Abstract:
Abundant evidence exists to confirm that fibrinolytic
treatment saves lives in patients with acute myocardial
infarction and that the earlier the treatment the higher
the benefit obtained.' There is also evidence to suggest
that administration of fibrinolytic treatment, under
certain conditions, before hospital admission may lead
to further improvement in patients' prognosis with no
significant additional risk.2-4
John Rawles attempts to quantify the benefit of
earlier fibrinolytic treatment using the data from the
311 patients included in the GREAT trial, which
evaluated the feasibility, safety, and efficacy of domiciliary
fibrinolysis by general practitioners.5 Such
quantification is essential if providers of health care are
to make an informed decision on whether to allocate
resources to domiciliary fibrinolysis. The magnitude
of the benefit is controversial, and the trial that could
fully resolve this will never be performed for obvious
ethical reasons. This trial would require randomising
patients to, say, four or five groups, each group having
a predetermined delay from diagnosis of acute myocardial
infarction to fibrinolytic treatment. Thus, the
only available way to assess the magnitude of benefit of
earlier fibrinolytic treatment compared with later treatment
is to retrospectively analyse data from fibrinolytic
studies, performing indirect comparisons of the randomised
groups or using an epidemiological approach.
