Assessing the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delay: a Bayesian evidence synthesis

Abstract

Background: Meta-analyses of trials have shown greater benefits from angioplasty than thrombolysis after an acute myocardial infarction, but the time delay in initiating angioplasty needs to be considered. Objective: To extend earlier meta-analyses by considering 1-and 6-month outcome data for both forms of reperfusion. To use Bayesian statistical methods to quantify the uncertainty associated with the estimated relationships. Methods: A systematic review and meta-analysis published in 2003 was updated. Data on key clinical outcomes and the difference between time-to-balloon and time-to-needle were independently extracted by two researchers. Bayesian statistical methods were used to synthesise evidence despite differences between reported follow-up times and outcomes. Outcomes are presented as absolute probabilities of specific events and odds ratios (ORs; with 95% credible intervals (CrI)) as a function of the additional time delay associated with angioplasty. Results: 22 studies were included in the meta-analysis, with 3760 and 3758 patients randomised to primary angioplasty and thrombolysis, respectively. The mean (SE) angioplasty-related time delay (over and above time to thrombolysis) was 54.3 (2.2) minutes. For this delay, mean event probabilities were lower for primary angioplasty for all outcomes. Mortality within 1 month was 4.5% after angioplasty and 6.4% after thrombolysis (OR = 0.68 (95% CrI 0.46 to 1.01)). For non-fatal reinfarction, OR = 0.32 (95% CrI 0.20 to 0.51); for non-fatal stroke OR = 0.24 (95% CrI 0.11 to 0.50). For all outcomes, the benefit of angioplasty decreased with longer delay from initiation. Conclusions: The benefit of primary angioplasty, over thrombolysis, depends on the former's additional time delay. For delays of 30-90 minutes, angioplasty is superior for 1-month fatal and non-fatal outcomes. For delays of around 90 minutes thrombolysis may be the preferred option as assessed by 6-month mortality; there is considerable uncertainty for longer time delays.

Is primary angioplasty cost effective in the UK? Results of a comprehensive decision analysis

“…A systematic review was conducted to update the most comprehensive meta-analysis in this area,10 and Bayesian statistical methods were used to synthesise the effectiveness evidence from 22 randomised control trials 11. The model was developed as a comprehensive decision analysis,12 13 where the individual components of the decision modelling were dealt with simultaneously and evaluated using a Markov Chain Monte Carlo simulation implemented in the specialist software WinBUGS 14…”

“…The model considered the costs from the perspective of the NHS, using 2003–4 prices, with costs and benefits discounted at 3.5% a year 15. Details of the updated systematic review and evidence synthesis are presented in a companion paper to this 11. Full technical details of all methods can be found in a technical report (available at http://heart.bmj.com/supplemental).…”

“…Bayesian evidence synthesis was used to inform the clinical effectiveness measures for the short-term model, based on an average of all streptokinase and fibrin-specific trials 11. Outcomes were estimated as a function of the additional time delay associated with primary angioplasty compared with thrombolysis defined as the mean difference between time-to-balloon in primary angioplasty and time-to-needle in thrombolysis (mean (SE) 54.3 (2.2) minutes).…”

Knowledge, Self-efficacy, and Self-perceived Risk for Cardiovascular Disease among Asians Living With HIV: The Influence of HIV Stigma and Acculturation

“…Rapid recognition of ACS symptoms and prompt medical care are critical to minimize morbidity and mortality (Asseburg et al, 2007). Survival rates associated with reperfusion therapy (standard of care for ACS symptoms) initiated within 60 minutes of symptom onset are as much as 50% higher than those associated with reperfusion therapy initiated after 60 minutes (Moser et al, 2006).…”

Primary angioplasty versus thrombolysis for acute ST-elevation myocardial infarction: an economic analysis of the National Infarct Angioplasty project

“…Although current NHS policy for the treatment of ST elevation myocardial infarction (STEMI) recommends rapid thrombolytic drug treatment,1 evidence from a number of trials dating from the early 1990s suggests that primary angioplasty may be more effective in reducing mortality, reinfarction and stroke 2. However, the benefits from either type of treatment diminish as the time from symptom onset to treatment increases.…”