University Assignment: Critical Appraisal of Review Articles

This report presents a critical appraisal of three review articles focusing on the treatment of ST-segment elevation myocardial infarction (STEMI). The first article, "Reperfusion therapy in the acute management of ST‐segment‐elevation myocardial infarction in Australia," is evaluated for its validity, results, and implications, highlighting the benefits of timely reperfusion therapy. The second article, "Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction," is analyzed for its study design and outcomes, particularly regarding the use of fibrinolysis and its associated risks. The third article, "Optimizing the use of thrombolytic in ST-segment elevation myocardial infarction," is assessed for its focus on thrombolytic therapy. Each article is critically examined based on its methodology, results, and applicability to clinical practice, with a focus on the effectiveness and limitations of various treatment strategies for myocardial infarction.

Running head: CRITICAL APPRAISAL OF REVIEW ARTICLES
CRITICAL APPRAISAL OF REVIEW ARTICLES
Name of the Student:
Name of the university:
Author note:

1CRITICAL APPRAISAL OF REVIEW ARTICLES
Article 1:
Paper for appraisal and reference: “Huynh, L. T., Rankin, J. M., Tideman, P., Brieger, D. B.,
Erickson, M., Markwick, A. J., ... & Chew, D. P. (2010). Reperfusion therapy in the acute
management of ST‐segment‐elevation myocardial infarction in Australia: findings from the
ACACIA registry. Medical Journal of Australia, 193(9), 496-501”.
Section A: Are the results of the study valid?
1. Did the study address a
clearly Yes

Focused issue? Can’t Tell
No
Yes, the study has clearly addressed the focused issue of detecting the beneficial effect of reperfusion therapy for the
management of myocardial infraction in Australia. This study also focused on the outcome evaluated on the
management of ST-segment-elevation (STEM).
2. Was the cohort recruited
in Yes

an acceptable way?
Can’t Tell


No

Yes, cohort was conducted in an acceptable way. The patients with STEMI in Australia were considered for
this study. 70% of the patients were given with reperfusion therapy, rest were given with timely reperfusion
therapy, and accordingly cohort study was conducted to analyse the result.
Is it worth continuing?

2CRITICAL APPRAISAL OF REVIEW ARTICLES
3. Was the exposure accurately Yes
measured to minimise bias?
Can’t Tell
No
Can’t tell if there was any exposure accuracy to minimise the measurement bias. In this study, no effective
validation tool was used to completely validate the objective measurements and the subjects were classified
under two different exposure groups.
4. Was the outcome accurately Yes
Measured to minimise bias?
Can’t Tell
No
No effective validation tool was used to check for the accuracy. In this study, Acute Coronary Syndrome
Prospective Audit (ACACIA) were involved in recording the outcomes established from the patient.



3CRITICAL APPRAISAL OF REVIEW ARTICLES
5. (a) Have the authors
identified Yes 
all important confounding
factors? Can’t Tell
No
Yes, the authors have identified all the important factors such as inclusion of patient with STEMI, advantage of using
reperfusion therapy for acute management, factors included in reperfusion therapy and change in mortality factor due to the
therapy.
5.(b) Have they taken
account of the
confounding factors in
the design and/or
analysis?

4CRITICAL APPRAISAL OF REVIEW ARTICLES
Yes

Can’t
Tell
No

5CRITICAL APPRAISAL OF REVIEW ARTICLES
The researcher did consider the entire confounding factor necessary for the analysis of the study in order to estimate the necessary changes
in mortality rate and to determine the effect of reperfusion therapy in treatment of myocardial infraction.
6. (a) Was the follow up of Yes
subjects complete
enough?
Can’t
Tell
No 
6. (b) Was the follow up of Yes
subjects long enough? Can’t
Tell
No 

6CRITICAL APPRAISAL OF REVIEW ARTICLES

7CRITICAL APPRAISAL OF REVIEW ARTICLES
In this study, only a observational design of approach was
considered with the aim to just confirm the robustness of already
used treatment effect. A more extensive study should have been
considered with improved data infrastructure in order to match the
clinical infrastructure
Section B: What are the results?
7. What are the results of this study?
The result stated that timely reperfusion therapy was
beneficial in reducing the mortality rate of the patient
suffering with myocardial infraction. The benefit of using
early reperfusion therapy was highlighted in the result stating
that no crucial difference in mortality rate was estimated in
the rural and metropolitan patients of Australia.
8.How precise are the results?
The result was precise in stating the advantages of reperfusion therapy for the
patients suffering with myocardial infraction but the outcome of the individuals
involved in this observational study was not mentioned precisely with no description
of the effect of treatment in those patients.

8CRITICAL APPRAISAL OF REVIEW ARTICLES
9. Do you believe the
results? Yes
Can’t Tell
No 
The result lack in explaining the effect of treatment on the patients involved in the study.
This study also lacked in using any new approach or method of dealing with myocardial
infraction using thrombolytic method instead only focused on confirming the robustness of
the previous treatment.
Section C: Will the results help locally?
10. Can the results be
applied to Yes 
the local population?
Can’t Tell
No
The result can be applied to
the local population as the
people who are suffering
with myocardial infraction
can be assessed using
reperfusion therapy and the
effect of the therapy can be
determined by monitoring
the patient health and
determining the change in
mortality of the considered
population.
11. Do the results of this
study fit Yes
with other available
evidence? Can’t Tell 
No

9CRITICAL APPRAISAL OF REVIEW ARTICLES
There were no such
additional information
available to understand
the detail of the study in
comparison to other
evidence.

