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(Circulation. 2004;110:1754-1760.)
© 2004 American Heart Association, Inc.

Coronary Heart Disease

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

Padma Kaul, PhD; Paul W. Armstrong, MD; Wei-Ching Chang, PhD; C. David Naylor, MD, DPhil; Christopher B. Granger, MD; Kerry L. Lee, PhD; Eric D. Peterson, MD, MPH; Robert M. Califf, MD; Eric J. Topol, MD; Daniel B. Mark, MD, MPH

From the University of Alberta (P.K., P.W.A., W.-C.C.), Edmonton, Alberta, Canada; the University of Toronto (C.D.N.), Toronto, Ontario, Canada; Duke Clinical Research Institute (P.K., C.B.G., K.L.L., E.D.P., R.M.C., D.B.M.), Durham, NC; and the Cleveland Clinic Foundation (E.J.T.), Cleveland, Ohio.

Correspondence to Padma Kaul, PhD, University of Alberta, 7221 Aberhart Center I, 8440 112 St, Edmonton, AB T6G 2B7, Canada. E-mail pkaul{at}ualberta.ca

Received February 25, 2004; revision received May 26, 2004; accepted May 28, 2004.

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.

Key Words: myocardial infarction • mortality • revascularization

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