Randomized trials of clinical networks in the management of ST-elevation MI: can they be performed?
1Flinders University, Flinders Medical Centre, South Australia, Australia. derek.chew@flinders.edu.au
Insights
Reducing mortality in ST-elevation myocardial infarction (STEMI) requires coordinated clinical networks. Further research is needed to establish the benefits of integrated reperfusion networks for STEMI patients.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Networks
Background:
- Mortality in ST-elevation myocardial infarction (STEMI) correlates with myocardial damage from vessel occlusion.
- The time window for myocardial salvage in STEMI is limited.
Purpose of the Study:
- To review strategies for augmenting the temporal window in STEMI reperfusion.
- To highlight the need for system-based approaches and coordinated clinical networks for improved outcomes.
Main Methods:
- Review of strategies including prehospital thrombolysis, facilitated percutaneous coronary intervention (PCI), and prompt transfer to primary PCI centers.
- Discussion of the limitations of current reperfusion strategies.
- Proposal for network-level randomization in clinical trials for evaluating integrated reperfusion networks.
Main Results:
- Current reperfusion strategies (thrombolysis, facilitated PCI) have shown mixed results in augmenting the temporal window.
- System-based and highly coordinated clinical networks are identified as crucial for further mortality reductions in STEMI.
Conclusions:
- The mortality benefit of integrated reperfusion networks in STEMI requires further establishment.
- Network randomization in trials offers a method for collecting robust data applicable to real-world practice, including complex comorbidity patients.
Purpose Of This Review:
Mortality in ST segment elevation myocardial infarction is directly related to the degree of myocardial damage sustained as a result of vessel occlusion. It is well established that the temporal window during which myocardial salvage may be achieved is limited.
Recent Findings:
Prehospital thrombolysis, facilitated percutaneous coronary intervention (PCI) and prompt transfer to institutions with primary PCI capabilities have all been proposed as strategies to augment the temporal window. These different approaches all seek to modify the way reperfusion is delivered, as opposed to the manner of restoring flow, but have been associated with mixed results. Hence, it has become clear that further mortality reductions will require system-based and highly coordinated clinical networks.
Summary:
The extent of the mortality benefit associated with the development of an integrated reperfusion network has yet to be established. Collection of robust data in the context of a clinical trial may be obtained by the random allocation of clinical networks as opposed to randomization of patients. Furthermore, such data would be applicable to 'real world' clinical practice, as optimal reperfusion could be examined in patients whose complex comorbidity would preclude their inclusion in conventional ST segment elevation myocardial infarction (STEMI) trials.
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