Management of myocardial infarction: looking beyond efficacy.

Over the last two decades, management of acute myocardial infarction (MI) has shifted from a “wait and watch” strategy to an increasingly aggressive strategy of restoring and maintaining (e.g., thrombolytics, antiplatelet agents) early patency to the infarct-related vessel and to other approaches that directly protect the myocardium (e.g., beta-blockers, angiotensin-converting enzyme inhibitors). Improved outcomes in MI have been achieved largely by using a combination of simple pharmacologic therapies and by the introduction of specialized coronary care units (1). In recent years advances in catheter based technologies have improved reperfusion success in MI patients with ST elevation. Randomized clinical trials of primary balloon percutaneous transluminal coronary angioplasty (PTCA) versus thrombolytic therapy have demonstrated that primary PTCA results in higher rates of coronary patency and lower rates of stroke, reinfarction and death (2). However, the relative benefit of PTCA over thrombolytic therapy is still unknown in a community setting in which access to catheterization laboratories (cath labs) and operator expertise is less uniform than in the trial setting (3). Whether immediate availability of invasive facilities, compared with referral of sick or high-risk patients to offsite cath labs, will improve outcomes is not known. This question has important medical, organizational, cost and training implications. Rogers et al. (4) attempt to answer this question using