Future Pandemics Need Research Networks Ready Before Crisis Strikes: Here's Why

When COVID-19 began disrupting hospitals in early 2020, cardiologists faced a dangerous double uncertainty. Patients were arriving later with heart attacks, cardiac catheterisation volumes were falling, and the virus itself appeared to be changing the biology and severity of acute coronary events. Conventional research systems were too slow for a crisis in which treatment decisions had to be made in real time.

The review "Using Pragmatic Research Methods to Address a Global Pandemic: Lessons Learned from NACMI," published in the journal COVID, examines how the North American COVID-19 STEMI registry turned that uncertainty into usable clinical evidence. Its authors, Jyotpal Singh, Payam Dehghani, Rishi Thakkar, Chase J. Ellingson, Kevin R. Bainey, G. B. John Mancini, Cindy Grines, Ehtisham Mahmud, Shy Amlani, Ross Garberich, Odayme Quesada, Santiago Garcia and Timothy D. Henry, argue that NACMI offers a practical model for research during future pandemics.

Built through cardiology societies, WhatsApp groups, social-media networks and a central coordinating centre, the registry was launched in just 14 days. Within six months, 56 sites had enrolled 230 patients with COVID-19 and ST-segment elevation myocardial infarction, or STEMI. The speed was extraordinary, but the deeper lesson is not simply that research can move faster. It is that speed works only when governance, data standards, clinical networks and communication systems are ready to move with it.

A Registry Built Before the Evidence Window Closed

The early pandemic created a research problem that conventional trials were poorly equipped to solve. Hospitals were reorganising care, elective procedures were being cancelled, and patients were delaying treatment because they feared infection. One early analysis cited in the review recorded a 38% fall in US cardiac catheterisation laboratory activations, giving rise to the phrase "missing STEMIs."

At the same time, clinicians were seeing unusual presentations. Some patients had classic signs of a major heart attack but no clear obstructive coronary lesion. Others had exceptionally heavy clot burdens and poor blood flow even after intervention. The urgent question was whether COVID-19 was merely coinciding with STEMI or fundamentally changing its presentation, treatment and prognosis.

NACMI responded with a pragmatic registry rather than waiting for a conventional multicentre study. A centralised ethics approach, waivers of patient consent, standardised forms and a single coordinating centre reduced administrative friction. Professional societies helped recruit sites, while WhatsApp and CardioTwitter accelerated communication across the United States and Canada.

The model produced evidence while the crisis was still unfolding. Initial results were presented within six months, showing a sevenfold higher mortality rate among patients with COVID-19 and STEMI than among matched pre-pandemic controls. Patients also faced longer treatment delays and were less likely to undergo invasive angiography.

The achievement was not that NACMI replaced randomised trials. It did not. Its value was different: it created a rapidly updating picture of real-world care when clinicians could not wait years for answers. For future pandemics, that distinction is crucial. Emergency research needs systems designed to identify patterns, test assumptions and guide immediate practice even before more definitive studies become available.

COVID Rewrote the Anatomy of a Heart Attack

NACMI did more than count deaths; it helped reveal that COVID-associated STEMI often looked different from the heart attacks clinicians were accustomed to treating. Core-laboratory angiographic analysis found excess thrombus, multiple culprit lesions and poor coronary flow. Roughly one-third of patients undergoing percutaneous coronary intervention had an unsuccessful procedure under conventional definitions. Women were more likely than men to present with myocardial infarction with non-obstructive coronary arteries, while men were more likely to show multiple culprit lesions.

These findings were consistent with the hypothesis that COVID-19 created a hyper-inflammatory and prothrombotic state involving both larger vessels and the microvasculature. NACMI was not designed to prove that mechanism directly, and the review is careful not to overstate the evidence. The registry lacked intracoronary imaging and long-term mechanistic follow-up. Even so, its angiographic patterns aligned with external evidence of microvascular thrombosis and endothelial injury.

A related electrocardiogram substudy found that the extent of ST-segment elevation predicted in-hospital mortality more strongly than angiography. This has practical significance because ECGs are fast, inexpensive and widely available, including in health systems with limited access to advanced imaging.