10CRITICAL APPRAISAL OF REVIEW ARTICLES
12. What are the
implications of Yes 
this study for practice?
Can’t Tell
No
The administration of thrombolysis in the patient receiving reperfusion therapy
was helpful in decreasing the mortality rate of the population. The implication
of timely reperfusion is beneficial for the patient suffering with myocardial
infraction by decreasing the mortality rate of such patients.

11CRITICAL APPRAISAL OF REVIEW ARTICLES
Article 2:
Paper for appraisal and reference: Armstrong, P. W., Gershlick, A. H., Goldstein, P., Wilcox, R.,
Danays, T., Lambert, Y., ... & Carvalho, A. C. (2013). Fibrinolysis or primary PCI in ST-segment
elevation myocardial infarction. New England Journal of Medicine, 368(15), 1379-1387.
Section A: Are the results of the study valid?
1. Did the study address a
clearly Yes
focused issue? Can’t Tell
No
Yes, the study did focus on the issue of ST- segment elevation myocardial infraction
(STEMI). The concept of using prehospital fibrinolysis with coronary angiography for
increasing the effectiveness of the treatment of the patient suffering from the
disease.
2. Was the cohort recruited
in Yes
an acceptable way?
Can’t Tell
No
Yes, the cohort study was conducted in an acceptable way. The study was more of a proof-
of-concept study with the record of patients who underwent randomization and follow up
with informed consent.

12CRITICAL APPRAISAL OF REVIEW ARTICLES
Is it worth continuing?

13CRITICAL APPRAISAL OF REVIEW ARTICLES
3. Was the exposure accurately Yes
measured to minimise bias?
Can’t Tell
No
No, the exposure was not validated properly using any validation tool but the
subjects were included under the same exposure groups i.e. within 3 hours of the
onset of symptom.
4. Was the outcome accurately Yes
measured to minimise bias?
Can’t Tell
No
No, the outcomes were not accurately measured to minimise bias. The patient’s
record was collected from an electronic device application and the requirement was
processed accordingly. There was no proper validation tool used to minimise the risk
of the patient with high chances of myocardial infraction.

14CRITICAL APPRAISAL OF REVIEW ARTICLES
5. (a) Have the authors
identified Yes
all important confounding
factors? Can’t Tell
No

No, the patient was randomly assessed according to their onset of the symptoms and a
risk factor was considered if the patient was not responding to the fibrinolysis therapy. The
risk factor was considered before conducting the study.
6.(b) Have they taken
account of the
confounding factors in
the design and/or
analysis?
Yes
Can’t
Tell
No 

15CRITICAL APPRAISAL OF REVIEW ARTICLES
No the researcher did not took into an account of the confounding factor and after
evaluating the result they were analysing the time period of increasing risk stating
fibrinolysis therapy is linked with high risk of bleeding.
6. (a) Was the follow up of Yes 
subjects complete
enough?
Can’t
Tell
No
6. (b) Was the follow up of Yes
subjects long enough? Can’t
Tell
No


16CRITICAL APPRAISAL OF REVIEW ARTICLES
The follow up of the study was made and was approved by the
sponsor and national regulatory authority and local ethics
committee. The follow up the study did include the therapeutic
challenge
Section B: What are the results?
7. What are the results of this study?
The result showed that the patient who could not
undergo PCI within an hour showed better result
when treated with reperfusion therapy including
fibrinolysis and coronary angiography. The result
also highlighted that fibrinolysis is associated
with high risk of intracranial bleeding.
9. How precise are the results?
The result was precise in comparing the reperfusion strategy with the patient with
minimal risk of myocardial infraction and the patient with higher risk of myocardial
infraction. The study also precisely mentioned that early stage of fibrinolysis is
associated with high risk intracranial bleeding.

17CRITICAL APPRAISAL OF REVIEW ARTICLES
9. Do you believe the
results? Yes 
Can’t Tell
No
Yes, I do believe in the result because outlined all the necessary characteristics of the patient with key interval time of
fibrinolysis and primary PCI and further primary and secondary analysis was done on the basis of risk factors. The end points
of this study was noted and used accordingly for interpretation of the result.
Section C: Will the results help locally?
10. Can the results be
applied to Yes
the local population?
Can’t Tell
No 
The result cannot be applied
to the local population as
the people who are included
under such investigation
need to sign an informed
consent stating that they
are aware of the process
and are accepting the
observational period for
analysis of the result based
on the therapy.
11. Do the results of this
study fit Yes
with other available
evidence? Can’t Tell 
No
No such information could

18CRITICAL APPRAISAL OF REVIEW ARTICLES
be derived from the above
study.

