Primary percutaneous coronary intervention was associated with the lowest risk of mortality compared with fibrinolytic therapy (OR 0.73; 95% CI 0.61-0.89).
Meta-Analysis (n=15,357)
Does primary PCI or a pharmacoinvasive approach improve clinical outcomes in patients with ST-segment-elevation myocardial infarction compared to fibrinolytic therapy alone?
Primary PCI remains the preferred reperfusion strategy for STEMI, but a pharmacoinvasive approach is a safe and effective alternative when timely primary PCI is unavailable.
Effect estimate: OR 0.73 (95% CI 0.61-0.89)
Background We systematically reviewed trials comparing different reperfusion strategies for ST-segment-elevation myocardial infarction and used multivariate network meta-analysis to compare outcomes across these strategies. Methods and Results We identified 31 contemporary trials in which patients with ST-segment-elevation myocardial infarction were randomized to ≥2 of the following strategies: fibrinolytic therapy (n=4212), primary percutaneous coronary intervention (PCI) (n=6139), or fibrinolysis followed by routine early PCI (n=5006). We categorized the last approach as "facilitated PCI" when the median time interval between fibrinolysis to PCI was <2 hours (n=2259) and as a "pharmacoinvasive approach" when this interval was ≥2 hours (n=2747). We evaluated outcomes of death, nonfatal reinfarction, stroke, and major bleeding using a multivariate network meta-analysis and a Bayesian analysis. Among the strategies evaluated, primary PCI was associated with the lowest risk of mortality, nonfatal reinfarction, and stroke. For mortality, primary PCI had an odds ratio of 0.73 (95% CI, 0.61-0.89) when compared with fibrinolytic therapy. Of the remaining strategies, the pharmacoinvasive approach was the next most favorable with an odds ratio for death of 0.79 (95% CI, 0.59-1.08) compared with fibrinolytic therapy. The Bayesian model indicated that when the 2 strategies examining routine early invasive therapy following fibrinolysis were directly compared, the probability of adverse outcomes was lower for the pharmacoinvasive approach relative to facilitated PCI. Conclusions A pharmacoinvasive approach is safer and more effective than facilitated PCI and fibrinolytic therapy alone. This has significant implications for ST-segment-elevation myocardial infarction care in settings where timely access to primary PCI, the preferred treatment for ST-segment-elevation myocardial infarction, is not available.
Fazel et al. (Fri,) conducted a meta-analysis in ST-segment-elevation myocardial infarction (n=15,357). Primary percutaneous coronary intervention (PCI) vs. Fibrinolytic therapy was evaluated on Mortality (OR 0.73, 95% CI 0.61-0.89). Primary percutaneous coronary intervention was associated with the lowest risk of mortality compared with fibrinolytic therapy (OR 0.73; 95% CI 0.61-0.89).
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