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No man can be a pure specialist without being in the strict sense an idiot George Bernard Shaw
In this issue, Asseburg and colleagues report a systematic review of 22 randomised trials to assess the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delays (see article on page 1244).1 They conclude that angioplasty is superior provided that the additional time delay is less than 90 minutes. Although both a systematic review2 examining essentially the same studies and a meta-regression3 showing the importance of the additional time delays have been previously published, Asseburg’s work makes several unique contributions. First, it provides an updated review using full publications rather than abstracts, includes an additional study and makes several data corrections. Second, the authors have extended the analysis from 1 to 6 months’ follow-up. Finally, the authors have performed a more rigorous and comprehensive analysis using Bayesian statistics. They conclude that while the additional benefits of angioplasty are affected by the associated time delays, this option is generally better than thrombolysis for delays of less than 90 minutes. Given the overall high quality of this systematic review, a reasonable question is whether there is still a place for thrombolysis.
Although Asseburg’s conclusion is qualitatively similar to the much quoted previous meta-analysis2 (mortality odds ratio (OR) = 0.70, 95% CI 0.58 to 0.85), their probability of a qualitative benefit is less certain and does not quite reach conventional statistical significance (OR = 0.68, 95% credible interval 0.46 to 1.01). The increased uncertainty results from their appropriate use of a random effects statistical model that accounts not only for within-study but also between-study variability, as well as their inclusion of a measure for additional time delays. Although each model undoubtedly has its proponents, the lack …