The much published TRANSFER -AMI study has few important queries to ponder about.It was supposed to test the role of routine PCI following thrombolysis. In other words it compared rescue only strategy with routine strategy.The caveat is , even among failed thrombolysis, the rescue strategy has not convincingly proven superior to medical management (if the time is lapsed ) as much of the damage is done .
In essence , Acute MI is more about time management than drug or cath lab management
- Why the 67 % of standard therapy cohort underwent PCI. Technically , you are supposed to transfer for rescue only if there is a failed thrombolysis ?That is the standard approach , if most of the cases are any way land up in cath lab , then you are trying to compare two similar groups .
- Why the rate of failed thrombolyis with TNK-TPA in both arms not disclosed ?
- How can a 92% of study population be in class 1 Killip still considered to be high risk group ?
- Why the recurrent ischemia was very vaguely defined and still included and clubbed with primary end point along with deaths. If only recurrent ischemia was removed from primary end point . . .this study will straight away land in a regret bin.
- Why there were 6 additional deaths at 30 days in routine early PCI group , What was he cause of death ? Mind you these deaths have happened in a 92 % Killip class one cohort . Is it not important ? The trend looks vitally significant .We can not afford take refuge under a false statistical roof .
- How many patients died or developed MI because of the early PCI in-spite of having successful thrombolysis.This again could be vital . Complications during intervention for a failed thrombolysis may be acceptable. While ,complications , when we try to improve upon the already successful thrombolysis is simply not acceptable .
Will the investigators share their experience ?
Why the title of the paper says it is about “Routine angioplasty” and the conclusion emphasizes it is indeed “high risk subsets ofangioplasty” (While the study itself involves a 92 % least risk Killip class 1 ) . Why this double dose of confusion ? (Is it deliberate ! Which i think is unlikely )
NEJM please take note of this . . .
All that glitters are not natural glitter . . .some are made to glitter !