Methodologic Sources of Inconsistent Prognoses for Post-Acute Myocardial Infarction

To investigate basic methodologic problems that could explain inconsistent and contradictory results for predictor variables in studies of prognosis after myocardial infarction (MI). Studies on postinfarct prognosis published in English between 1979 and 1991 were identified with a MEDLINE literature search. The key words used for the computer search were: “prognosis” and “myocardial infarction” in the title and “mortality” or “survival” or “outcome” in the title or abstract. Reference lists in the reports captured by the search were examined for pertinent articles, and additional articles were sought in the index pages of two prominent journals. To be included in the analysis, a study had to fulfill the following eligibility criteria: a cohort study or randomized, controlled trial; sample size ≥50 patients; a clear identification of the time when follow-up began, after the acute phase of MI and either before or at hospital discharge; follow-up for a minimum of 6 months or median/mean of 1 year; and multivariable analysis for intervals no longer than 2 years after the MI. Eight methodologic standards addressing sources of major problems were established and applied to each study. Of 766 reports identified, 111 fulfilled the eligibility criteria. The median number of standards fulfilled was 3, the highest 6. The proportions of studies complying with each of the 8 methodologic standards were: (1) inception cohort, 60%; (2) total death as an unequivocal outcome, 54%; (3) verification of cause-specific deaths (in 62 studies analyzing cardiac death), 37%; (4) analysis of crucial variables describing baseline severity, 13%; (5) indication of quantitative scope of the spectrum of baseline severity, 20%; (6) reproducible classification of candidate predictor variables, 40%; (7) adequate identification of quantitative importance of and boundaries for statistically significant predictor variables, 39%; and (8) evaluation of impact of treatment on predictor variables, 13%. The results show that studies on postinfarct prognosis have frequently disregarded basic methodologic principles. Suitable adherence to these principles in future research will allow improved interpretation of results and can reduce inconsistent findings, while improving the applicability of the identified predictors.