Strengths and Limitations:
It’s crucial to acknowledge certain limitations in the present study.
First of all, the cross-sectional design of our study did not allow us
to investigate the association of CRI and influenza with onset of AMI.
For this inaugural Bangladeshi study, we favored a cross-sectional
design, lacking a control group, over a case-control approach due to
time sensitivity, the need for rapid data collection, its efficiency,
cost-effectiveness, and capability to study a larger population.
Therefore, in our recommendation for future research, we recognize that
a case-control design would be the appropriate method to enable
statistical investigation of the association of CRI and influenza with
AMI. Secondly, any clinical definition for acute respiratory illness has
inherent limitations including subjectivity, limited specificity, and
variability of respiratory symptoms depending on the patient’s age and
individual experiences, compounded by the lack of standardization. This
could lead to potential bias in our prevalence estimates. A more
standardized and objective measures of respiratory illness may improve
the reliability and generatability of the findings. Third, we were
unable to further confirm every AMI diagnosis through angiogram findings
of coronary artery blockage and echocardiogram findings of regional wall
motion abnormalities. Fourth, due to delay in initiation of the field
implementation we had not enrolled participants during peak influenza
months June-July of 2017 which might significantly affect our overall
estimates for frequencies of CRI and influenza. Our study only
investigated two annual influenza seasons, which may not fully reflect
the broader trends of influenza prevalence among AMI patients. As
influenza activity varies significantly year to year, a longer study
period would yield a more comprehensive understanding of these patterns
and their impact on AMI. Fifth, we utilized only qRT-PCR to identify
influenza among participants which had limited sensitivity due to
diminution of viral shedding. We believe addition of influenza serology
would have significantly enhanced the sensitivity of the current study
to identify additional influenza positive participants. Lastly as our
study was conducted in a single center in Bangladesh, our results are
limited due lack of generalizability and hence may not represent the
broader population of the country.