Key result
Percutaneous coronary intervention was the most effective reperfusion strategy for reducing 30-day mortality (5.1%), stroke (0.6%), and re-infarction (2.2%) compared to thrombolytic agents in STEMI.
Why the study?
Does PCI or specific thrombolytic agents reduce 30-day mortality, stroke, and re-infarction in patients with acute myocardial infarction?
Meta-Analysis (n=36,161)
Does PCI or specific thrombolytic agents reduce 30-day mortality, stroke, and re-infarction in patients with acute myocardial infarction?
PCI is the most effective reperfusion strategy for AMI, but tenecteplase is the preferred thrombolytic when PCI is unavailable and stroke risk is low.
Answers are grounded in this paper and cite their sources.
PCI should be prioritized for STEMI reperfusion; confirms and extends meta-analytic superiority over thrombolytics when available.
Coronary heart disease is the single largest cause of mortality in the UK with acute myocardial infarction (AMI) being responsible for the greatest amount of deaths. Improving perfusion to the myocardium to prevent further damage or death of the cardiac tissue is the aim of treating AMI. In the UK reperfusion is achieved either through the use of an thrombolytic agent (streptokinase, alteplase, reteplase or tenecteplase) or by percutaneous coronary intervention (PCI). Reteplase and tenecteplase are newer agents, to the author's knowledge; no review has been conducted that has included these agents. This review will compare all licensed reperfusion strategies in the UK to determine the optimum reperfusion strategy. The databases PubMed, Medline, Science Direct and EBSCO were searched to identify randomised control trials (RCT's) comparing streptokinase, alteplase, reteplase, tenecteplase and PCI in the prevention of 30-day mortality, stroke and re-infarction. 99 articles were identified but after application of the inclusion and exclusion criteria a total of 12 trials (n=36,161) remained. Data analysis was performed using IBM SPSS Statistics 20. PCI is the most effective intervention for the reduction of mortality, stroke and re-infarction in the short term (incidences of 5.1% (=0.8), 0.6% (=0.78) and 2.2% (=0.6) respectively) despite being associated with the greatest time delay between symptom onset and treatment receipt. Tenecteplase is the most effective thrombolytic agent at reducing 30-day mortality (incidence of 6.2% (=0.8)) and has a comparable re-infarction risk to alteplase and reteplase but does have a greater stroke risk. Tenecteplase has the shortest time-to-treatment however timeto-treatment had no significant impact on 30-day mortality within, and across treatment groups (OR=1.0, P<0.05). PCI is the most effective method of reperfusion and should be first choice. Tenecteplase is showing great promise in efficacy and ease of use and should be the thrombolytic agent of choice if PCI is unavailable and the patient's stroke risk is low.
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Leanne Marie Nation (2015) conducted a meta-analysis in ST-segment Elevation Myocardial Infarction (STEMI) (n=36,161). Percutaneous Coronary Intervention (PCI) vs. Thrombolytic agents (Streptokinase, Alteplase, Reteplase, Tenecteplase) was evaluated on 30-day mortality (ϕ=0.8, p=<0.05). Percutaneous coronary intervention was the most effective reperfusion strategy for reducing 30-day mortality (5.1%), stroke (0.6%), and re-infarction (2.2%) compared to thrombolytic agents in STEMI.
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