Randomized trials of clinical networks in the management of ST-elevation MI: can they be performed?

Abstract

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.