Relevance of clinical trial results in myocardial infarction to medical practice: comparison of four year outcome in participants of a thrombolytic trial, patients receiving routine thrombolysis, and those deemed ineligible for thrombolysis

Objective-To assess the medium to long term outcome of patients ineligible for thrombolysis compared to those enrolled in a clinical trial of thrombol ysis and patients receiving non-trial thrombolysis. Design-Cohort study based on the Nottingham heart attack register. Setting-Two district general hospitals serving a defined urban/rural popula tion. Subjects-All patients admitted with a confirmed acute myocardial infarction during 1992 categorised as either participants of a thrombolytic trial (gr oup A, n = 140), receiving non-trial thrombolysis (group B, n = 329), or de emed ineligible for lytic treatment (group C, n = 431). Main outcome measures-Background characteristics, inhospital treatment, pat terns of follow up, referrals to cardiologists, revascularisation rates, an d short and long term survival. Results-Clinical trial recruits were younger by almost 10 years, were less likely to have a previous history of myocardial infarction, and more likely to be in Killip class 1 on admission than those ineligible for thrombolysi s. Cardiology follow up was mandatory for all surviving trial participants but 22% of patients in group B and 31% of patients in group C received no f ollow up, and during four years less than 50% ever saw a cardiologist. Reva scularisation was performed in 17.2% of patients in group A, 13.6% of patie nts in group B, and 7.5% of patients in group C. Cumulative mortality at a median of four years was 24.3% in group A, 36.8% in B, and 59.6% in group C . Adjusting for age, sex, previous myocardial infarction, type of infarctio n, and Killip class in a logistic regression model the odds ratios (OR) of death at four years for groups B and C were 1.60 (95% confidence intervals (CI) 0.97 to 2.63, p = 0.065) and 2.64 (95% CI 1.61 to 4.32, p < 0.001), re spectively, when compared to group A (OR 1). Conclusions-Patients enrolled into thrombolytic trials are at low risk. Pat ients deemed ineligible for thrombolysis are high risk, receive less survei llance, are less likely to be revascularised or receive trial proven treatm ents, have a poor long term outcome not entirely explained by increased age or severity of infarction, and deserve further evaluation.