarction / drug therapy,  mortality*,  surgery,  therapy
Myocardial Revascularization / methods,  utilization
Physician's Practice Patterns
Proportional Hazards Models
Streptokinase / therapeutic use
Survival Analysis
Thrombolytic Therapy / utilization
Tissue Plasminogen Activator / therapeutic use
Treatment Outcome
United States / epidemiology
Reg. No./Substance:
0/Anticoagulants; 0/Fibrinolytic Agents; 9005-49-6/Heparin; EC 3.4.-/Streptokinase; EC Plasminogen Activator

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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