The registry also supported a mortality-risk score based on routinely collected variables: cardiogenic shock, respiratory rate, oxygen saturation, age, chest X-ray infiltrates and comorbidities. Because the score required no specialised tests, it offered a low-cost triage tool during periods of severe pressure on intensive-care beds, catheterisation laboratories and mechanical support.

Vaccination emerged as another important signal. NACMI analyses found vaccination strongly associated with lower in-hospital mortality, with one report recording no hospital deaths among vaccinated patients. The finding is encouraging but observational. Vaccination status was not captured from the registry's beginning, and the data cannot prove causation. Still, the association offered timely real-world support for vaccination among high-risk cardiovascular patients.

Speed Exposed Inequality, and Data Blind Spots

The registry also showed that a pandemic does not distribute cardiovascular risk evenly. Black and Hispanic patients were overrepresented compared with conventional STEMI populations and experienced higher mortality. Minority patients were less likely to undergo coronary angiography, even though the registry did not consistently identify additional clinical risk that would fully explain the treatment difference.

The evidence pointed towards unequal access or decision-making, but NACMI could not determine the relative contribution of insurance, socioeconomic conditions, comorbidities, hospital capacity or structural racism because it did not collect sufficiently detailed contextual data.

Sex differences were equally instructive. Men more often presented with chest pain, while women more frequently reported shortness of breath. Women were also more likely to have non-obstructive coronary arteries and therefore underwent intervention less often. In an emergency, protocols built around a narrow model of "typical" symptoms risk missing patients whose presentations fall outside it.

These findings demonstrate why equity variables must be designed into registries from the outset rather than added later. Race, ethnicity and sex should be collected alongside insurance status, income, geography, transfer pathways and other structural determinants. Otherwise, emergency research may identify disparities without explaining them well enough to guide policy.

NACMI's operational limitations reinforce that lesson. Sites joined voluntarily and at different times. Definitions such as "person under investigation" were left partly to local discretion. Important variables, including vaccination status, pathogen variant, antithrombotic therapy and transfer times, were added later. Site-reported outcomes were not independently adjudicated across the full registry, and imaging substudies were weighted towards earlier, more severely affected cases.

Rapid communication posed another tension. Social media allowed findings to reach clinicians quickly, but it also risked spreading preliminary or decontextualised claims before peer review. Future networks need structured rapid-dissemination systems: designated communication leads, internal verification and coordinated release through professional societies.

The Next Pandemic Needs Research Infrastructure on Standby

The most important policy lesson from NACMI is that pandemic research cannot be improvised from scratch every time. Governments, universities, professional societies and hospital networks should establish "sleeping" registries that can be activated when a new pathogen emerges. These systems need pre-approved ethics and data-sharing templates, secure digital infrastructure, a mandatory core dataset, central case definitions and clear arrangements for independent adjudication.

Key variables should include vaccination, pathogen variant, symptom-to-hospital and transfer times, treatment, race, ethnicity, sex and socioeconomic context. Long-term follow-up should be built in from the beginning because NACMI later showed that excess mortality persisted for a year after discharge. A registry focused only on hospital outcomes can underestimate the true burden.

The NACMI experience also carries lessons beyond North America. Pragmatic registries could be especially valuable in low- and middle-income countries because they can use routinely collected clinical data and cost less than many conventional studies. Yet their success depends on reliable digital systems, research staff, ethics capacity and inclusive networks. Development agencies should invest in regional platforms that remain functional between emergencies rather than creating isolated, disease-specific databases after each crisis begins.

The review has important limitations. It synthesises findings from an observational registry rather than presenting a new trial, and NACMI cannot establish causal relationships. The Canadian sample was relatively small, limiting cross-country comparisons, while several analyses involved selected subgroups. Nevertheless, the registry's contribution is substantial because it shows how real-world evidence, professional trust and digital communication can be combined under pressure.

NACMI's deepest insight is institutional. Pandemic preparedness is often discussed in terms of laboratories, protective equipment, hospital beds and vaccine supply. Research infrastructure belongs on that list. During a fast-moving emergency, clinicians need evidence before uncertainty hardens into practice and before unequal treatment becomes embedded in response systems.

The next pandemic will again force decisions before perfect evidence exists. The goal should not be to eliminate uncertainty overnight, but to build systems capable of reducing it quickly, transparently and equitably. NACMI shows that this is possible, but only when the network is ready before the crisis arrives.