Remarks about postinfarction prognosis in light of the experience with the Gruppo Italiano per lo Studio della Sopravvivenza nell' Infarto Miocardico (GISSI) trials.

The contribution of large-scale trials to the impressive therapeutic advances that have occurred over the past 10 years in the area of acute myocardial infarction (AMI) is universally acknowledged. A less frequently considered aspect of trials on AMI is their capacity of acting as “new-generation” data bases providing real-time updated prognostic information. This aspect seems to apply specifically to the case of the Gruppo Italiano per lo Studio della Sopravvivenza nell' Infarto Miocardico (GISSI) trials.1 2 3 Indeed, their open design, the absence of age limits in the enrollment criteria, and the countrywide coverage of the recruitment appear to be crucial for close mimicking of routine conditions of care. Moreover, the very large number of patients enrolled (>40 000 in three trials) and the prospective collection of clinical and laboratory data of prognostic relevance provide a privileged perspective for evaluation of postinfarction prognosis. Last, but not least, the observed low frequency of coronary revascularization procedures (≈8%) limits the workup bias. Therefore, the purpose of this report is to propose a view of postinfarction prognosis in the light of the experience of the GISSI trials. Accordingly, emphasis is placed on questions that have been specifically addressed by GISSI trial investigators. The establishment of a new therapeutic standard for AMI that is centered on thrombolytics and aspirin in addition to intravenous β-blockers has led to a substantial reduction in early mortality after the acute coronary event. Although doubts have been cast as to whether the survival benefit documented in large-scale trials can actually be transferred to routine clinical practice, in view of the underutilization of recommended treatments in some countries, including the United States and Canada,4 5 6 7 it is worth noting that a >70% use of thrombolytic drugs has been reported in the multinational ISIS-4 and Italian GISSI-3 trials. …