Is there evidence of implicit exclusion criteria for elderly subjects in randomized trials? Evidence from the GUSTO-1 study.
BACKGROUND
Some experts have raised concerns about the ability to generalize randomized trials, emphasizing that patients who participate in these studies are often not representative of those seen in clinical practice, particularly in the case of elderly patients. To determine the effect of implicit exclusion criteria on a trial study sample, we compared data from the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) trial with data from a retrospective registry from selected hospitals, the National Registry of Myocardial Infarction (NRMI), and a nationally representative study of myocardial infarction care, the Cooperative Cardiovascular Project (CCP).


METHODS
We compared GUSTO subjects aged 65 years and older who were enrolled in the United States with similarily aged patients in the 2 observational studies who met the trial's eligibility criteria. We examined baseline characteristics, clinical presentation, treatments, procedures, clinical events, and in-hospital mortality rates.


RESULTS
We found modest, although significant, differences between patients in NRMI, CCP, and GUSTO in demographic and clinical characteristics, treatment, and outcome. For example, GUSTO patients were significantly younger (73.1 +/- 5.7 vs 74.7 +/- 6.8 for NRMI and 75.8 +/- 7.2 for CCP), less likely to have Killip class III/IV at presentation (3.1% vs 6.2% for NRMI and 32.7% for CCP), and more likely to receive aspirin (95.5% vs 86.3% for NRMI and 86.5% for CCP) and beta-blockers (71.9% vs 43.5% for NRMI and 52.7% for CCP). Overall, NRMI and CCP patients had a lower risk of 30-day mortality after adjustment for demographic, clinical, and hospital characteristics than patients in GUSTO (odds ratio, 0.79; 95% CI, 0.73-0.86 for NRMI; odds ratio, 0.65; 95% CI, 0.59-0.71 for CCP).


CONCLUSIONS
Older patients enrolled in a randomized trial without an age restriction had many similarities compared with patients seen in clinical practice. The higher mortality rate of the GUSTO patients does not support the hypothesis that the trial enrolled a healthier cohort than is seen in practice.
Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Conn 06520-8088, USA. harlan.krumholz@yale.edu
Harlan M
HM
Krumholz
Cary P
CP
Gross
Eric D
ED
Peterson
Hal V
HV
Barron
Martha J
MJ
Radford
Lori S
LS
Parsons
Nathan R
NR
Every
D017677:Age Distribution; D000368:Aged; D003327:Coronary Disease / Q000188:drug therapy / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D018579:Patient Selection; D011287:Prejudice; D016032:Randomized Controlled Trials as Topic / Q000379:methods*; D012189:Retrospective Studies; D013300:Streptokinase / Q000627:therapeutic use; D015996:Survival Rate; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014481:United States / Q000453:epidemiology
D013300:Streptokinase; D010959:Tissue Plasminogen Activator