Comparison of Primary Percutaneous Coronary Intervention and Fibrinolytic Therapy in ST-Segment-Elevation Myocardial Infarction

Abstract

Background-Published meta-analyses comparing primary percutaneous coronary intervention with fibrinolytic therapy in patients with ST-segment-elevation myocardial infarction include only randomized controlled trials (RCTs). We aim to obviate the limited applicability of RCTs to real-world settings by undertaking meta-analyses of both RCTs and observational studies. Methods and Results-We included all RCTs and observational studies, without language restriction, published up to May 1, 2008. We completed separate bayesian hierarchical random-effect meta-analyses for 23 RCTs (8140 patients) and 32 observational studies (185 900 patients). Primary percutaneous coronary intervention was associated with reductions in short-term (Յ6-week) mortality of 34% (odds ratio, 0.66; 95% credible interval, 0.51 to 0.82) in randomized trials, and 23% lower mortality (odds ratio, 0.77; 95% credible interval, 0.62 to 0.95) in observational studies. Primary percutaneous coronary intervention was associated with reductions in stroke of 63% in RCTs and 61% in observational studies. At long-term follow-up (Ն1 year), primary percutaneous coronary intervention was associated with a 24% reduction in mortality (odds ratio, 0.76; 95% credible interval, 0.58 to 0.95) and a 51% reduction in reinfarction (odds ratio, 0.49; 95% credible interval, 0.32 to 0.66) in RCTs. However, there was no conclusive benefit of primary percutaneous coronary intervention in the long term in the observational studies. Conclusions-Compared with fibrinolytic therapy, primary percutaneous coronary intervention was associated with short-term reductions in mortality, reinfarction, and stroke in ST-segment-elevation myocardial infarction. Primary percutaneous coronary intervention was associated with long-term reductions in mortality and reinfarction in RCTs, but there was no conclusive evidence for a long-term benefit in mortality and reinfarction in observational studies. Key Words: angioplasty Ⅲ coronary disease Ⅲ fibrinolysis Ⅲ myocardial infarction Ⅲ percutaneous coronary intervention Ⅲ thrombolysis S everal randomized controlled trials (RCTs) show that primary percutaneous coronary intervention (PCI) is associated with reductions in mortality, reinfarction, and stroke compared with fibrinolytic therapy. However, many aspects of reperfusion therapy might not be optimally assessed in RCTs. First, the benefit of primary PCI may not be replicable under suboptimal conditions such as at low-volume and less expert PCI centers, 24 outside regular working hours, or after lengthy interhospital transfer. Second, use of rescue or elective PCI was limited (Ͻ20%) in several RCTs, 1,8,11,12,14,16-17,20 -22 whereas rescue or elective PCI is generally performed as indicated in the real world. Furthermore, patients with ST-segment-elevation myocardial infarction (STEMI) enrolled in RCTs are generally younger with fewer comorbid conditions than patients in the real world. 25 Therefore, extrapolation of the safety and effectiveness of primary PCI and fibrinolytic therapy observed...

Five-Year Survival in Patients With ST-Segment–Elevation Myocardial Infarction According to Modalities of Reperfusion Therapy

“…6 More recent data have shown trends to improved results with rescue PCI in patients with no evidence of reperfusion after fibrinolytic treatment, as well as routine coronary angiography within hours of the administration of fibrinolytic treatment, even when fibrinolysis appears successful. [7][8][9][10][11] The Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) trial, although underpowered, has suggested that prehospital fibrinolytic therapy with the patients brought to PCI-capable centers and with one third undergoing rescue angioplasty could do at least as well as primary PCI up to 5 years after the initial episode, 12 and a pooled analysis of the CAPTIM and Which Early ST-Elevation Myocardial Infarction Therapy (WEST) trials found a reduction in 1-year mortality with fibrinolysis in patients seen early.…”

Comparison of Treatment Strategies Preferred in Patients Admitted to Our Clinic with ST-Segment Elevation Myocardial Infarction (Thrombolytic Therapy for Life)

“…Perkütan koroner girişim ile TT'yi karşılaştıran çok sayıda randomize çalışma ve gözlemsel çalışmalardan yapılmış bir meta-analizde, randomize çalışmalarda, PKG ile gerek kısa gerekse uzun dönemde tutarlı ölüm oranı yararları olduğu gösterilmekte iken, gözlemsel çalışmaların meta-analizinde erken dönemde göz-lenen yararların uzun dönemde görülmediği saptanmıştır (16) . Bu sonuçlara dayanarak, STEMI'de tercih edilen tedavi şekli PKG olsa da, ulaşım, acil servisteki beklemeler ve kateterizasyon laboratuvarının hazırlanması gibi nedenlerle tedavi gecikmektedir.…”

Pharmacoinvasive strategy and its role in the management of patients with acute ST-segment elevation myocardial infarction

“…Metoda pPCI u odnosu na fibrinolitiËku terapiju znaËajno smanjuje ukupnu kratkoroËnu smrtnost (7% naspram 9%), nefatalni reinfarkt (3% naspram 7%), moaedani udar (1% naspram 2%) te u zajedniËki ishod od smrti, nefatalnog reinfarkta te moaedanog udara (8% naspram 14%), a bolji rezultati pPCI su perzistirali i na dugoroËnom praÊenju. Huyn i sur 4 su 2009. objavili noviju metaanalizu usporedbe pPCI i fibrinolitiËke terapije koja osim 23 RCT ukljuËuje i 32 opservacijske studije. Opservacijske studije obuhvaÊaju puno veÊi broj bolesnika i time su sveobuhvatnije i realnije predstavljaju svakodnevnu praksu.…”