Published Online
on September 20, 2004

A more recent version of this article appeared on September 28, 2004

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Submitted on February 25, 2004
Revised on May 26, 2004
Accepted on May 28, 2004

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, and 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.

^* To whom correspondence should be addressed. E-mail: pkaul{at}ualberta.ca.

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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