19CRITICAL APPRAISAL OF REVIEW ARTICLES
12. What are the
implications of Yes 
this study for practice?
Can’t Tell
No
This study can be used to determine if the therapeutic therapy is efficient for
treatment in the patient with high risk of myocardial infraction and for
understanding the usage of fibrinolysis conjugated with coronary angiography
for effective treatment.

20CRITICAL APPRAISAL OF REVIEW ARTICLES
Article 3:
Paper for appraisal and reference: Morse, M. A., Todd, J. W., & Stouffer, G. A. (2009). Optimizing
the use of thrombolytic in ST-segment elevation myocardial infarction. Drugs, 69(14), 1945-1966.
Section A: Are the results of the study valid?
1. Did the study address a
clearly Yes
focused issue? Can’t Tell
No
Yes, the study addressed the focus of the study well by stating the aim of the study
as the usage of thrombolytic therapy in effective treatment of ST-segment elevation
myocardial infraction and reviewing the decrease in mortality rate after using
fibrinolytic reperfusion therapy.
2. Was the cohort recruited
in Yes
an acceptable way?
Can’t Tell
No
Yes, the cohort study was recruited in an acceptable way as different trails of
thrombolytic therapy was conducted and the patency rate was noted to understand
the need of improvement in case of any prediction failure.
Is it worth continuing?

21CRITICAL APPRAISAL OF REVIEW ARTICLES

22CRITICAL APPRAISAL OF REVIEW ARTICLES
3. Was the exposure accurately Yes
measured to minimise bias?
Can’t Tell
No
Yes, the exposure was accurately measured to minimise any bias by conducting an
extensive literature review on the various procedure and treatment method to
understand the accuracy of thrombolytic therapy in the treatment of myocardial
infraction.
4. Was the outcome accurately Yes
measured to minimise bias?
Can’t Tell
No
No the outcome was not accurately measured to minimise bias. The patient suffering
from myocardial infraction the time of achieving thrombolytic therapy remains
constant and the most important factor for improving the outcome of the patient.

23CRITICAL APPRAISAL OF REVIEW ARTICLES
5. (a) Have the authors
identified Yes
all important confounding
factors? Can’t Tell 
No
In case of thrombolytic therapy many ongoing researches are being conducted that is
focusing on both adjuvant staregies and novel therapeutic strategy that is missing in this
study. No such focus was highlighted in this study.
7.(b) Have they taken
account of the
confounding factors in
the design and/or
analysis?
Yes
Can’t
Tell
No 

24CRITICAL APPRAISAL OF REVIEW ARTICLES
The confounding factor related to the adjunctive strategy was missed in this study and the
analysis concerning the time of the patient with reperfusion therapy in myocardial
infraction was constant.
6. (a) Was the follow up of Yes 
subjects complete
enough?
Can’t
Tell
No
6. (b) Was the follow up of Yes 
subjects long enough? Can’t
Tell
No

25CRITICAL APPRAISAL OF REVIEW ARTICLES
The provided information of the study was
successful in interpreting the result as an
extensive literature review was also performed
stating the advantages of therapeutic therapy for
the treatment of myocardial infraction. The
thrombolytic agents were also considered and
was explained in this study.
Section B: What are the results?
7. What are the results of this study?
The result stated that the outcome of thrombolytic therapy could be
improved with conjugated with adjuvants like aspirin, anti-thrombin
agent and clopidogrel. The increasing use of thrombolytic therapy
for the effective treatment of myocardial infraction using
reperfusion therapy was also analysed.
9.How precise are the results?
Different trails were conducted in case of thrombolytic therapy to demonstrate the
patency rate and to evaluate the need for any further improvement by using a non-
invasive marker to predict the risk factors. The importance of rapid reperfusion were
analysed and coordinated for further diagnosis.

26CRITICAL APPRAISAL OF REVIEW ARTICLES
9. Do you believe the
results? Yes 
Can’t Tell
No
The result stated that therapeutic therapy is effective in treating the patient with
myocardial infraction and I do believe in the result as many such literature review was
conducted stating the advantages of thrombolytic therapy and in reducing the mortality
level of the population.
Section C: Will the results help locally?
10. Can the results be
applied to Yes 
the local population?
Can’t Tell
No
The result can be applied to
the local population as large
number of population are
facing the problem of
myocardial infraction and
therapeutic treatment is
considered for such
population to decrease the
mortality rate of the
population.

27CRITICAL APPRAISAL OF REVIEW ARTICLES
11. Do the results of this
study fit Yes 
with other available
evidence? Can’t Tell
No
The result obtained from
this study do fit in the
other available evidence
of promoting the usage of
therapeutic therapy in
treating the population
who are suffering from ST-
segment elevation
myocardial infraction
(STEMI).

28CRITICAL APPRAISAL OF REVIEW ARTICLES
12. What are the
implications of Yes 
this study for practice?
Can’t Tell
No
The result can be implicated in demonstrating the importance of rapid
reperfusion and stating the role of conventional treatment approaches for the
patient suffering from STEMI through transfer and delivery of appropriate care
and pre-hospitalization administration for rapid treatment or diagnosis. This
study can be used to examine the optimal timing of providing coronary
angiography after thrombolytic therapy.